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Circumcision

MagazineJanuary 1999 (Vol. 9 Issue 10)Circumcision

My 6 year old son has a foreskin which does not retract

My 6 year old son has a foreskin which does not retract. Our doctor has allowed us to just wait and see what happens, but now that he is over 5, wants to refer him for surgery for a medical circumcision. We know that circumcision is a routine operation in many parts of the world, but wonder if there are any possible side effects.

If we choose not to have him circumcised, are there any other ways to sort out his problem, which, incidentally, isn't causing any pain or problem at the moment? G B, Birmingham.......

Although circumcision isn't routinely performed in Britain any longer, 21,000 boys under 15 are circumcised every year, supposedly for a non retractile foreskin, or prepuce, a condition which goes by the technical name of "phimosis". This translates into an overall circumcision rate, for medical and religious reasons, of 6 per cent of British boys by the age of 15.

Although many doctors look upon the foreskin as a dispensible covering, that definition represents a gross oversimplification of its function or development. At birth, the foreskin is still developing and so solidly adheres to the shaft of the penis and is naturally intractible. In one study, only 4 per cent of newborns have a fully retractable foreskin, while in 42 per cent, not even the tip of the glans of the penis could be uncovered (BMJ, 1949; 2: 1433-7). In this same study, only half the children could retract the foreskin at a year, while at three, 10 per cent still could not.

In a later study of older boys in Denmark (where circumcision is rarely performed), a non retractible foreskin was present in 8 per cent of 6 to 7 year olds; 6 per cent of 8 to 11 year olds, 3 per cent of 12 to 13 year olds and 1 per cent of 14 to 17 year olds (Arch Dis Child, 1968; 43: 200-3). Yet another study estimates that it is only 1 per cent of 17 year olds who have a pathological problem.

What this means is that non retractibility is a normal part of the physiology of growing boys, except for this 1 per cent which means that doctors in Britain are circumcising 5 per cent too many boys. Indeed, a study of phimosis found that the majority of referrals for cicumcision had non retractible foreskins as a consequence of development, not true pathological phimosis. They also found no cases of true phimosis in boys under 5. There were also higher incidences of circumcision in some parts of England than others. Most circumcisions were performed on boys under 5, two thirds of which, the authors concluded, were clearly unnecessary (Ann Royal Coll Surg Engl, 1989, 71: 275-7).

It is overwhelmingly likely that your boy doesn't have true phimosis, but simply a non retractable foreskin with adhesions at the moment, which are likely to break down spontaneously as he gets older. If it isn't bothering him, there is no harm in watchful waiting.

Two big causes of true phimosis at a young age are inflammation, usually after the child's penis has had prolonged exposure to urine soaked nappies; or the well intentioned but ultimately damaging attempts by doctors or nurses to pull back the foreskin on babies or toddlers. This can lead to paraphimosis, where the foreskin is stuck in a retracted position, or fibrosis, tearing and scarring (Ann R Coll Surg Engl, 1994; 76: 257-8).

If your boy is found to have true phimosis, there are ways of treating the problem conservatively. Numerous studies have shown that topical steroids have worked effectively (Aust NZ J Surgery, 1994; 64: 327-8; Pediat Surg Int, 1993; 8: 329-32). Although steroids are never a particularly welcome choice, particularly in children, short term use may be a preferable option to irrevocable, mutilating surgery. The usual regime is daily external applications over the length of the foreskin with betamethasone 0.05 per cent cream for four to six weeks. According to one study, patients with true phimosis can be treated successfully with topical steroids in 65 per cent to 95 per cent of cases (Pediatrics, 1998; 102: 43). Nevertheless, in some patients, once the drug is stopped, the problem recurs.

A new operation, entitled prepuceplasty, much favoured in Europe, is a more conservative alternative to circumcision. In this surgery, the narrowed opening of the foreskin is cut and then repaired across, allowing a larger opening. In one of the first long term studies of the procedure, 55 patients underwent this surgery, aged between 1 and 14, and were reviewed five to eight years later; 50 patients were satisfied with the results, although one complained about his foreskin looking "dog eared". Of the remaining five, four patients required subsequent circumcision one to five years after the initial operation, and in one patient, the slit had been far too wide (Ann Royal Coll Surg Engl, 1994; 76: 257-8).

