circumcision

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Circumcision

 

Definition

The surgical removal of the foreskin of the penis or prepuce.

Purpose

In the United States, circumcision in infant boys is performed for social, medical, or cultural/religious reasons. Once a routine operation urged by pediatricians and obstetricians for newborns in the middle of the twentieth century, circumcision has become an elective option that parents make for their sons on an
A typical circumcision procedure involves the following steps: Figure A: The surgeon makes an incision around the foreskin. Figure B: The foreskin is then freed from the skin covering the penile shaft. Figure C: The surgeon cuts the foreskin to the initial incision, lifting the foreskin from the mucous membrane. Figure D: The surgeon sutures the top edge of the skin that covers the penile shaft and the mucous membrane.
A typical circumcision procedure involves the following steps: Figure A: The surgeon makes an incision around the foreskin. Figure B: The foreskin is then freed from the skin covering the penile shaft. Figure C: The surgeon cuts the foreskin to the initial incision, lifting the foreskin from the mucous membrane. Figure D: The surgeon sutures the top edge of the skin that covers the penile shaft and the mucous membrane.
(Illustration by Electronic Illustrators Group.)
individual basis. Families who practice Judaism or Islam may select to have their sons circumcised as a religious practice. Others choose circumcision for medical benefits.
Female circumcision (also known as female genital mutilation) is usually performed for cultural and social reasons by family members and others who are not members of the medical profession, with no anesthesia. Not only is the prepuce removed but often the vaginal opening is sewn to make it smaller. This practice is supposed to ensure the virginity of a bride on her wedding day. It also prevents the woman from achieving sexual pleasure during coitus. This practice is not universally approved by the medical profession and is considered by some as a human rights violation.
Though the incidence of male circumcision has decreased from 90% in 1979 to 60% in 1996, it is still the most common surgical operation in the United States. Circumcision rates are much lower for the rest of the industrialized world. In Britain, it is only done for religious practices or to correct a specific medical condition of the penis.
Some of the medical reasons parents choose circumcision are to protect against infections of the urinary tract and the foreskin, prevent cancer, lower the risk of getting sexually transmitted diseases, and prevent phimosis (a tightening of the foreskin that may close the opening of the penis). Though studies indicate that uncircumcised boys under the age of five are 20 times more likely than circumcised boys to have urinary tract infections (UTIs), the rate of incidence of UTIs is quite low. There are also indications that circumcised men are less likely to suffer from penile cancer, inflammation of the penis, or have many sexually transmitted diseases. Here again, the rate of incidence is low. Good hygiene usually prevents most infections of the penis. Phimosis and penile cancer are very rare, even in men who have not been circumcised. Education and good safe sex practices can prevent sexually transmitted diseases in ways that a surgical procedure cannot because these are diseases acquired through risky behaviors.
With these factors in mind, the American Academy of Pediatrics has issued a policy statement that states though there is existing scientific evidence that indicates the medical benefits of circumcision, the benefits are not strong enough to recommended circumcision as a routine practice.

Precautions

Circumcision should not be performed on infants with certain deformities of the penis that may require a portion of the foreskin for repair. The most common
A. uncircumcised penis. B. circumcised penis.
A. uncircumcised penis. B. circumcised penis.
(Illustration by Argosy Inc.)
condition for surgery using the foreskin is hypospadias, a congenital deformity of the penis where the urinary tract opening is not at the tip of the glans. Also, infants with a large hydrocoele or hernia may suffer important complications through circumcision. Premature infants and infants with serious infections are also poor candidates to be circumcised, as are infants with hemophilia, other bleeding disorders, or whose mothers had taken anticoagulant drugs. In older boys or men, circumcision is a minor procedure. Therefore, it can be performed in virtually anyone without a serious illness or unusual deformity.

Description

The foreskin of the penis protects the sensitivity of the glans and shields it from irritation by urine, feces, and foreign materials. It also protects the urinary opening against infection and incidental injury.
In circumcision of infants, the foreskin is pulled tightly into a specially designed clamp, and the foreskin pulls away from the broadened tip of the penis. Pressure from the clamp stops bleeding from blood vessels that supplied the foreskin. In older boys or adults, an incision is made around the base of the foreskin, the foreskin is pulled back, and then it is cut away from the tip of the penis. Stitches are usually used to close the skin edges.

Preparation

Despite a long-standing belief that infants do not experience serious pain from circumcision, most authorities now believe that some form of local anesthesia is necessary. The physician injects local anesthesia at the base of the penis or under the skin around the penis (subcutaneous ring block). Both anesthetics block key nerves. EMLA cream, a topical formula of several anesthetics can also be used.

Aftercare

After circumcision, the wound should be washed daily. An antibiotic ointment or petroleum jelly may be applied to the site. If there is an incision, a wound dressing will be present and should be changed each time the diaper is changed. Sometimes a plastic ring is used instead of a bandage. The ring will usually fall off in five to eight days. The penis will heal in seven to 10 days.
Infants who undergo circumcision may be fussy for some hours afterward, so parents should be prepared for crying, feeding problems, and sleep problems. Generally these go away within a day. In older boys, the penis may be painful, but this will go away gradually. A topical anesthetic ointment or spray may be used to relieve this temporary discomfort. There may also be a "bruise" on the penis, which typically goes away with no particular attention.

