Circumcision

INTRODUCTION

All over the world, circumcision is one of the most frequently performed operations in infants and children. Circumcision is performed for medical, social or religious reasons and in certain cases to prevent cancer of the foreskin. In our paediatric surgical department we perform approximately 250 circumcisions every year. The average age of our patients who undergo circumcision is 4.5 years.

This article was written to help you understand the correct medical indications for a circumcision and to assist you in choosing the right time for surgery. In our opinion the decision to circumcise for hygienic reasons and to prevent cancer should be made unreservedly.

HISTORY

Ancient cave paintings in Egypt represent evidence that circumcision might have been performed as long ago as 2400 years B.C. Slaves and prisoners were circumcised in order to make them recognizable to others. Ritual circumcision is still widely found among native tribes in Africa and Australia. It is often a sign of sexual maturity and understood as evidence for bravery and manliness.

Religious circumcision as practiced by Jews, Christians and Muslims has its origin in the Old Testament (1.Moses 16.17.). When there were no medical contraindications circumcision should be performed on the 8th day of life, even if that day happened to be the Sabbath.

EMBRYOLOGY AND PREPUCIAL DEVELOPMENT

The prepuce (foreskin) and glans (the bulky tip of the penis) develop from the tissue of the distal part of the phallus during the 3rd month of pregnancy. The foreskin develops from the tissue on the base of the glans and commences it’s growing process in a dorsal direction, to cover the back of the glans . Eventually the ventral (lower) aspects of the prepuce fuse and form the frenulum, a band like structure, that contains a little arteria (arteria frenularis). Shortly before child birth the inner aspect of the prepuce and the epithelia of the glans commence a process of separation from each other. The space between them contains pearls of smegma, a white, sluggish substance that derives from old epithelial cells. This separation process is completed, or close to completion, in only 4% of newborns. In 80% of boys it takes another 2 years for the prepuce to be entirely separated from the glans. As a rule of thumb, the foreskin should be easily retractable by the age of 3. However, forcible retraction of the foreskin must always be avoided. In half of newborns the tip of the glans and the orifice of the urethra (meatus urethrae) are visible and there is no need, whatsoever, to mechanically release the physiological adhesions between the inner and outer layer of the prepuce. These physiological adhesions are called conglutinations.

INDICATION FOR PEDIATRIC SURGICAL TREATMENT

The indication for a circumcision may be medical, e.g. abnormality or disease of the foreskin or the lower urinary tract. It may be to prevent cancer of the foreskin or recurrent infections or for social or religious reasons. (1-8)

This article will inform you about the most common conditions of the foreskin and diseases of the lower urinary tract that may require circumcision.

1) Relevant conditions of the prepuce

Conglutinations, the physiological partial adhesions between the layers of the prepuce and the glans are normal until the age of 3. Whenever conglutinations persist, smegma pearls will be found to some degree. Despite these adhesions the urethral orifice is usually visible and voiding is possible without problem. The prepuce is not freely retractable but this is not caused by a tight prepucial orifice. This condition is frequently misdiagnosed as phimosis. Conservative treatment is usually effective, surgical intervention rarely necessary.
Phimosis is defined as tightness of the foreskin resulting in too small a prepucial orifice in relation to the diameter of the glans. This condition may be congenital or it may be acquired. Phimosis is the most common indication for circumcision. The prepuce is not freely retractable. Voiding may cause problems and the urine stream is noticeably thin. A particularly thin urine stream should raise concern even in a newborn. Phimosis causes obstruction of normal urinary flow. It causes ballooning of the foreskin as soon as it is completely separated from the glans. This is a significant hygienic problem and there is a risk of recurrent infections (balanitis). Recurrent infections are likely to cause scarring that may itself increase the degree of the prepucial stenosis.
A paraphimosis occurs when a tight foreskin has been retracted and forms a constricting ring around the coronal groove of the glans (sulcus coronarius) causing venous engorgement and painful swelling of the glans. This problem demands an urgent solution. If left alone, ischemia may cause prepucial gangrene and scarring. Cautious manual reposition is usually successful. If manual reposition is not successful, a surgical dorsal slit must be performed urgently. Depending on the state of the oedema circumcision may be performed immediately or on the following day when the swelling has subsided.
Frenulum breve. A short frenulum may cause problems for the retraction of the prepuce. It causes the glans to bend ventrally, whenever the foreskin is retracted and during erection. Later in life, problems, such as frenular tears or bleeding, may occur during sexual intercourse.
A long prepuce may cause hygienic problems. This condition leads to significantly higher concentration of periurethral bacteria. (9-10) Circumcision should be considered.

