Overview of Circumcision
Circumcision is a surgical procedure that removes the skin covering the head of the penis, known as the foreskin. This operation is usually performed on newborn boys. It has been a tradition in many cultures and religions for thousands of years, often marking a boy’s transition to adulthood and improving personal hygiene. In modern times, however, the practice is under scrutiny due to changing cultural norms and new research findings. Concerns about female circumcision have also sparked debates about the procedure for boys. Therefore, doctors should provide parents and caregivers with clear, unbiased information about the potential medical benefits, risks, and complications of circumcision. It’s important to underline that the decision to circumcise is totally up to the parents.
In the United States, many parents choose circumcision for their newborn sons for various reasons. About half of them believe it improves hygiene and offers medical benefits. Around 30% choose it due to personal or family preference. And around 15% cite religious requirements. Some parents, however, decide against the procedure because they feel it’s not necessary, they’re worried about the pain it could cause their child, or the father himself is not circumcised. About eight out of ten men in the United States are circumcised. But globally, the figure is closer to four out of ten, with significant variation across different regions and cultures. In fact, 70% of all circumcisions worldwide are performed for religious reasons.
Circumcision is least common in places like Armenia, Iceland, the Caribbean, and Central and South America. On the other hand, it’s very prevalent in Islamic countries and Israel. Interestingly, circumcision has been found to reduce the risk of HIV infection by up to 60% and is recommended by the World Health Organization for countries with high rates of HIV infection.
Anatomy and Physiology of Circumcision
The development of the foreskin in a male fetus begins around 12 weeks into pregnancy and is usually completed by 20 weeks. The penis is made up of various parts; the top side (dorsal surface), the underside (ventral surface), the base, shaft, and head or tip of the penis (glans).
On the dorsal surface, or top side of the penis, there are blood vessels (veins and arteries) and nerves. These nerves are numbed during a procedure called a dorsal nerve block. This is often done to manage pain during a circumcision. However, because some sensory nerves come from another nerve (the perineal nerve), another nerve block on the underside of the penis might be needed to numb the foreskin around the frenulum. This is a small ridge or fold of skin that helps to anchor the foreskin over the glans of the penis.
The penis consists of several major parts such as the urethra, two corpora cavernosa, a corpus spongiosum, the glans, and foreskin.
The two corpora cavernosa are located under the top side of the penis, and they fill with blood to create an erection. The corpus spongiosum is located under these two chambers and contains the urethra. The urethra is a tube that starts at the bladder, goes through the prostate gland, and runs along the length of the penis to end at the glans. The foreskin covers the entire penile head and is usually removed during a procedure known as circumcision to expose the glans.
About one-third of the total length of the penis is made up by the foreskin. It consists of three layers which are:
The inner foreskin which is made up of a particular type of cell (squamous mucous membrane.) The middle layer, or dartos, is composed of loose connective tissue with bundles of smooth muscle. The outer foreskin layer is made from keratinized squamous epithelium, which is a type of skin cell.
Why do People Need Circumcision
Circumcision is a medical procedure that involves the removal of the foreskin from the penis. It may be suggested by a doctor for several reasons including, but not limited to, phimosis (a condition where the foreskin can’t be pulled back from the head of the penis), paraphimosis (swelling of the foreskin that causes it to become stuck after being pulled back), balanoposthitis (an inflammation of the head of the penis and foreskin), balanitis (an inflammation of the head of the penis), early signs of skin cancer on the foreskin, a skin condition called Zoon balanitis, a need for long-term use of a tube to empty the bladder (intermittent catheterization), and frequent urinary tract infections. In adults, one of the most common reasons for circumcision is phimosis that causes problems with urinating and discomfort during sexual activity.
Choosing to have a circumcision may be recommended in areas where there are high rates of HIV, certain sexually transmitted diseases such as syphilis and chancroid, and infection with human papillomavirus (HPV). However, it should be noted that circumcision doesn’t protect against all sexually transmitted infections – for example, Chlamydia, Gonorrhea, or Trichomonas. In addition to these medical reasons, circumcision is sometimes done for personal, cultural, or religious reasons – it is a common practice in the Jewish, Druze, and Islam faiths.
