[Previous Section] [Back to Contents] [Next Section]6. HEALTH REASONS FOR REMOVAL OF PREPUCE (a) Neonatal Circumcision There appear to be no universally accepted, unequivocal medical indications for neonatal circumcision.54 The Australian Medical Association does not encourage routine neonatal circumcision. The Association has written to the Commission stating:55 Circumcision of the newborn male is a practice which the Australian medical profession generally discourages, always recognising that there may be medical justification for it in conditions such as phimosis. While the AMA has no formal policy on this matter, it generally supports the relevant position adopted by the Australian College of Paediatrics. The Australian College of Paediatrics policy statement reads: 1. The Australian College of Paediatrics should continue to discourage the practice of circumcision as in the newborn male infant. 2. Educational material on the topic of circum- cision should be available to parents before the birth of their baby and also in maternity hospitals. This will facilitate informed discussion with their medical attendant. 3. Some parents after considering medical, social religious and family factors will opt for circumcision of their male child. It is then the responsibility of the medical attendant to recommend that this circumcision be performed at an age and under medical circumstances that reduce the hazards to a minimum. The Royal Australian College of Obstetricians and Gyncaecologists also discourages routine male circumcision. The College states:56 The suggested benefit does not outweigh the financial cost of the procedure on a community basis and the real cost of the occasional fatality in male infants directly arising from circumcision. The Queensland Nurses Union does not have a specific policy on routine circumcision but would support the refusal of any of its members to participate in the procedure.57 Neonatal circumcision should not be considered when the neonate is premature, has a neonatal illness, any congenital anomaly (most importantly hypospadious58) or has a bleeding disorder. The procedure should never be performed within the first 24 hours of life.59 Routine neonatal circumcision continues to be performed by a number of general medical practitioners and possibly specialists in Queensland. (b) Non-neonatal Circumcision There are a number of conditions which may indicate a need for circumcision in older children or men. (i) Phimosis60 This is a medical condition in which the prepuce will not pull back over the glans of the penis because the `opening' is too tight. This is not a problem for young boys. When erections occur the preputial opening may split. Healing then causes linear contraction and further narrowing of the circular orifice. If very tight, it may restrict urine flow and cause ballooning of the preputial sac. It may also lead to infection or balanoposthitis.61 This would be an indication for circumcision. (ii) Paraphimosis This is an uncommon condition resulting in the inability of the phimosed prepuce to be pulled forward again. The prepuce tends to became oedematous63 and a tight constriction then develops at the coronal sulcus behind the glans, aggravating the condition. This is more common in older men and rare in children. Circumcision will be necessary in younger men but in the elderly a dorsal slit, under local aeaesthetic will suffice. In one study, paraphimosis in boys was found to be usually caused by an overzealous parent forcibly retracting, in the bath, a still congenitally adherent foreskin in a child less than three years of age, on the misguided advice of a doctor.64 (iii) Non-retractable Prepuce Adhesions normally exist between the prepuce and the glans from birth are are progressively broken down as erections occur. By three or four years of age the prepuce is usually fully retractable. Plugs of smegma65 may be retained behind the prepuce and be mistaken for `pus' or may predispose to infection. Dr E P Arnold has observed:66 Non-retractable prepuce is not usually an indication for circumcision and can be managed conservatively in the expectation that the adhesions will break down as the child grows. If infections become a problem, the adhesions can be separated an hour after applying a transcutaneous local anaesthetic cream (e.g. EMCA). [sic, should be EMLA] For two weeks after this, daily saline baths, gently withdrawing the prepuce for cleaning and then applying vaseline to the glans before pulling the prepuce forward again are useful manoeuvres to prevent re-formation of adhesions. Should they recur or infections remain a problem, circumcision should be advised. Leitch observes:67 A prepuce made fully retractable after the age of 3 years by simple separation of adhesions with a blunt probe, not necessarily under anaesthesia, would assist hygiene, decrease balanitis and true phimosis, and prevent the accumulation of smegma, thus decreasing the risk of carcinoma of the penis, possibly to an almost negligible level. By 16 years of age only about one per cent of boys still have a non-retractable prepuce.68 (iv) Recurrent balanitis69 This is a condition of inflammation of the glans penis, usually where phimosis is present. (v) Complications of previous, inadequate neonatal circumcision. Notes: 54 Hirst G. Controversies surrounding circumcision Patient Management. September 1984, 14. 55 Letter to the Commission from the Assistant Secretary-General of the Australian Medical Association, 5 October 1993. 56 Letter to Commission from the President of the Royal Australian College of Obstetricians and Gynaecologists, 12 October 1993. 57 The Australian Nursing Federation (of which the Queensland Nurses' Union is a branch) adopted the following policy in September 1992: 1. Nurses (including students of nursing) have a right to refuse to participate in procedures to which they hold a conscientious objection, except that nurses in the course of their employment should not refuse to carry out urgent tasks which are life-saving measures. 2. In cases of conscientious objection, the nurse should express a desire not to participate and should be removed from the procedure area as soon as possible without any discriminatory action being taken. Definition: Conscientious Objection is a right to refuse to participate where the refusal is based on beliefs about that which is right or wrong to do, and where the belief of personal conscience is the dominant guide to the individual's decision. Fear, personal convenience or preference are not sufficient basis for conscientious objection. 58 A congenital defect of the wall of the male urethra so that instead of the normal external orifice there is an opening for a greater or lesser distance on the underside of the penis. 59 It has also been suggested that it should not be performed within the first eight days of life - to allow clotting factors to develop. 60 From the Greek word for "muzzled". 61 Inflammation of the glans penis and prepuce. 62 Cooper GG, Thomson GL, and Raine PAM. Therapeutic retraction of the foreskin in children. British Medical Journal 1983, 186-187. 63 Excessive fluid in intercellular tissue spaces due to increased transudation of fluid from the capillaries. 64 Leitch IOW. Circumcision - A Continuing Enigma Australian Paediatric Journal Vol 6 (1970): 59, at 64. Leitch states: Surely this shows the need for proper education of those members of the medical profession most closely associated with these problems. 65 An oily substance with a peculiar odor. Secreted by small preputial glands on the raised posterior margin of the glans penis and on the neck of the penis. A similar substance is secreted by glands around the clitoris and labia minora in females. 66 Arnold EP. If Anyone Asks `Should I Have Him Circumcised'? Patient Management. November 1990: 15. 67 Leitch IOW. Circumcision - A Continuing Enigma. Australian Paediatric Journal Vol 6 (1970): 59, at 63-64. 68 Id at 63. 69 From the Greek word `balanus' meaning the glans penis.
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