2) Diseases and abnormalities of the lower urinary tract

There is an increased risk of urinary tract infections (UTI) in children with structural abnormalities of the lower urinary tract (e.g. vesicoureteral reflux, urethral valve, etc). Even a simple UTI in boys should raise suspicion of an underlying structural abnormality and always requires further investigation, e.g. ultrasound, intravenous urography (IVU), ureterocystoscopy, urodynamics, post-void residual volume measurement, etc.

The foreskin, in particular with the presence of phimosis, is an additional reservoir for bacteria and may be a source of recurrent UTIs (11). The incidence of UTIs in circumcised males is 10 to 20 times lower compared to non-circumcised (4,8,12,13). The risk to non-circumcised males of developing a UTI seems to be particularly increased in the first few months of life (4). A complicated UTI has the potential of severe, non-reversible complications, such as scarring of the renal parenchyma. The younger the child the higher the risk of renal damage. Infection prophylaxis with antibiotics is indicated and circumcision advisable, regardless of the nature of the underlying abnormality in the urinary tract and the possible necessity for a variety of surgical treatments(14).

Furthermore it is important in children with urological abnormalities to have their urine tested for bacteria on a regular basis. In uncircumcised boys the urine culture results are not reliable as contamination from the foreskin is common. Therefore the urine would need to be obtained via suprapubic aspiration or catheterisation.

3) Cancer prevention

Circumcised men have a lower incidence of penile cancer and the incidence of cervical cancer may be decreased in their sexual partners.

TREATMENT OPTIONS

1) Conservative strategies

Conservative treatment may be an option for phimosis or conglutination when the foreskin is not fully retractable but the urethral orifice is visible and the urine stream is normal. For conglutinations that persist after the age of 2 or 3, treatment should be commenced.

One option is to carefully retract the prepuce while bathing the child in warm water. This should be done on a regular basis. The aim is to slowly and carefully stretch the tight prepucial ring. It is important to find the correct amount of force. If it is done too cautiously, it won’t succeed. If too much force is used, it will result in tiny lacerations of the inner prepucial layer and scarring is likely to increase the degree of the phimosis.

A further option is the application of creams. They should contain oestrogen (e.g. Ovestin

Inflammation of the glans (balanitis) and the foreskin (posthitis) usually occur together as balanoposthitis. Treatment with an antibiotic ointment (e.g. Nebacin

2) Surgical strategies

The aim of circumcision, when medically indicated, is to

release the tight prepucial ring
enable voiding with a normal and free urinary stream
optimise local hygiene
decrease the risk of infection

Circumcision should be performed in a state-of-the-art manner and under a combination of local and general anaesthesia. Local anaesthesia can be achieved via ring block of the penis and subpubic penile block with 2-3 ml of 0.5% Xylocain. Rectal Midazolam (0.5-1 mg/kg bodyweight) can be used for general sedation. Newborns are sensitive to pain! Anaesthesia is a must!

Prepucial lysis. This is the surgical separation of the inner, prepucial layer from the glans. Smegma pearls can easily be removed during this procedure. After the operation there will be tiny lacerations of the epithelia and thorough postoperative care with creams (e.g. Solcoseryl Gelee
The dorsal slit technique should only be used in an emergency situation when a paraphimosis cannot be manually reduced. Cosmetic results are usually not brilliant. The incidence of recurrence is high if this technique has been used, particularly after balanoposthitis.
Circumcision and frenulotomy.

