Boys are circumcised for three reasons. The first - and, for all but the most recent sliver of history, the only reason - is as an item of religious practice or, occasionally, as a rite of passage. The origin of the custom is ancient and obscure but is often traceable to peoples inhabiting hot, sandy, regions. A colleague who had served in the VIIIth (Desert) Army averred, without elaboration, that circumcision had advantages in such conditions. Ritual circumcision impinges upon ordinary practice only by its complications (secondary haemorrhage, circumcision of hypospadias) and which usually follow procedures privately performed by practitioners of arguable competence. Where medical care is free at delivery it has been proposed that extending this facility to religious circumcision would obviate its complications; in the spirit of the times this issue seems destined to be determined by the moral precepts of chartered accountancy rather than by humanitarian concerns.
The second reason for circumcision, also usually undertaken neonatally and without anaesthetic, has been termed `social', or a `routine' and is intended as a prophylactic measure, or talisman, against future ailments. This practice, almost exclusive to the (white) English-speaking Diaspora,1 took root around the turn of the century. The ostensible benefits claimed were splendidly diverse (protection against gout, hernia, asthma, epilepsy etc.),2 although the underlying theme most likely lay in its supposed discouragement of masturbation,1 a habit peculiarly abhorrent to the `muscular Christianity' then triumphant in English cultures and plausibly explaining the geographical distribution of the practice.
In the British Isles `routine' circumcision, fashionable mainly within society's upper crust,3 declined to negligible proportions after the war and a similar trend occurred within nations of the white Commonwealth.1 In the United States, by contrast, the practice increased during this same period and, by the mid-seventies, upwards of 80% of boys were circumcised neonatally.
The benefits claimed by its proponents had become sophisticated to the point of plausibility principally that it offered protection against preputial ailments, most forms of venereal disease, carcinoma of the penis and carcinoma of the cervix in some prospective spouse. When examined,1,4 those relating to venereal disease and cervical carcinoma lacked substance, Although penile cancer is reputedly exceptional in the uncircumcised, the incidence and mortality of this complaint in the United States differ little, if, at all, from those in nations where circumcision is rare.1,4 A properly executed circumcision is certain proof against phimosis and paraphimosis but not against other penile problems of childhood, notably balanitis which reportedly occurs in 3-8% of circumcised boys.5,6
In 1975 the American Academy of Pediatrics concluded that there was `no absolute medical indication for circumcision of the newborn.'7 The impact upon the American public of this delphic pronouncement, plus the more colourful advocacy of lay groups such as INTACT (International Organisation Against Circumcision Trauma), seems to have been muted, in that 10 years on, the incidence of routine circumcision had declined by less than 2%.
Latterly two further putative benefits of circumcision have entered the lists and have occasioned a voile face by the American Academy of Pediatrics.8 Some retrospective epidemiological studies have indicated that the uncircumcised are more susceptible to heterosexual transmission of HIV infection.9,10 On current evidence, any protective effect of circumcision seems no more than slight4 and those seeking to avoid AIDS would be advised to pursue other more effective means to that end.
A more persuasive case exists regarding urinary infections during infancy. In studies of children of American military personnel, Wiswell and associates11,12 presented evidence that during the first year of life the incidence of urinary infection in the uncircumcised, 1-2%, exceeded that in the circumcised by ten to twenty fold and, moreover, that the incidence of urinary infections had risen pari passu with a declining rate of neonatal circumcision.13 Herzog14 found urinary infections only in uncircumcised male infants and among these some 25% had urinary anomalies, principally minor vesicouteric reflux but also some obstructive uropathies. These and similar studies15,16 have justly attracted critical comment,4 especially for their uniformly retrospective nature, but the trend of their observations is sufficiently consistent to indicate that neonatal circumcision does indeed afford a measure of protection against infantile urinary infection. Should this influence European practice? One view, bearing in mind the expense a change in policy would entail, is that for every 100 procedures just one or two individuals would stand to benefit and then arguably since urinary infection may draw attention to some anomaly notably posterior urethral valves, where early detection is advantageous. An exception might exist in boys at risk from known anomalies, especially those with vesicoureteric reflux detected by prenatal ultrasonography in which urinary tract infections are common.17 A controlled trial of neonatal circumcision in such specific circumstances would be worthwhile.
