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Circumcision

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Circumcision



Introduction 

Male circumcision is the surgical removal of the foreskin. The foreskin is the hood of skin covering the end of the penis, which can be gently pulled back.

Circumcision may be performed for:


religious reasons – circumcision is a common practice in the Jewish and Islamic faiths, and is also practised by many African communities as a tribal or ethnic tradition

medical reasons, although alternative treatments are usually preferred to circumcision


This article focuses on the medical aspects of circumcision.

Routine circumcision

During the 19th century, many medical practitioners believed that being circumcised was more hygienic than not being circumcised.

As a result, the routine medical circumcision of all boys, regardless of religious faith, became a widespread practice in England. However, routine male circumcision gradually became less common as many members of the medical community began to argue that it had no real medical benefit in the vast majority of cases.

Routine circumcision may offer a number of potential benefits, such as reducing the risk of some types of bacterial or viral infections. However, most healthcare professionals now agree that the risks associated with routine circumcision, such as infection and excessive bleeding, outweigh any potential benefits.

The majority of clinical commissioning groups (CCGs) do not fund routine circumcision or circumcision that is carried out for religious reasons.

In such cases, circumcision is usually regarded as a "treatment of last resort", when all other treatment options have failed.

The decision is based on priorities that relate to its own local population.

In rare cases, circumcision may be considered for the following health conditions:


paraphimosis – a condition where the foreskin gets trapped under the tip of the penis

balanitis xerotica obliterans – an uncommon condition causing hardening and inflammation of the tip of the penis


However, these conditions are extremely rare in children and other treatments are often preferred.

Circumcision may also be considered in some cases with the following health conditions:


severe cases of phimosis – a tight foreskin that can't be retracted 

recurrent balanitis – inflammation of the tip of the penis and foreskin


 

How circumcision is performed

Circumcision for medical reasons is usually carried out on a day-patient basis. This means that you will not have to stay overnight in hospital.

Older children and adults who are circumcised are usually given a general anaesthetic, where they are put to sleep.

The circumcision procedure is relatively simple. The foreskin is removed with a scalpel, scissors or a surgical clamp. Any bleeding is either cauterised (closed using heat) or the remaining edges of skin are stitched together using dissolvable stitches.

After circumcision, there may be some pain and swelling, and the penis will be easily irritated until it heals. The healing process can take up to four to six weeks.

If there are signs of any bleeding or infection after a circumcision, speak to your GP. Complications are rare when circumcision is performed for medical reasons, but there are some risks of circumcision that should be considered.



Most health professionals in England would argue that there are no medical reasons why a baby boy should be circumcised 

 

Female circumcision

Female circumcision has no medical benefits and is illegal under the Female Genital Mutilation Act (2003).



Pregnancy and baby

All you need to know about pregnancy, birth and looking after a baby, including feeding and trying to get pregnant

 

Advantages and disadvantages of circumcision 

There are several potential advantages and disadvantages associated with circumcising boys shortly after they are born.

For example:


Circumcision may reduce the risk of developing a urinary tract infection (UTI), such as a bladder infection.

Circumcision may reduce the risk of getting some types of sexually transmitted infections, such as HIV and genital herpes.

Circumcision may reduce the risk of female partners developing some types of sexually transmitted infections, such as bacterial vaginosis and trichomoniasis.

Circumcision may reduce the risk of developing cancer of the penis.


However, there are much more effective and less invasive ways of preventing these conditions. For example, practising good hygiene to prevent UTIs, or using a condom to prevent STIs.

Most healthcare professionals maintain that the potential benefits of circumcision are not strong enough to justify routine childhood circumcision. Critics of circumcision argue that it has disadvantages, such as:


Reduced sensitivity – an uncircumcised penis is more sensitive than a circumcised penis, meaning that circumcised men may experience less pleasure during sex.

Potential complications of circumcision – these include excessive bleeding, post-operative infection and, in rare cases, injury to the urethra. These complications are thought to outweigh any potential benefits.


Critics have also argued that routinely circumcising baby boys on medical grounds violates the principle of consent to treatment. They say that circumcision should only be performed when a boy is old enough to make an informed decision about whether he wishes to be circumcised.

 

When circumcision may be necessary 

This section describes only the medical reasons when circumcision may be necessary. It is outside the scope of this article to discuss religious or cultural reasons for circumcision.

