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Globally, an estimated 30% of males have been circumcised, 7% of whom are Muslim. There are an estimated 30,000 ritual circumcisions performed in England each year. The number of operations has fallen from 80% to approximately 56% in the USA in recent years and similar falls have been seen in England and Northern Ireland.
Circumcision of males involves removal of the fold of skin which covers the glans penis. It was performed 15,000 years ago in Egypt and may have developed independently amongst different cultures. Columbus discovered that many New World natives were circumcised. Throughout the ages, cultures have ascribed benefits to circumcision (including, amongst others, hygiene, rite of passage to manhood and cultural identity). However, in the last 20 years it has become more controversial and more scrutinised because of the potential risks to the child's well-being. American physicians are advised to provide appropriate counselling and informed choice before circumcision is undertaken. A rigid ban on circumcision for non-medical reasons is likely to drive the practice underground, leading to an increase in complications.
Indications for circumcision
The most common reason given for circumcision is to fulfil ritual/religious requirements although it is being increasingly performed to prevent the acquisition of HIV in areas where that disease is rife, such as East and Southern Africa. Strict medical reasons for circumcision include:
- Phimosis: when the distal prepuce cannot be retracted over the glans penis, it is known as phimosis. In preschool children it is not unusual for there to be thin adhesions to the glans. This physiological phimosis is quite normal. At age 3 years about 10% of boys are unable to retract the foreskin but, by adolescence, 99% of boys achieve retraction. Severe phimosis is quite rare in young children and can be demonstrated by bulging of the foreskin during micturition. It should be remembered that circumcision is not the only option and preputioplasty can also be performed (this preserves the prepuce). Acquired phimosis occurs because of:
- Paraphimosis: this is the inability to pull the foreskin from the retracted state back over the foreskin. It is a urological emergency which can lead to ischaemia of the glans if left untreated. This can arise, for example, after retraction of the foreskin for catheterisation. If it cannot be reduced, a dorsal incision may be required, followed by circumcision electively.
- Recurrent balanitis: balanitis is infection of the glans (posthitis is infection of the foreskin). Balanitis and posthitis respond to antibiotics and warm baths. Both may be caused by poor hygiene.
- Balanitis xerotica obliterans.
Circumcision has other suggested benefits and indications:
- Recurrent urinary tract infection (UTI). An American meta-analysis reported that uncircumcised males were 23.3% more likely to develop a UTI in their lifetime compared to circumcised males. However, a Cochrane review recommended further research before routine circumcision could be recommended for the prevention of UTIs in all males. Even in children who have complex renal problems, such as uretero-vesicular reflux, the situation is far from clear and decisions have to be taken based on the risks and benefits for individual patients.
- Prevention of penile cancer. A UK meta-analysis reported a strong link between childhood circumcision and a reduction in the subsequent development of invasive penile cancer. This was thought to be more marked where there was a history of phimosis. There was some evidence that circumcision in adulthood was associated with an increased risk of invasive penile cancer. There was no effect on the development of intra-epithelial penile cancer when circumcision was performed at any age.
- Reduction in the risk of sexually transmitted infection (STI). The evidence-base.supporting circumcision for the prevention of syphilis is equivocal. Trials report that circumcision reduces HIV acquision by 53-60%, herpes simplex virus type 2 acquisition by 28-34% and human papillomavirus prevalence by 32-35% in men. Bacterial vaginosis was reduced by 40% and Trichomonas vaginalis infection was reduced by 48% in the female partners of circumcised men.
Assessment prior to circumcision
- Estimate how much foreskin should be removed.
- Exclude hypospadias, epispadias, chordee and other relevant conditions.
In phimosis, circumcision may be avoided by daily cleaning (without forceful retraction) when this is uncomplicated (no urinary obstruction or pain). Topical steroid may be used to separate adhesions between foreskin and glans (applied for four weeks daily).
This should be performed by an experienced person using the correct, sterile equipment in an aseptic environment.
The penis should be anaesthetised with either a nerve block (local or regional anaesthesia) or anaesthetic cream. However, swelling after use of local anaesthetic cream, causing loss of anatomical landmarks has been reported.
General anaesthesia can also be used, particularly in adults. The patient should be given analgesics afterwards (paracetamol or ibuprofen usually or, with adults, oral narcotics). Full recovery requires 4-6 weeks of complete sexual abstinence with loose-fitting briefs and instructions to shower and gently wash around the incision site.
In infants various devices are used. The Gomco® clamp and the Mogen® clamp are useful in infants but not toddlers (increased risk of bleeding). The Plastibell® technique can be used in toddlers up to 10 kg. The Shang Ring® can be used in males of all ages - from neonates to adults. When used in children, adequate analgesia is essential.
Contra-indications to circumcision
Small penis, buried penis, hypospadias, chordee (ventral penile curvature) without hypospadias, deformity of dorsal hood, penile webbing, epispadias, ambiguous genitalia, and bleeding diatheses (relative contra-indication).
Complications of circumcision
There is a higher complication rate in adolescents and adults than in neonates and children.