When a Person Should Avoid Circumcision
There are several situations in which a baby boy might not be able to have a circumcision. These include if the baby is not healthy, if the baby’s genitals are structured differently, or if the baby has a blood disorder that might make healing difficult. It’s crucial that the baby’s overall health is looked at before deciding on this procedure. Circumcision does not need to be done immediately and can be put off if necessary.
Before the circumcision, the doctor should examine the baby boy’s penis for any abnormalities. Some issues might include a particularly small penis, abnormal swelling, complications with the foreskin, the penis being positioned differently, or any differences in the baby’s genitals. A baby with any uncorrected bleeding problem or if there’s a family history of blood disorders, should get the circumcision in a healthcare facility which provides specialized care.
The circumcision should not take place within the first 12 hours after birth. If the baby has any current infections, is unwell, in the intensive care unit, experiencing neonatal jaundice, or hasn’t started urinating yet, these are all reasons for putting off the circumcision.
Who is needed to perform Circumcision?
Circumcision is not always done by medical professionals. Because of this, there might be differences in how pain is managed, hygiene standards are maintained, surgical techniques are used, and results are evaluated when circumcisions are done outside of a regular hospital or clinic. Those planning on having a circumcision done, and their families, can meet and talk to the person who will be performing it. The surgeon should be able to share what they usually expect to see after the surgery and discuss the pros and cons of the procedure.
Preparing for Circumcision
To ensure a comfortable experience during a circumcision procedure, managing pain is very important. The person performing the operation will take measures to ensure that you don’t feel pain. For infants, a mix of sweet oral solutions, numbing creams and local painkillers often work well. The creams, like LMX-4 and EMLA cream, and injected medicines like lidocaine or bupivacaine are usually used. While for adults, lidocaine or a mixture of lidocaine and bupivacaine is applied as anesthesia.
The pain relief methods for newborns aren’t always the same. Simple options like swaddling or sucrose pacifiers aren’t enough. Numbing creams can work, but they need at least half an hour to take effect. They can also cause skin issues in premature and low-weight babies. So, it’s generally best to use a method called penile nerve blocks for these babies. This procedure, where medicines are injected around the nerves in the penis, is more effective than using creams. A combination of numbing cream and an injection can provide even better relief.
As children grow older, they might need to be put to sleep (general anesthesia) for the procedure. For adults, local anesthesia with a sedative, regional anesthesia, or general anesthesia are options. The penis’s sensitivity mainly comes from nerve roots branching from the pudendal nerve. These branches form the nerves at the backside of the penis. Also, the frenulum (the part of the penis underneath the head) receives sensation from a different nerve, the perineal nerve. Hence, this area may retain some sensation even after numbing the back of the penis.
A ring block or penile nerve block means that the anesthesia has to be injected into two separate places around the base of the penis. This creates a complete ring of numbing effect. These medicines go just beneath a layer of tissue, lateral to the penile arteries. But this method might not numb the frenulum completely, because of its different nerve supply. It can be avoided by a partial nerve block at the base of the penis.
How is Circumcision performed
There are various methods for carrying out a circumcision, which is the surgical removal of the foreskin, the skin covering the end of the penis. The aim of all these methods is to remove the inner and outer skin of the foreskin without causing damage to the sensitive tip of the penis (the glans) and the tube carrying urine out of the body (the urethra).
Circumcision for Newborns and Babies
Circumcision is a quick procedure when performed on newborns, taking only a few minutes. However, it’s a bit more complicated when it’s done in adults. How long healing takes and how successful the procedure is, depends on the method used and the skill and experience of the surgeon. We’ll discuss the three most commonly used methods for performing circumcision on newborns.
Bell, Ring, or Clamp Techniques for Babies and Newborns
Several devices that use a clamp, cover, or shield over the glans that produce similar results. The choice of device is based on what is available and the surgeon’s preference and experience.
Before starting any of these procedures, numbing cream should be applied at least 30 minutes in advance, a local anesthetic can be injected (this is optional), and an antiseptic (a substance that prevents infection) should be applied.
Disposable Plastic Bell with Delayed Sloughing
This simple technique utilizes a plastic bell shield which is put over the glans. A thread or band is tied over the bell and after several days the foreskin falls off naturally. This procedure has a low risk of bleeding but there have been cases where the ring has been retained. This technique is also used on a larger scale in countries with high rates of HIV, with a usage rate of about 20%.