The third reason for circumcision is for immediate medical indications. Currently the National Health Service in England and Wales funds around 31,000 operative circumcisions annually of which all but a small fraction are for medical reasons. Should such wholesale surgical endeavour, at appreciable public expense, be a matter for congratulation or concern? Some two thirds of procedures are upon boys and among these 87% are indicated for `phimosis'.18 Any suspicion that numbers are excessive must, therefore, lie in over-diagnosis of 'phimosis' in boys. This hypothesis begins - and ends - with definition. From its derivation (muzzling) phimosis could be, and often is, diagnosed whenever the prepuce is wholly or partly nonretractable.
A different perspective comes from considering the developmental history of this organ. During fetal life, as the foreskin grows forwards over the glans, no plane of separation exists between these structures. Thus preputial `adhesions' are normal, not pathological. Spontaneous separation commences distally around the time of birth and proceeds proximally at a rate varying widely from one individual to another. Until separation is well established, the preputial orifice, while relatively narrow, is supple and unscarred, a state sometimes termed `physiological phimosis'. At this stage, the prepuce tends to `balloon' during micturition although this is seldom noticed prior to toilet training. This phenomenon rarely betokens urinary obstruction and ceases as the prepuce becomes more retractable. The natural history of preputial development has been classically described by Gairdner3 and subsequently amplified by Øster19 in a study of almost 2,000 boys serially examined from school entry to physical maturity. At 5 years of age, some 10% still had a wholly non-retractable foreskin and upwards of 50% preputial adhesions. By 17 years of age, without any intervention, the foreskin had become fully and easily retractable in all boys excepting 1% who had developed true phimosis.
What is true phimosis? In a small number of boys (and some adults) the tip of the prepuce becomes white, scarred arid indurated, appearances which are unmistakeable and clearly pathological. The histological changes are of Balanitis Xerotica Obliterans20 and the cause is unknown. The condition mainly affects the prepubertal but is exceptional before 5 years of age. It is the only absolute indication for circumcision. In a survey of practice in the Mersey Region of England almost half the circumcisions for `phimosis' were in boys under five years of age and the age distribution curve of procedures for this indication exactly paralleled that for developmental nonretractile foreskin in boys referred to a specialised unit,18 both findings indicating that `phimosis' is indeed appreciably over-diagnosed. Balanoposthitis accounts for some 10% of medical circumcisions. The incidence of this complaint among uncircumcised boys is reportedly as high as 14%. Here, again, definition intrudes as many so labelled complain only of mild irritation and soreness of the prepuce.
The pathognomonic feature of true balanoposthitis is purulent discharge from the preputial orifice and in a series where this criterion applied the incidence was just 3% of which only one-third suffered recurrent episodes.21 Here, indications for circumcision are relative and debatable. Some consider circumcision advisable for boys suffering recurrent, troublesome, episodes21 while others believe that lysis of preputial adhesions to allow full retractabilty of the prepuce is sufficient treatment.22 EMLA cream may be employed as a local anaesthetic for this purpose.22
Other indications for circumcision are few, if any. The ever-popular `pinhole' meatus occurs in reality only in a few boys with pathological phimosis and deserves consignment to the diagnostic dustbin. Likewise the 'redundant' foreskin, a non-existing entity except when constituting a self-fulfilling prophecy at the hands of some practitioners. Paraphimosis accounts for less than 1 in 8,000 paediatric surgical admissions3 and results from abuse, not disease, of the foreskin. If treated by reduction only rather than by circumcision, recurrence is exceptional.
How many boys really need medical circumcision? Generously 1% for true phimosis19,20 and, perhaps, similarly for recurrent balanoposthitis.21 Yet, cumulatively some 6% of boys in England and Wales have undergone medical circumcision by their fifteenth birthday20 indicating that two thirds of current procedures are unnecessary - not a matter for congratulation. Perhaps affairs are more admirably conducted in the Irish Republic; the author would be agreeably surprised to learn of this.
Anthony M. K. Rickwood
Consultant Urological Surgeon
Royal Liverpool Children's Hospital
Liverpool L12 2AP
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