Under what circumstances (no pun intended) is circumcision acceptable?

[Asher]

I never knew about phimosis before this, and I have met someone who has it. He claims it didn't really affect anything, but apparently it increases infection rates.

I should let him know he can get it treated.

The internet.

[SuperSneak]

Here's a few more reasons to consider both sides of the issue. Being uncut seems to have a variety of potential liabilities:

Normal
The normal foreskin is adherent to the glans and is non-retractile in most newborns. Over time the adhesions disappear, the foreskin separates and becomes retractile. The proportion of boys with retractile foreskins is: 40% at 1 year, 90% at 4 years and 99% at 15 years.

Non-retractile foreskin is a normal variant and needs no intervention. It is different from true phimosis (see below).
The foreskin should never be forcibly retracted for cleaning. Once it becomes freely retractile naturally then the boy should retract it as part of routine bathing.
See parent leaflet on care of the normal uncircumcised penis.


Adhesions
Sometimes the normal process of separation is uneven and the foreskin becomes partially retractile but with a residual adhesion to the glans. This is normal and needs no intervention. It will resolve spontaneously by the time of puberty.

Sometimes the normal separation of an adhesion between the foreskin and glans will lead to a day or two of soreness and dysuria.



Smegma
Before the foreskin becomes separate and retractile, it is common for smegma to collect in small yellow / white lumps which may be visible or palpable through the foreskin. These are normal, and need no intervention.

Discharge of smegma from the foreskin opening is sometimes mistaken for pus.


Minor inflammation
Minor redness / soreness of the tip of the foreskin is very common. A number of factors may contribute, including: irritation from wet / soiled nappies, inappropriate attempts at retracting the foreskin for cleansing, bubble bath, soap residue etc. Avoiding these factors, reassurance, and application of a napkin barrier cream to the tip of the foreskin will help. See also napkin rash guidelines.

Hydrocortisone 1% cream or ointment may help.



Balanitis
More severe inflammation of the glans penis +/- foreskin is often due to infection and is usually termed balanitis. It is common, affecting around 6% of uncircumcised and 3% of circumcised males.

Soaking in a warm bath with the foreskin retracted (if retractile and not too painful) will help with cleaning and urination may be easier in the bath. Topical hydrocortisone 1% cream or ointment may help in mild cases. Topical antibiotics creams are sometimes used but are of unproven efficacy.

Candida infection may be responsible in some infants. It is usually associated with more generalised napkin candidiasis and the presence of satellite lesions. Topical anti yeast creams (eg nystatin, clotrimazole, miconazole) will be helpful. See also napkin rash guidelines.



Bacterial infection
If there is significant cellulitis of the whole of the foreskin or the skin of the penile shaft then bacterial infection is likely and antibiotics should be given. Pain and swelling sometimes produce marked dysuria.

Streptococci (including Group A), staphylococci, and gram negative organism are most often responsible.
Swabbing the discharge is unhelpful because the normal foreskin is usually colonised with multiple organisms.
Most cases respond to oral antibiotics (eg Co-trimoxazole 4/20 mg/kg (max 160/800) 12 hourly or Amoxycillin 15 mg/kg (max 500 mg) 8hourly).
Analgesia is important, and sitting in a warm bath may ease dysuria.
Occasional cases require admission for parenteral antibiotics, and rarely urgent surgery (eg dorsal slit / circumcision) is indicated.Significant recurrent balanitis may be an indication for circumcision. Also, true phimosis may lead to recurrent balanitis and should be treated (see below).


Zipper Injury
The tip of the foreskin or other skin (eg scrotum) may become entrapped in the teeth of a zipper. This is painful.

Treatment options include:
Prior to these procedures, adequate analgesia +/- sedation should be given. See sedation Guidelines Liberal application of topical anaesthetic cream may work or local infiltration may be necessary (never use local agents with adrenaline on the penis).

If trapped between teeth below the slider (see figure):

Cutting the median bar of the zipper with wire cutters. The median bar is the part at the top of the slider which joins the front and back plates of the slider. Once cut, the slider falls off and the zipper can be separated (see figure).
Cutting through the material either side of the zipper below the entrapped skin and then cutting across the zipper with wire cutters / strong scissors. Then the zipper can then be separated from below (see figure).
If trapped between slider and teeth of zipper:

Liberal application of topical anaesthetic cream, then ease slider down.
Always check for injury to urethral meatus.


Phimosis
Non-retractile foreskin is a normal variation (see above). (Confusingly some refer to this as "physiologic phimosis").

True phimosis is when scar tissue is present in the distal foreskin and this prevents retraction. It may result from attempts to forcibly retract the foreskin before it has become naturally retractile.