Gomco Clamp
This technique, which is used in about 70% of circumcisions, was introduced in 1950. It involves pulling the foreskin through an opening in a heavy base and clamping it. This method can be challenging if the device is not properly aligned or does not fit together correctly. In such a case, a different technique should be used or the procedure should be postponed.
With all these techniques, it’s important to make sure the glans is not damaged, and that the clamp is not inside the urethra. While these procedures are typically performed on babies up to 3 months old or weighing up to 5.5 kg, they can also be safely used for older, heavier individuals.
Possible Complications of Circumcision
Circumcision, or the removal of the foreskin from the penis, doesn’t reduce the chance of getting sexually transmitted infections like gonorrhea, chlamydia, or syphilis. But in areas with a high rate of HIV, such as some places in Africa, being circumcised can cut a heterosexual man’s risk of getting HIV by about 40% to 60%. Circumcision also seems to lower your chances of getting HPV (a virus that can cause genital warts and cancer) and genital herpes.
However, circumcision has risks too. Some of these—like pain, bleeding, or infection—are pretty common with any surgery. But sometimes the penis can get hurt during the surgery, which can cause problems like trouble urinating (pee comes out too slowly or not at all) or unwanted adhesions (when the skin grows together). Sometimes the penis looks shorter because not enough skin was left, or the penis can get trapped under skin, which might need another surgery to fix.
Sometimes people can have problems with bleeding if they have a blood disorder they didn’t know about, like hemophilia. Other issues can include an overly sensitive tip of the penis, complications from an illness that causes hardening and thinning of the skin, or a poorly healed wound which may result in an unsatisfactory appearance. In very rare instances, a mistake could result in part or all of the penis being removed, or a severe infection could spread rapidly causing damage to tissues (necrotizing fasciitis). Deaths from circumcision are extremely rare but have been reported.
To minimize some of these risks and complications, doctors recommend various treatments like applying petroleum jelly to the tip of the penis soon after circumcision, using steroid creams for some conditions, or doing regular cleaning routines. It’s also important to pay careful attention during the operation to avoid problems. If there are any problems with wound healing or if too much skin was removed, it might be necessary to pay extra attention to the healing process. In all cases, it’s important to discuss with your doctor the potential benefits and risks before proceeding with the circumcision.
What Else Should I Know About Circumcision?
The topic of newborn circumcision is often influenced by family views due to religious or cultural reasons. In the United States, more than half of newborn boys are circumcised, although the practice has decreased slightly over time. For some families, circumcision is a traditional practice, while in others it might be advised against for medical reasons.
Circumcision can have several benefits, including reducing the risk of certain types of infections and conditions affecting the penis, such as balanitis, inflammation, phimosis, and penile cancer. Circumcision also can decrease the chance of getting sexually transmitted diseases like syphilis, HIV and HPV. Men who are circumcised have a 20% lower risk of urinary tract infections over their lifetime and improved genital cleanliness. Female partners of circumcised men also have a reduced risk of getting cervical cancer and sexually transmitted infections. Additionally, there’s no proven effect on future sexual experience or sensitivity.
Local anesthetics can minimize any pain from the procedure without requiring a regional or general anesthetic. The occurrence of complications is low if the circumcision is correctly done. The procedure also eliminates the chance of penile cancer, a rare but potentially lethal disease.
Despite these benefits, there are some drawbacks to consider. Circumcision can sometimes lead to complications and it doesn’t protect against all sexually transmitted infections. The procedure could cause significant pain to the baby, which, in some cases, may have long-lasting psychological impacts. Some argue that removing the foreskin is unnatural and impedes its role in protecting the tip of the penis during early childhood. Others believe circumcision can negatively affect future sexual enjoyment. The procedure is permanent and cannot be reversed. In rare cases, serious complications like infections and excessive bleeding can occur.
Different medical professionals may have diverse views on circumcising newborns. Urologists often recommend the procedure to avoid potential complications in adulthood, while pediatricians and OB-GYN clinicians might be hesitant due to the possible immediate side effects. A recent analysis concluded that the medical benefits of circumcision vastly outweigh the risks, but the topic is still controversial.
Ultimately, the decision is based on the family’s preferences, unless there are medical reasons not to do the procedure. It’s important for healthcare professionals to provide factual information to the family about the pros and cons of circumcision, without imposing their personal views, and allow the family to make an informed decision.