Conditions that may benefit from circumcision

 

Paraphimosis

Paraphimosis is a medical emergency. The foreskin is pulled back underneath the tip of the penis, becomes trapped and cannot be returned to its original position.

Paraphimosis sometimes happens as a complication of a medical procedure that involves pushing back the foreskin for a prolonged period of time. Such procedures include:


an examination of the penis 

a cystoscopy – a medical procedure where a thin, flexible tube (catheter) with a camera on the end is inserted through the penis and up into the bladder

urinary catheterisation – a procedure in which a catheter is inserted through the penis and up into the bladder to drain urine out of the bladder


Paraphimosis causes a band of swelling to develop around the penis, which can block the blood supply. If paraphimosis is not treated, the lack of blood supply will mean that the tissue of the penis will begin to die.

In most cases, paraphimosis can be treated using medication to reduce the swelling, or minimally invasive surgery to return the foreskin to its original position.

Paraphimosis is extremely rare in children and other treatments are preferred. Circumcision is usually only required in adults in rare cases when medication and surgery fail. Occasionally, circumcision may be recommended if someone has repeated episodes of paraphimosis.

 

Balanitis

Balanitis is inflammation of the foreskin, usually caused by a bacterial infection.

Symptoms of balanitis include:


pain when urinating

a discharge of pus from the penis

inflammation of the shaft of the penis


Balanitis can be successfully treated using antibiotics. Most people do not have further infections. Circumcision is usually recommended only in adults in rare cases where someone has repeated infections (recurrent balanitis).

 

Urinary tract infections

A urinary tract infection (UTI) is an infection of the urinary system. It is estimated that 1 in 50 boys develop a UTI between their first and second birthdays. Around 1 in 2,000 men develop a UTI every year.

Research has found that circumcised boys are around 10 times less likely to catch a UTI than uncircumcised boys. This is because many UTIs are thought to be caused by bacteria that gather inside the foreskin before spreading to the urinary system.

However, most UTIs are mild and do not cause serious damage. Circumcision is usually only recommended if a boy has a risk factor that increases the likelihood of repeated UTIs. Repeated UTIs can cause kidney damage.

An example of a pre-existing risk factor is a birth defect that causes urine to leak back up into the kidney. This carries the risk of bacteria spreading from the foreskin, through the urine, and infecting the kidney. In such circumstances, circumcision may be recommended.


urinary tract infections in children

urinary tract infections in adults


Sexually transmitted infections

Circumcision is thought to reduce the risk of catching some types of sexually transmitted infections (STIs). These are:


HIV

human papilloma virus (HPV)

genital herpes

syphilis

chancroid – an uncommon STI in England that causes painful sores on the genitals


Circumcision has also been shown to reduce the chance of certain conditions occurring in female partners, including:


bacterial vaginosis

trichonomoniasis

cervical cancer


Research in Africa found that heterosexual circumcised men are 38-66% less likely to contract HIV than uncircumcised men.

It is thought that the foreskin contains special cells that attract the cells of the HIV virus. This means that uncircumcised men who have vaginal sex with an HIV positive woman are more likely to develop the infection.

However, it is still unclear whether circumcision has the same protective effect for homosexual men who have unprotected anal sex.

Circumcision is thought to reduce the risk of a man getting syphilis and chancroid because:


the foreskin may provide a warm, moist environment that allows the syphilis and chancroid bacteria to grow and multiply

the foreskin often sustains tiny cuts (micro-abrasions) during sexual intercourse, which allow the bacteria to pass into the bloodstream


It is estimated that uncircumcised men are:


twice as likely to get syphilis

10 times as likely to get chancroid


However, circumcision is nowhere near as effective as condoms in preventing STIs. If used correctly, condoms are 98% effective in preventing STIs.

 

Cancer of the penis

Research has shown that men who are circumcised in childhood are three to four times less likely to develop penile cancer than men who are uncircumcised. This is because many cases of penile cancer develop in the foreskin.

However, cancer of the penis is very rare. On average, 550 new cases are diagnosed each year in the UK. It would, therefore, be very difficult to justify routine circumcision as a method for preventing penile cancer.

However, in some rare cases a person may be more at risk, for example if they have a family history of penile cancer or a weakened immune system. In such cases, circumcision is recommended as a preventative measure.

 

Conditions that require circumcision

Balanitis xerotica obliterans (BXO) is a skin condition that can only be cured with circumcision. However, the condition is rare in young children and usually affects children over nine years old and adults.