This operation is not appropriate for many adults when the foreskin is scarred or thickened, since the narrowing usually recurs after the operation.

The Chinese have also developed a a non surgical treatment with a balloon catheter, designed for pediatric use. In this treatment, after local anaesthesia is applied, the balloon is gradually inflated until the foreskin orifice is about 3 to 5 mm larger than the maximum diameter of the penis shaft. The balloon is kept inflated for 20 to 30 seconds, and the entire procedure repeated two to three times. This is only possible if there no adhesions, which are difficult to detach (Chinese Medical J, 1991; 104: 491-3).

(Bear in mind that, as with virtually every study published in Chinese journals, this study showed an unabashedly positive result, which means that it may be suspect.)

If you elect watchful waiting as an approach, and your boy reaches young adulthood but the foreskin still doesn't retract, Michel Beaug, a French practitioner of preventive medicine, has a novel solution. He discovered that many of his patients aged 18 through 22 with phimosis shared common characteristics. Either they never masturbated or they did so in a method that differed markedly from the usual which is to mimic the dynamics of sexual intercourse, and so naturally push the foreskin back toward the base of the glans.

In such instances, he recommends that his patients practise conventional masturbation. After at most three weeks, he finds that the opening of the foreskin widens and the problem is corrected, unless there is some serious pathological condition.

If you do decide to go ahead with this operation, you should be aware that, however "routine" circumcision is, it is not risk free. According to one review, complications can include removal of inadequate skin, requiring a repeat operation (which occurs in 9.5 per cent of cases) (B J Surg, 1993; 80: 1231-6). This may result in scarring, which ends up causing true phimosis in 2 per cent of cases (Br J Surg, 1981; 68: 593-5). Laceration of the penis, haemorrhage, sepsis, removal of too much skin, partial or total amputation of the penis and formation of obstructions to the urethra are not unknown (B J Surg, 1993; 80: 1231-6).

Excessive bleeding is the commonest complication occurring up to nearly one third of cases. When gentle pressure is insufficent to control local haemorrhage, the usual treatment is electrosurgical diathermy to coagulate the blood. However, if it is employed overzealously, it may cause coagulation in many more blood vessels than intended. In four reported cases, this caused loss of the penis. Unbelievably, the four children were "managed" as the report says, by "gender reassignment" that is, the doctors and parents felt that growing up without a penis would be so traumatic that they turned them, surgically and hormonally, into girls (J Urology, 1989; 142: 799-801). Infection is also known to occur in 10 per cent of cases, and ulceration of the urethra in 8 to 20 per cent of boys, two to three weeks after the operation, which can lead to permanent narrowing.

Besides the physical issues, there are also psychological ones, particularly in older boys. One study of 12 boys undergoing circumcision in Turkey between ages 4 and 7 found that their intelligence quotients fell afterward. The study concluded that circumcision was perceived by the child as an "aggressive" attack upon his body, which "damaged, mutiliated and in some cases totally destroyed him. The feeling that 'I am now castrated' seems to prevail in the psychic world of the child" (Br J Med Psychol, 1965; 38; 321-31).

Finally, removing a foreskin may permanently interfere with your son's later sex life. One review convincingly argued that the foreskin is not simply a flap of skin but a double layer of sensitive skin which covers the penile glans. The inner layer, a mucous membrane, has many specialized and highly sensitive nerves and blood vessels. Cutting this off removes an "important component of the overall sensory mechanism of the human penis" (Br J Urology, 1996; 77: 291-5).

Much is written about the ritual mutiliation of girls and women. Perhaps it is time that more were written about the dangerous and the medically unnecessary routine practice of circumcising infant and young boys, barbarically still performed, in the case of newborns, without pain relief. One study even demonstrates that male infants who have been circumcised exhibited a greater pain response than those who haven't been circumcised, thus putting paid to the ludicrous argument in medicine that newborns getting circumcised don't feel a thing (Lancet, 1997; 349; 599-603).


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