Pediatric Surgery, AlSadik Hospital, Qatif, Saudi Arabia
Male circumcision is derived from Latin circumcidere, meaning “to cut around”.
It is defined as the surgical removal of the foreskin (prepuce) from the human penis (Fig. 22.1).
A clinical photograph showing an uncircumcised infant
The origin of male circumcision is not known with certainty.
The oldest documentary evidence for circumcision comes from ancient Egypt.
It is part of religious law in Judaism and is an established practice in Islam, Coptic Christianity and the Ethiopian Orthodox Church.
The practice and frequency of circumcision is different worldwide.
Circumcision is one of the world’s most widely performed procedures.
The frequency of circumcision varies worldwide depending on geographic location, religious affiliation, and socioeconomic classification.
Approximately one-third of males worldwide are circumcised, most often for religious or cultural reasons.
The procedure is most prevalent in the Muslim world and Israel (where it is near-universal as a religious obligation), the United States and parts of Southeast Asia and Africa.
Almost 70 % of circumcised children are Muslim.
Circumcision is relatively rare in Europe, Latin America, parts of Southern Africa and most of Asia.
Circumcision is most prevalent in:
The Muslim world
The United States of America
Parts of Southeast Asia and Africa
Circumcision is relatively rare in Europe, Latin America, parts of Southern Africa and Oceania and most of Asia.
Non-religious circumcision in Asia, outside of the Republic of Korea and the Philippines, is fairly rare.
The prevalence of circumcision is generally low (<20 %) across Europe.
The estimated prevalence of circumcision for individual countries is as follows:
Taiwan 9 %
Australia 58.7 %
The United States 75 %
Canada 30 %
In Africa, the prevalence varies from less than 20 % in some southern African countries to near universal in North and West Africa.
In the United States of America, neonatal circumcision rates are different among racial and ethnic groups:
81 % in whites
65 % in African-Americans
54 % in Hispanics
Circumcision is performed by general practitioners, family physicians, general surgeons, urologist, pediatric surgeons, pediatric urologist, plastic surgeons, pediatricians and obstetricians.
In the United States of America, approximately 70 % of obstetricians, 60 % of family practitioners, and 35 % of pediatricians practice newborn circumcision.
In some countries, circumcision is also performed by nurses, midwives and non-professional not well trained persons.
The procedure is most often performed on neonates and children for religious and cultural reasons.
In other cases, circumcision is performed to treat or prevent complications. These include (Figs. 22.2 and 22.3):
A clinical photograph of a child following formal surgical circumcision
A clinical photograph showing an infant following plastibel circumcision
Pathological phimosis and paraphimosis
Chronic urinary tract infections (UTIs)
Part of the corrective treatment of hypospadias, epispadias and chordee and ambiguous genitalia.
Circumcision is associated with reduced rates of HPV related cancer and risk of both UTIs and penile cancer.
It must be emphasized that circumcision does not appear to have a negative impact on sexual function.
It was found that the benefits of circumcision outweigh the risks.
This was supported by the fact that “Over their lifetime, half of uncircumcised males will require treatment for a medical condition associated with retention of the foreskin.”
Others consider elective neonatal and child circumcision as having no benefit and significant risks to having a modest health benefit that outweighs small risks.
Routine circumcision is not recommended by many medical organizations.
The World Health Organization (WHO) recommends circumcision for parts of Africa with high rates of HIV as part of a comprehensive HIV program. Evidence supports that male circumcision reduces the risk of HIV infection among heterosexual men.
There are several techniques used in neonatal circumcision.
The three most common devices used to date are:
The Gomco clamp (67 %)
The Plastibel device (19 %)
The Mogen clamp (10 %).
Both the Gomco clamp and the Mogen clamp are excellent instruments for infants but should not be used in toddlers who weigh more than 5 kg because of an increased risk of bleeding.
Cosmetic results are excellent with any of these devices if they are used correctly.
The bone cutter is rarely used now.
Plastibel circumcision can be used safely in children up to 10 kg under local anesthesia.
Plastibel circumcision induces tissue necrosis by means of suture compression of the foreskin over a plastic ring that protects the glans. The skin sloughs off in 5–7 days, and the ring separates spontaneously.
Plastibel circumcision is not without complications which include:
Failure of the plastibel to fall and needs to be removed manually or cut
Migration of the plastibel backward to the shaft and the plastibel needs to be cut
The use of improper size of plastibel can lead to incomplete circumcision.
Circumcision is not without complications and have been reported to have a median complication rate of 1.5 % for newborns and 6 % for older children.
These complication rates are higher when the procedure is performed by an inexperienced doctor. These complications include:
Removal of either too much or too little foreskin
A more serious complication is cutting part or whole glans penis
Iatrogenic hypospadias (urethral fistula)
22.2 Anatomy and Pathophysiology
The prepuce (foreskin) is formed as a result of folding of the penile skin on itself at the level of the corona.