BXO can cause hardening and inflammation of the penis, usually affecting the foreskin and tip of the penis. It causes symptoms such as:


difficulties passing urine

pain when passing urine

itchiness and soreness of the penis


In cases of BXO that primarily affect the foreskin, circumcision is usually the most effective treatment, and often results in a complete cure. In some cases, BXO can affect the urethra and treatment to widen the urethra may be necessary (a meatotomy).

 

Recovering from circumcision 

In babies who are circumcised, the foreskin usually takes about 7 to 10 days to heal. In older boys and men, the healing process can take up to four to six weeks.

 

Self-care advice

As circumcision is a painful procedure, painkillers such as paracetamol or ibuprofen will need to be taken for at least the first three days after the operation. Children aged 16 or younger should not take aspirin.

Circumcision exposes the sensitive skin of the tip of the penis (glans). In babies, nappies can rub against the glans, making it sore. Therefore, make sure that you tuck down your baby’s penis before putting the nappy in place. You may be advised to apply an antibacterial cream for up to a week.

After circumcision, the penis will be red and swollen for a few days. You or your child may find it more comfortable to wear loose clothing for a while. Putting petroleum ointment directly on to the area can also reduce irritation.

After a boy has been circumcised, make sure that he does not ride a bike or use other sit-on toys until the swelling has completely gone down. If he is of school age, he should be able to return to school about a week after being circumcised. However, let his teacher know that he has had the operation.

It is important to practise good hygiene and ensure that your child's nappies are frequently changed after a circumcision.

Do not use scented products in the shower or bath and leave the penis to dry naturally.

For adults, the surgeon will also give advice about sexual activity. Usually, sex should be avoided until the wound has healed, to avoid it reopening.

 

When to seek medical advice

After a child has been circumcised, speak to your GP if:


there is bleeding from your child’s penis

your child’s penis remains swollen after two weeks

your child still finds passing urine painful a few days after the operation


Older boys and men should also see their GP if they have any problems after circumcision.

 

Recovering from circumcision 

In babies who are circumcised, the foreskin usually takes about 7 to 10 days to heal. In older boys and men, the healing process can take up to four to six weeks.

Self-care advice

As circumcision is a painful procedure, painkillers such as paracetamol or ibuprofen will need to be taken for at least the first three days after the operation. Children aged 16 or younger should not take aspirin.

Circumcision exposes the sensitive skin of the tip of the penis (glans). In babies, nappies can rub against the glans, making it sore. Therefore, make sure that you tuck down your baby’s penis before putting the nappy in place. You may be advised to apply an antibacterial cream for up to a week.

After circumcision, the penis will be red and swollen for a few days. You or your child may find it more comfortable to wear loose clothing for a while. Putting petroleum ointment directly on to the area can also reduce irritation.

After a boy has been circumcised, make sure that he does not ride a bike or use other sit-on toys until the swelling has completely gone down. If he is of school age, he should be able to return to school about a week after being circumcised. However, let his teacher know that he has had the operation.

It is important to practise good hygiene and ensure that your child's nappies are frequently changed after a circumcision.

Do not use scented products in the shower or bath and leave the penis to dry naturally.

For adults, the surgeon will also give advice about sexual activity. Usually, sex should be avoided until the wound has healed, to avoid it reopening.

When to seek medical advice

After a child has been circumcised, speak to your GP if:


there is bleeding from your child’s penis

your child’s penis remains swollen after two weeks

your child still finds passing urine painful a few days after the operation


Older boys and men should also see their GP if they have any problems after circumcision.

 

Risks of circumcision 

As with all types of surgery, circumcision has some risks. However, complications from circumcisions carried out for medical reasons are rare in England.

Bleeding and infection are the most common problems associated with circumcision.

Other complications can include:


a decrease in sensation in the penis, particularly during sex

damage to the tube that carries urine inside the penis (urethra), causing it to narrow and making it hard to pass urine

removal of too much of the foreskin

accidental amputation of the head of the penis, which is very rare

a blood infection or blood poisoning (septicaemia)


Problems with circumcisions carried out for religious or cultural reasons may go unreported.

Circumcision is not carried out on boys born with a specific birth defect of the penis that affects where the opening of the urethra (urinary tube) is found. This is because the foreskin is used to reconstruct the urethra.


Circumcision