Indicators of true phimosis (rather than simple non-retractile foreskin):
Foreskin not retractile by the time of established puberty.
Previously retractile foreskin becomes non-retractile.
Obvious ring of scar tissue visible at foreskin opening
Inability to visualise urethral meatus when foreskin opening is lifted away from glans.
Ballooning of foreskin on micturition, with pinhole foreskin opening, and very narrow urinary stream. (Note: minor ballooning may occur in normal non-retractile foreskin).
Treatment options:
Application of topical steroid creams: 0.05% betamethasone cream should be used twice daily for 2 to 4 weeks.
Gently retract foreskin without causing any discomfort and apply a thick layer of cream to the tightest part of the foreskin.
Steroid creams ofhigher potency may be tried if this fails.


Circumcision (if significant phimosis and steroid creams fail)


Paraphimosis
This occurs when the foreskin is left in the retracted position. The the glans and the foreskin distal to the tight area become oedematous and swollen. Pain and swelling make it difficult to return the foreskin to the non-retracted position.

Paraphimosis can usually be corrected without surgery:
Adequate analgesia +/- sedation should be given. Liberally covering the entire foreskin and glans in topical anaesthetic cream & Gladwrap for 1 hour may be effective. Local infiltration of anaesthetic is best avoided as it increases the swelling.
The swollen area is gently but firmly compressed within one hand, for a few minutes, to squeeze out the oedema fluid. The glans may then be pushed back and the foreskin returned to the normal position.
If manual reduction fails, consult surgical registrar immediately. Surgical options include needle puncture to release oedema fluid or incision of the tight band of the foreskin.Once reduced, a single episode of paraphimosis is not an indication for circumcision. If the child has significant phimosis then it should be treated as above.

[Asher]

What's that from? About half of them are the same thing in different words (non-retractible), and some of them are very questionable:

Zipper Injury
The tip of the foreskin or other skin (eg scrotum) may become entrapped in the teeth of a zipper. This is painful.

in particular...

Cut and uncut are two versions of the same organ, each one has their own set of quirks.

The difference being, of course, everyone starts out uncut and we go through a surgical operation (with risks) to make them cut.

[SuperSneak]

And, of course, a recent article espousing circumcision as a way to reduce HIV transmission.
The jury is still OUT folks.

Circumcision may reduce HIV transmission

United Press International - June 1, 2002
Ed Susman, UPI Science News


--------------------------------------------------------------------------------
New cellular research suggests performing circumcision might help protect men -- and possibly their partners -- from contracting AIDS, researchers told United Press International.
The research examined laboratory specimens of healthy human foreskin -- the covering of the penis often removed in an operation, usually soon after birth -- and specimens of cervical tissue from women undergoing surgery. They searched for CD4 T-cells, macrophages and Langerhan's cells, all of which are targets for the human immunodeficiency virus, or HIV -- the virus that causes AIDS.

"We determined that the target cells that HIV infect are found in far greater numbers in the foreskin than in the cervix," said Dr. Carlos Estrada, a urologist at Rush-Presbyterian-St. Luke's Medical Center in Chicago. Estrada and colleagues presented a paper on their findings at the recent American Urological Association annual meeting in Orlando, Fla.

"Overall, the inner, mucosal surface of the foreskin had a seven-fold greater susceptibility to HIV infection than did cells in cervical tissue infected under the same conditions," Estrada said. The interactions between the cells were studied in culture dishes in the laboratory.

"The issue here is that epidemiologic data strongly suggests that circumcision protects against HIV," said Dr. John Krieger, professor of urology at the University of Washington at Seattle.

"These authors looked at pediatric and adult foreskins (and) ... found ... that foreskins have a lot of HIV target cells. So the increased risk of HIV infection in uncircumcised men is likely caused by large numbers of target cells in the foreskin. (Therefore circumcision) "is biologically plausible as a way to reduce HIV infection risk."

Estrada suggested reduced infection rates in men due to circumcision also should reduce HIV infections in women.

"There has been a lot of controversy over whether circumcision prevents infection with HIV or is simply a marker of more rigorous religious practices," Estrada told UPI.

"We think that our findings may show that the reason populations in Africa where Islam is practiced have lower HIV infections rates than in areas where circumcision is not practiced may be biological rather than faith-based."

Circumcision is routinely performed after birth in the United States and is required for males by Jewish and Muslim religious laws. Several studies have shown in African nations where Islam is predominant, rates of HIV infection can be one-tenth that of nations where circumcision is not practiced or its practice has been abandoned -- as in some of the nations of southern Africa, where AIDS has reached epidemic proportions.

