What is circumcision?
Circumcision is a surgical procedure that involves partial or complete removal of the foreskin (prepuce) of the penis. The first evidence of circumcision comes from early Egyptian wall paintings that are more than 5000 years old. About one-fifth of men worldwide have been circumcised, mostly for religious and cultural reasons when the procedure is commonly performed shortly after birth or around puberty. Although adults are occasionally circumcised as an act of religious dedication, adult circumcision is most commonly performed for medical reasons.
Reasons for circumcision fall into three broad groups.
- Circumcision for an immediate medical indication.
- Circumcision to prevent future disease.
- Circumcision as an act of religious dedication.
What are the medical conditions that require circumcision?
Non-retractable foreskin in children
Contrary to common belief, the foreskin cannot be pulled back (retracted) in almost all newborn babies. Well-meaning parents do not need to try cleaning under the foreskin until it has become fully retractable of its own accord because attempts to pull back a non-retractable foreskin can result in pain and possibly injury. The small percentage of adults who have a persistently non-retractable foreskin have a slightly increased chance of developing phimosis (see below), but this persistence is not a reason for circumcision.
In this condition, the opening of the foreskin is narrowed, preventing retraction. Provided that the skin of the foreskin is normal and inability to retract it does not cause problems with intercourse or recurrent infections, no action is necessary.
Occasionally, the edge of the foreskin has a white, scarred, inelastic appearance and will not pucker open as it is retracted. Some boys will develop this condition by the time they are 17 years old. Symptoms can include:
- Irritation or bleeding from the edge of the foreskin.
- Stinging or pain on passing urine (dysuria).
- Inability to pass urine (acute or, rarely, chronic urinary retention).
- The changes in the prepuce are known as balanitis xerotica obliterans, which can possibly become cancerous if left untreated. Circumcision is advisable in most cases.
This condition involves redness and swelling of the foreskin, together with a discharge of pus from the space between the foreskin and the glans. Sometimes the whole penis may be swollen and inflamed. Some boys will develop this condition, depending on how the condition is defined. Balanoposthitis is very occasionally the first sign of diabetes. If there is no underlying cause, simple hygiene measures, mild painkillers and the avoidance of tugging the foreskin are the only necessary treatments. Most cases will recover without further intervention. Circumcision is only done for recurrent and troublesome cases.
This condition is caused by forcibly pulling back the foreskin behind the coronal ridge of the glans or head of the penis, without its subsequent replacement. The foreskin then forms a tight tourniquet around the glans, causing severe pain. The condition can sometimes be treated by firmly but gently squeezing the trapped glans until the foreskin can slip over it again. If this is not possible, the paraphimosis needs to be reduced under a general anaesthetic. Circumcision is only very rarely necessary.
Does circumcision prevent future disease?
Prevention of disease is the second most commonly given reason for circumcision after religious reasons, although the evidence that it has any beneficial effect on future health is very poor. The practice is, more likely, rooted in cultural traditions, although western societies may find this an uncomfortable conclusion.
Cancer of the penis is an extremely rare disease and, in the early part of the last century, was almost unheard of in circumcised men. However, there is some evidence that circumcision may only offer protection from penile cancer if done in childhood, and adult surgery may not offer any protection. Poor personal hygiene, smoking and exposure to wart virus (human papilloma virus) increase the risk of developing penile cancer at least as much as being uncircumcised. Circumcised men are more at risk from penile warts than uncircumcised men, and the risk of developing penile cancer is now almost equal in the two groups. Therefore, routine circumcision cannot be recommended to prevent penile cancer.
Sexually transmitted diseases
Sexually transmitted infections that cause ulcers on the genitals (syphilis, chancroid, herpes simplex) are more common in uncircumcised men. However, urethritis or inflammation of the tube that carries urine through the penis (caused by gonorrhoea and non-gonococcal urethritis) is more common in circumcised men, as are penile warts. Yeast infection (caused by candida or thrush) is equally common in circumcised and uncircumcised men, although circumcised men are less likely to have symptoms with this infection so they are more likely to unknowingly pass on thrush to their sexual partners.
Far more effective and reliable methods than circumcision exist to reduce the risk of contracting sexually transmitted diseases, such as the use of condoms and adoption of safer sexual practices. Thus circumcision cannot be recommended to prevent these infections.
Human immunodeficiency virus (HIV) infection
Views conflict on whether circumcision can prevent HIV infection. Circumcision may be appropriate as a routine preventive measure only in regions that have a high rate of HIV infection, such as sub-Saharan Africa. The existing evidence is inadequate to recommend circumcision as an HIV-preventive measure in the UK.
A study in 1947 reported that Jewish women rarely developed cervical cancer and the author attributed this finding to the fact that their sexual partners were circumcised. Further studies over the past 50 years have had contradictory conclusions, with experts enthusiastically championing the case for and against circumcision. The evidence is inadequate to recommend it as a preventive measure against cervical cancer.
Urinary tract infection (UTI)
Since 1987, several studies have suggested that uncircumcised male infants are up to 10 times more likely to contract a UTI. More uncircumcised infants will develop a UTI, compared with circumcised infants. However, a UTI is not usually a great risk to health, so it does not seem reasonable to perform a surgical procedure on infants to reduce the risk of one developing UTI.
Should we avoid circumcision?
The foreskin is not simply a useless piece of skin, to be disposed of without careful thought. It forms the covering of the head (glans) of the penis in men and the clitoris in women. It is very rich in nerves responsible for touch and the movement of the foreskin backwards and forwards over the glans provides some of the pleasurable sensation experienced during sex. Adult males that were circumcised as infants do not usually report sexual problems linked with their circumcision, perhaps because they have never experienced sexual sensation with a foreskin. However, men circumcised as sexually active adults quite frequently complain of sexual problems arising from either reduced or altered penile sensation.
Can circumcision be reversed?
Attempts have been made to restore the foreskin following circumcision since ancient times. There are various surgical and non-surgical techniques to restore and stretch existing foreskin. The book, “Joy of Uncircumcising” is a great resource.