British Medical Journal) Vol 312, 3 February 1996, p 299

(photo and boxes on left, text on right):
ABC of General Surgery in Children


Mark Davenport

Natural History of the Foreskin

|(photo of baby's penis:                       |
|if actual size, ~40mm long in toto,           |
|with a foreskin extending                     |
|~15mm beyond the glans.                       |
|Astonishing.)                                 |
Non-retractile foreskin of infant boy (normal
for age).

| Natural course of foreskin                   |
| separation                                   |
|			Presence of retractile |
|			foreskin               |
| Newborn infants	4%                     |
| 1 year old boys 	50%                    |
| 4 year old boys	90%                    |

The foreskin envelops the glans from the fifth month of gestation. It begins dorsally and ends by fusing ventrally to cover the newly formed urethra. Actual fusion between the two epithelial layers of glans and foreskin is apparent at birth and has been termed physiological phimosis. This non-retractility remains in most boys for at least the first two years of life until natural separation ensues.

Two conditions that are related to the process of preputial separation may give cause for concern. Firstly, the process may be uneven, with adhesions between glans and prepuce persisting even up to adolescence. Secondly, the desquamation of epithelial cells between the glans and non-retractile foreskin leads to accumulation of "pearls' of a white smegma-like substance. Both conditions are usually without actual symptoms and, as they are usually harmless, should not precipitate undue intervention.

History of circumcision

|"And God said unto Abraham, Thou shalt keep my |
| covenant therefore, thou and thy seed after   |
| thee in their generations.                    |
|  This is my covenant, which ye shall keep,    |
| between me and you and thy seed after thee;   |
| Every man chld among you shall be             |
| circumcised.                                  |
|  And ye shall circumcise the flesh of your    |
| foreskin; and it shall be a token of the      |
| covenant betwixt me and you."                 |
|              Holy Bible. Genesis xvii, 9-11   |

| Circumcision for religious reasons is not     |
| funded by the NHS. This can sometimes be a    |
| problem in areas with a high proportion of    |
| Muslims in the community.                     |
Circumcision is one of the earliest operations, being recorded by the ancient Egyptians and other peoples of the Near East. Neonatal circumcision on the eighth day of life is a tenet of the Jewish faith and is performed by a mohel, often a vocation which is passed from father to son. In order to emulate the prophet Mohammed, Muslims also perform circumcision, and, though the timing is less strict, it is usually done well before puberty.

The fashion of routine neonatal circumcision, other than for overtly religious reasons, has varied over the years. After the second world war almost 95% of male infants born in the United States were circumcised (usually by obstetricians) for reasons of "hygiene." This practice has declined, and in 1971 the American Academy of Paediatrics stated: "There are no valid medical indications for routine circumcision in the neonatal period." Yet even today, there is still debate in the medical literature on the possible benefits of routine circumcision - though this is perhaps carried out with rather more heat than light. The arguments for the routine use of any operation, however simple, have to be outstandingly convincing as any surgical procedure has its attendant risks and complications. Certainly, circumcision has a long list of possible complications, the commonest being infection and bleeding.

It has been stated that circumcision is still performed too often in Britain, where routine circumcision has never been prevalent. For instance, of a group of 420 boys referred to paediatric surgical unit in Liverpool with a diagnosis of phimosis requiring circumcision, over half had a non-retractile foreskin appropriate to their age and required only reassurance.

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