In Nigeria, for example, where circumcision is routinely performed, United Nations AIDS Programme, or UNAIDS, data suggests the HIV infection rate is about 5 percent of adults. In Botswana, however, where circumcision is not widely practiced, the adult HIV infection rate has approached 40 percent.

Researchers and social commenters have been arguing both sides of this issue for some time. For example, at the 2000 World AIDS Conference, held in Durban, South Africa, some speakers argued the difference in rates has nothing to due with circumcision, but everything to do with religious requirements for general cleanliness and monogamy. Other speakers countered that even in heavily Islamic areas, adherence or non-adherence to religious prohibitions against sex outside of marriage parallels behavior in regions dominated by other faiths.

The new cellular research probably will not resolve the question. Dr. Thomas Brady, adjunct professor of urology at the University of Nevada-Reno, and chairman of the media committee of the AUA, said, "I'm not sure that I buy this explanation that more cells in the foreskin increase the risk of transmission of HIV. Just because there are more cells doesn't mean that there is a greater transmission risk."

Brady told UPI, however, he was not discounting the possibility circumcision could inhibit HIV transmission.

"I think it is far more logical to assume that during intercourse the penis suffers microabrasions and microscopic tears," he said.

In uncircumcized men, fluids that come in contact with the penis during intercourse can be trapped under the foreskin, which may make it easier for the virus to infect men through the organ's microscopic openings, Brady suggested.


020601
UP020601

[Asher]

Originally posted by SuperSneak
And, of course, a recent article espousing circumcision as a way to reduce HIV transmission.
The jury is still OUT folks.

Even if this were true (even though there are just as many studies contradicting it), isn't that what a condom is for...

[SuperSneak]

Originally posted by Asher
What's that from? About half of them are the same thing in different words (non-retractible), and some of them are very questionable:

It's just a simple informational bit from a hospital site: https://www.rch.unimelb.edu.au/clini...ges/penis2.php

I noticed that the risk for bacterial infection of a more than mildly unpleasant type was twice as much for the uncircumsized.

I'm not going to get into this again, and, actually, the last time had nothing to do with the topic, per se.

I think this particular issue is one that will only be iron-clad one way or the other far in the future.
In any case, it is not an easy decision at all and one that should not be taken lightly. Son #2 is coming in April and I haven't decided yet...our last go around didn't help my confidence in the procedure, but as all the evidence seems to be in the unverified stage, I will most likely err on the side of caution in regard to HIV transmission and infections of a more garden variety.

[Asher]

Son #2 is coming in April

Congrats

[SuperSneak]

Thanks...we're naming him Dave.

[Asher]

Really?

[molly bloom]

Originally posted by Boris Godunov


I think male circumcision may be medically necessary on rare occasions (Louis XIV, if I recall correctly, had it done as an adult because sex was somehow very painful for him).

Louis Seize, I believe you mean:

http://www.circumstitions.com/Misc.html

http://www.observer.co.uk/Print/0,3858,4475359,00.html

In Australia even now it is noticeable if you are uncut- it marks you out as a recent arrival from somewhere circumcision is not carried out routinely.

[Ben Kenobi]

Interesting. I don't think I've heard the baptism analogy used in reverse against circumcision, to let the child decide for himself. Very effective argument IMO.

However, that won't work for Jewish people.

Female 'circumcision' wasn't permitted by the Jews, so this doesn't fly with me either.

Male circumcision should be permitted only for religious reasons, where health does not intervene. Hemophilia carriers, as even Jews recognise, should not circumcise their children.

MtG:

What's the solution for poor sanitary conditions? Lop off foreskins?

[tandeetaylor]

To all the people who think that women won't sleep with you if they see your uncircumsized penis: If a woman is looking at your unerect penis, chances are you won't be sleeping with her anyway.

[molly bloom]

As practised in some Koori societies in Australia:

http://www.bmezine.com/news/ritcircs.html

Female circumcision, including removal of the labia minora and majora and radical clitoridectomy has no health benefits, and can result in prolonged illness and death. It may also lead to life long health problems, involving amongst other things, urinary tract infections, pelvic infections, septicaemia, and surgical intervention is sometimes required to allow intercourse.

http://www.nocirc.org/symposia/first/duffy.html

http://www.amnesty.org/ailib/intcam/femgen/fgm1.htm

[Alexander's Horse]

Great - another circumcision thread

I had all my 4 boys circed shortly after birth.

Why did I do it? Because I'm evil.

[Spiffor]

Erm, I thought circumcision was only a religious ritual in Judaism and Islam... Do you Americans actually circumcise just for the heck of it, even without religious obligation ?