There is a difference between the technique used for circumcision in the newborn and the one used in infants and children older then 2 month.

In the newborn the foreskin can be removed with the Gomco-bell, which has successfully been used since the 1930’s, or the Morgan´s plastibell, which was introduced in the 1960’s. Both techniques have the advantage of local haemostasis through pressure applied by the clamp. There is a risk of bleeding when pressure has not been applied long enough. However the risk of bleeding after this technique is particularly low in the newborn. Dehiscence of the wound may occur with erections straight after surgery.

In infants and children older than 2 months the vascular supply of the prepuce will have increased substantially. There is a need for more sophisticated techniques of haemostasis to avoid dangerous bleeding. This technique should always be performed under general sedation in combination with local anaesthesia (e.g. penile block with 0.5-1% Xylocain). As a first step the tight prepuce is going to be cautiously stretched and dorsally incised. This allows the foreskin to be retracted and it’s separation from the glans. If the frenulum is found to be particularly short, it is now going to be cut. Before cutting it needs to be undermined and the arteria frenularis is going to be cauterised or ligated with Maxon® 6-0. In the next step the two prepucial layers are now excised spearing a 3 to 4 mm wide coronal band of tissue from the inner layer. During this step the subcutaneous blood vessels need to be lifted away from the mucosa of the glans with forceps and thoroughly cauterised. Eventually the edges of the two prepucial layers are sutured together with absorbable stitches (e.g. Maxon® 6-0 or 7-0). If too much prepucial tissue has been left, recurrence is more likely.

After surgery, creams (e.g. Solcoseryl Gelee®, Lasepton Creme®), anaesthetic ointments (e.g. Xylocain®) and a non-adhesive dressing are going to be applied to the wound. From the 2nd day after surgery until wound healing is completed the child should have a bath in a sitting position with Kamilosan® or Betaisadona®, 2 or 3 times a day. Frequent nappy changes and thorough postoperative care with creams is crucial, as concentrated urine may cause inflammation and there is the risk of developing a stenosis of the urethral orifice. Publications in the US about the risk of meatal stenosis after circumcision reduced the rate of routine circumcisions from 95% in the 1960’s to 60-70% today. Overall problems after circumcision are more common in children who have already grown out of their nappies. They tend to have difficulties in coping with all the necessary aspects of postoperative care. Tight trousers or underwear should be avoided. The child must not ride a bicycle, a rocking horse or engage in similar activities within the first week after surgery. Usually postoperative care can be gradually decreased after the first week.

Other complications are extremely rare (0%-0.6%), particularly if the surgery was performed by an experienced paediatric surgeon. It is not uncommon for an oedema to occur until the 3rd day after surgery. It usually resolves spontaneously and is not a complication as such. Negative alteration in regard to sexual sensation is not expected and there is no evidence for it.

Complications

Bleeding is more common in older children. Simple measures such as compression and tamponade with vasoactive agents (e.g. POR8®) are usually sufficient to resolve this complication. Surgical haemostasis is rarely necessary.
Recurrence. If too much of the prepucial tissue has been left, the development of a recurrence is more likely.
Urethral injury in case of an atrophic corpus spongiosum (hypospadia sine hypospadia)
Wound infection.
Meatal stenosis, caused by ulcerative meatitis in the newborn or local ischaemia after legation of the frenular arteria.

Epispadias, hypospadias and other genital abnormalities are contraindications for circumcision. Here the prepucial tissue may be needed to correct the primary abnormality. A condition called “Palmure”, where the scrotal skin reaches the top of the penis is not an indication for circumcision as such. Other diseases, e.g. haemophilia, always need to be taken into account when the risk of surgery is calculated.

Summary

Taking into account the panopticum of medical reasons (recurrent inflammation, carcinoma of the penis, etc.), one is rather inclined to argue in favour of circumcision. A circumcision is an operation with minimal risk of complications, particularly when performed by an experienced paediatric surgeon. If the indication for surgery has been made, the operation should be done sooner rather than later.