This folded foreskin covers the glans penis.
The corona is the grove that separate the shaft of the penis from the glans.
The glans is covered with smooth hairless skin.
The subcutaneous connective tissue of the penis and scrotum has a distinct layer with abundant smooth muscle called the dartos fascia.
This layer continues into the perineum and fuses with the superficial perineal (Colle’s) fascia.
In the penis, the dartos fascia is loosely attached to the skin and deep penile (Buck’s) fascia and contains the superficial arteries, veins, and nerves of the penis.
The prepuce that covers the glans penis, is lined up by two layers, an external keratinized layer and an internal mucosal layer.
This creates a pouch between these two linings.
The pouch thus created can collect desquamated epithelial cells forming the so-called keratin pearls in infants and toddlers.
In adolescence, cellular debris and local secretions collect in the form of smegma if the penis is not cleaned regularly.
These secretions of the prepuce provides protection to the glans from dryness and keratinization.
The nerve supply of the prepuce is from the dorsal nerve of the penis and branches of the perineal nerve. The autonomic nerve supply is primarily from the pelvic plexus.
Groups that oppose neonatal circumcision argue that:
The foreskin has specialized nerve endings that enhance sexual pleasure.
The foreskin has important functions, including natural protection of the glans penis.
Permanent externalization of the glans penis results in desensitization due to keratinization of the glans that buries nerve endings deep into this structure.
Smegma is formed by desquamated epithelial cells trapped between the glans penis and foreskin through a natural process that aids in the normal separation of the glans from the foreskin. It appear as a white, cheese like substance (smegma) and it is considered a normal finding that is not indicative of infection.
22.3 History of Circumcision
Circumcision is the world’s oldest surgical procedure.
The origins of circumcision is not well known.
Some have suggested that this procedure originated in Egypt some 15,000 years ago and that its practice later spread throughout the world during prehistoric human migrations.
This was supported by the findings of Egyptian mummies and wall carvings discovered in the nineteenth century documenting some of the earliest records of circumcision dating this procedure to at least 6,000 years BC.
However, other authors believe that circumcision developed independently in different cultures.
Columbus on his arrival to the New World found that many of the natives were already circumcised.
In the lands south and east of the Mediterranean, starting with Sudan and Ethiopia, the procedure was practiced by the ancient Egyptians and the Semites, and then by the Jews and Muslims, with whom the practice travelled to and was adopted by the Bantu Africans.
In Oceania, circumcision is practiced by the Australian Aborigines and Polynesians.
Evidence suggests that circumcision was practiced in the Arabian Peninsula by the fourth millennium BCE, when the Sumerians and the Semites moved into the area that is modern-day Iraq.
Many cultures have historically used circumcision:
For hygienic reasons
As a rite of passage to manhood
As a mark of cultural identity
As a ceremonial offering to the gods
Ritual circumcisions in Middle Eastern cultures have been practiced for at least 3,000 years.
Late in the nineteenth century, this ancient ritual evolved into routine medical practice influenced by reports that associated it with miraculous cures for hernias, paralysis, epilepsy, insanity, masturbation, headache, strabismus, rectal prolapse, hydrocephalus, clubfoot, asthma, enuresis, and gout.
Circumcision is commonly practiced in the Jewish and Islamic faiths.
Circumcision is very important to most branches of Judaism, with over 90 % of adherents having the procedure performed as a religious obligation.
In addition to proposing that circumcision was taken up by the Israelites purely as a religious mandate, scholars have suggested that Judaism’s patriarchs and their followers adopted circumcision to make penile hygiene easier in hot, sandy climates; as a rite of passage into adulthood; or as a form of blood sacrifice
Jewish circumcision is part of the brit milah ritual, to be performed by a specialist ritual circumciser (a mohel) on the eighth day of a newborn son’s life (with certain exceptions for poor health).
Jewish law requires that the circumcision leave the glans bare when the penis is flaccid.
Circumcision (called khitan) is practiced nearly universally by Muslim males.
Although it is not explicitly mentioned in the Quran, circumcision is considered essential to Islam, and it is nearly universally performed among Muslims.
Circumcision is a tradition established by Islam’s prophet Muhammad directly, and so its practice is considered a Sunnah (prophet’s tradition) and is very important in Islam.
The practice of circumcision spread across the Middle East, North Africa and Southern Europe with Islam.
There is no agreement across the many Islamic communities about the age at which circumcision should be performed.
It may be done from soon after birth up to about age 15; most often it is performed at around 6–7 years of age.
The timing can correspond with the boy’s completion of his recitation of the whole Quran, with a coming-of-age event such as taking on the responsibility of daily prayer.
Circumcision is considered a major event and usually celebrated with an associated family or community.
Christianity does not require circumcision; Christianity does not forbid it either.
The Catholic Church currently maintains a neutral position on the practice of non-religious circumcision, although in 1442 it banned the practice of religious circumcision.