Minor complications include:
- Local infection
- Meatal stenosis
- Secondary phimosis (especially in babies with a hernia or large hydrocele)
- Adhesions or skin bridge joining the penile shaft and glans
More severe complications include:
- Removal of end of the penis
- Removal of too much foreskin
- Urethrocutaneous fistula
Problems with sexual function have been reported,and a large Belgian study reported that circumcised men had more pain, discomfort or unusual sensations than uncircumcised men.
Further reading & references
- Hargreave T; Male circumcision: towards a World Health Organisation normative practice in resource limited settings. Asian J Androl. 2010 Sep;12(5):628-38. doi: 10.1038/aja.2010.59. Epub 2010 Jul 19.
- Guidelines on Paediatric Urology, European Association of Urology (2011)
- Male Circumcision, World Health Organization, UNAIDS, 2007
- Atkin GK, Butler C, Broadhurst J, et al; Ritual circumcision: no longer a problem for health services in the British Isles. Ann R Coll Surg Engl. 2009 Nov;91(8):693-6. doi: 10.1308/003588409X12486167520957. Epub 2009 Sep 25.
- Collier R; Circumcision indecision: the ongoing saga of the world's most popular surgery. CMAJ. 2011 Nov 22;183(17):1961-2. doi: 10.1503/cmaj.109-4021. Epub 2011 Oct 17.
- Groves H, Bailie A, McCallion W; Childhood circumcision in Northern Ireland: a barometer of the current practice of general paediatric surgery. Ulster Med J. 2010 May;79(2):80-1.
- Robinson JD, Ortega G, Carrol JA, et al; Circumcision in the United States: where are we? J Natl Med Assoc. 2012 Sep-Oct;104(9-10):455-8.
- Paranthaman K, Bagaria J, O'Moore E; The need for commissioning circumcision services for non-therapeutic indications in the NHS: lessons from an incident investigation in Oxford. J Public Health (Oxf). 2011 Jun;33(2):280-3. doi: 10.1093/pubmed/fdq053. Epub 2010 Jul 14.
- Hayashi Y, Kojima Y, Mizuno K, et al; Prepuce: phimosis, paraphimosis, and circumcision. ScientificWorldJournal. 2011 Feb 3;11:289-301. doi: 10.1100/tsw.2011.31.
- Morris BJ, Wiswell TE; Circumcision and Lifetime Risk of Urinary Tract Infection: A Systematic Review and Meta-Analysis. J Urol. 2012 Nov 28. pii: S0022-5347(12)05623-6. doi: 10.1016/j.juro.2012.11.114.
- Jagannath VA, Fedorowicz Z, Sud V, et al; Routine neonatal circumcision for the prevention of urinary tract infections in infancy. Cochrane Database Syst Rev. 2012 Nov 14;11:CD009129. doi: 10.1002/14651858.CD009129.pub2.
- Bader M, McCarthy L; What is the efficacy of circumcision in boys with complex urinary tract abnormalities? Pediatr Nephrol. 2013 Feb 12.
- Larke NL, Thomas SL, dos Santos Silva I, et al; Male circumcision and penile cancer: a systematic review and meta-analysis. Cancer Causes Control. 2011 Aug;22(8):1097-110. doi: 10.1007/s10552-011-9785-9. Epub 2011 Jun 22.
- Weiss HA, Thomas SL, Munabi SK, et al; Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Infect. 2006 Apr;82(2):101-9; discussion 110.
- Tobian AA, Serwadda D, Quinn TC, et al; Male circumcision for the prevention of HSV-2 and HPV infections and syphilis. N Engl J Med. 2009 Mar 26;360(13):1298-309. doi: 10.1056/NEJMoa0802556.
- Tobian AA, Gray RH, Quinn TC; Male circumcision for the prevention of acquisition and transmission of sexually transmitted infections: the case for neonatal circumcision. Arch Pediatr Adolesc Med. 2010 Jan;164(1):78-84. doi: 10.1001/archpediatrics.2009.232.
- Brady-Fryer B, Wiebe N, Lander JA; Pain relief for neonatal circumcision.; Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004217.
- Plank RM, Kubiak DW, Abdullahi RB, et al; Loss of anatomical landmarks with eutectic mixture of local anesthetic cream for neonatal male circumcision. J Pediatr Urol. 2013 Feb;9(1):e86-90. doi: 10.1016/j.jpurol.2012.09.013. Epub 2012 Oct 24.
- Wu X, Wang Y, Zheng J, et al; A Report of 918 Cases of Circumcision With the Shang Ring: Comparison Between Children and Adults. Urology. 2013 Feb 25. pii: S0090-4295(12)01490-2. doi: 10.1016/j.urology.2012.11.046.
- Weiss HA, Larke N, Halperin D, et al; Complications of circumcision in male neonates, infants and children: a systematic review. BMC Urol. 2010 Feb 16;10:2. doi: 10.1186/1471-2490-10-2.
- Bronselaer GA, Schober JM, Meyer-Bahlburg HF, et al; Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int. 2013 Feb 4. doi: 10.1111/j.1464-410X.2012.11761.x.
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Dr Richard Draper
Dr Laurence Knott
Dr Hayley Willacy