Coptic Christians practice circumcision as a rite of passage.
The Ethiopian Orthodox Church calls for circumcision, with near-universal prevalence among Orthodox men in Ethiopia.
In South Africa, some Christian churches disapprove of the practice, while others require it of their members.
In the Philippines, circumcision known as “tuli” is sometimes viewed as a rite of passage. About 93 % of Filipino men are circumcised.
Certain African cultural groups, such as the Yoruba and Igbo of Nigeria, customarily circumcise their infant sons.
The procedure is also practiced by some cultural groups or individual family lines in the Sudan, Zaire, Uganda and in southern Africa.
For some of these groups, circumcision appears to be purely cultural, done with no particular religious significance or intention to distinguish members of a group.
For others, circumcision might be done for purification, or it may be interpreted as a mark of subjugation.
Among these groups, even when circumcision is done for reasons of tradition, it is often done in hospitals.
It is not clear how many deaths and injuries result from traditional circumcisions which occur outside of hospitals.
Routine neonatal circumcision has become a controversial issue in the past two decades as many of the previously accepted medical indications have come under considerable scrutiny.
The first medical doctor to advocate for the adoption of circumcision, was the eminent English physician, Jonathan Hutchinson. In 1855, he published a study in which he compared the rate of contraction of venereal disease amongst the gentile and Jewish population of London. His study appeared to demonstrate that circumcised men were significantly less vulnerable to such disease.
Circumcision was also employed as a means of discouraging masturbation. Circumcision was also recommended to prevent masturbation.
In America, one of the first modern physicians to advocate circumcision was Lewis Sayre, a founder of the American Medical Association. In 1870, Sayre began using circumcision to prevent or as a cure for several array of medical problems and social ills. As a result of his publications and promotion, in both America and Great Britain, infant circumcision was near universally recommended.
In 1949, Douglas Gairdner showed that the risks of circumcision outweighed the known benefits.
In the 1970s, national medical associations in Australia and Canada issued recommendations against routine infant circumcision.
The United States made similar statements in the 1970s, but stopped short of recommending against it—simply stating that it has no medical benefit.
Subsequently, they have amended their policy statements several times. The current recommendation being that the benefits outweigh the risks, but they do not recommend it routinely.
Because neonatal circumcision poses both potential benefits and risks and because the procedure is not necessary for a child’s well-being, the American Academy of Pediatrics (AAP) Task Force on Circumcision in its latest policy statement in 1999 affirms that “existing scientific evidence demonstrates potential benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision.” As a consequence, parents should be appropriately counseled so that they can make an informed choice and decide whether a circumcision is in the best interest of their child.
Worldwide, most legal jurisdictions do not have specific laws concerning the circumcision of males.
Infant circumcision is considered legal under the existing laws in countries such as Australia, Canada, New Zealand, the United Kingdom, and the United States.
A few countries have passed legislation on the procedure: Germany allows non-therapeutic circumcision under certain conditions, while routine neonatal circumcision is illegal in Finland, non-religious routine circumcision is illegal in South Africa and Sweden.
In the 9th edition of the Encyclopedia Britannica published in 1876, discusses the practice of circumcision as a religious rite among Jews, Muslims, the ancient Egyptians and tribal peoples in various parts of the world.
In 1910 the Encyclopedia Britannica changed the statement regarding circumcision: “This surgical operation, which is commonly prescribed for purely medical reasons, is also an initiation or religious ceremony among Jews and Muslims”.
An association between circumcision and reduced heterosexual HIV infection rates was suggested in 1986. To establish this, trials took place in South Africa, Kenya and Uganda and showed the circumcised group had a lower rate of HIV contraction than the control group.
Subsequently, the World Health Organization promoted circumcision in high-risk populations as part of an overall program to reduce the spread of HIV.
The Male Circumcision Clearinghouse website was formed in 2009 by WHO, UNAIDS, FHI and AVAC to provide current evidence-based guidance, information and resources to support the delivery of safe male circumcision services in countries that choose to scale up the procedure as one component of comprehensive HIV prevention services.
22.4 Pain Management
It is well known that circumcision causes pain, and for neonates this pain may interfere with mother-infant interaction or cause other behavioral changes.
To avoid this, pre and post circumcision analgesia is advocated.
There are several methods to achieve this.
Paracetamol orally or suppository
Topical analgesic creams (EMLA cream which is a mixture of prilocaine and lidocaine)
Localized or regional nerve blocks (ring block and dorsal penile nerve block)
The ring block and dorsal penile nerve block (DPNB) are the most effective at reducing pain.
The ring block may be more effective than the DPNB.
The ring block and dorsal penile nerve block are more effective than EMLA cream.
Non-pharmacological methods to reduce circumcision pain include:
The use of a comfortable, padded chair
The use of a sucrose or non-sucrose pacifier
The American Academy of Pediatrics (AAP) states that such methods are insufficient alone and should be used to supplement more effective techniques.
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