Risks

Complications following newborn circumcision appear in one out of every 500 procedures. Most complications are minor. Bleeding occurs in half of the complications and is usually easy to control. Infections are rare and present with fever and signs of inflammation.

Key terms

Foreskin — A covering fold of skin over the tip of the penis.
Glans — The cone-shaped tip of the penis.
Hernia — Bulging of abdominal structures through an abnormal opening in the muscular wall.
Hydrocele — Collection of fluid in the scrotum.
Hypospadias — A congenital deformity of the penis where the urinary tract opening is not at the tip of the glans.
Phimosis — A tightening of the foreskin that may close the opening of the penis.
Prepuce — A fold like the foreskin that covers the clitoris; another name for foreskin.
There may be injuries to the penis itself, and these may be difficult to repair. In 2000, there were reports that the surgical clamps used in circumcision were at fault in over 100 injuries reported between July 1996 and January 2000. In nearly all cases, the clamps were assumed to be in working order but had been repaired with replacement parts that were not of the manufacturer's specifications. Physicians were urged to inspect the clamps before use and ensure that their dimensions fit their infant patients.

Resources

Books

Gollaher, David L. Circumcision: A History of the World's Most Controversial Surgery. Basic Books, 2000.

Periodicals

Imperio, Winnie Anne. "Circumcision Appears Safe, But Not Hugely Beneficial." OB GYN News 35, no. 7 (April 1, 2000): 9.
Schmitt, B. D. "The Circumcision Decision: Pros and Cons." Clinical Reference Systems 2000: 1579.

Other

American Academy of Pediatrics. New AAP Circumcision Policy Released (Press Release). March 1, 1999. http://www.aap.org/advocacy/archives/marcircum.htm.

circumcision

 [ser″kum-sizh´un]
1. in males, surgical removal of all or part of the foreskin (prepuce) of the penis; see discussion below.
2.
Female Circumcision is any of various operations to remove part or all of the female external genitalia. It is a widespread practice in some parts of the world, especially in Africa, the Middle East, Indonesia, and Malaysia. In 1979 the world health organization sponsored a conference in The Sudan that unanimously condemned this practice as indefensible on medical as well as humane grounds.

Female circumcision is classified according to the extent of what is removed. Sunna circumcision involves removal of the prepuce or excision of the tip of the clitoris or both. Excision circumcision usually includes removal of the clitoris, the labia majora, and the labia minora. Infibulation is the most extreme form, involving excision of all or part of the clitoris, labia minora, and medial aspect of the labia majora. The raw edges of the wound are sutured or otherwise held together until healing and scarring form a wall over the upper part of the vestibule. A small opening is left for the flow of urine and menstrual discharge. When a woman marries who has had this latter procedure done as an infant or child, she must be forcibly penetrated or the opening made larger. In these women such complications as painful intercourse, possible perineal lacerations, infections, and hemorrhage are common. At the time of childbirth the scar tissue must be cut and the opening enlarged to allow passage of the infant. Otherwise, both mother and child are at risk for serious complications.
Male Circumcision. This has been traditionally done for hygienic and medical reasons and is the oldest known religious rite. In the Jewish faith the circumcision is a ritual that is performed by a mohel (ordained circumciser) on the eighth day after birth if possible. The circumcision is followed by a religious ceremony during which the baby also receives his name.

Circumcision in the hospital usually is done very shortly after birth, provided the newborn is full-term and in good health. The procedure is not without risk from complications, the most common being infection, hemorrhage, and surgical trauma to the penis. Although there is some evidence of a relationship between lack of circumcision and penile cancer, which is relatively rare, poor hygiene seems equally important as an etiologic factor. Cancer of the prostate cannot be linked to lack of circumcision, nor are there good data to support a cause-effect relationship between cervical cancer in females and coitus with an uncircumcised spouse.

The American Academy of Pediatrics and the American College of Obstetricians have found no medically valid reasons for routine circumcision of newborns. While the practice is declining in the United States and is not routinely done in Canada, Great Britain, or Western European countries, almost two thirds of North American newborns are circumcised. For parents who are undecided about circumcision for their newborn sons, the American Academy of Pediatrics provides a brochure that can be obtained from AAP, Dept. C, 141 Northwest Point Blvd., Elk Grove Village, IL 60007. A stamped, self-addressed business envelope should accompany the request.
Patient Care. Preoperative care for the older male child or adult undergoing circumcision includes laboratory tests to determine coagulation or clotting time and a general checkup to assure that the patient is in good health. A mild sedative may be given, though newborns usually do not receive any special preoperative care or sedation.

The patient is watched closely after the operation for signs of bleeding; however, excessive bleeding is extremely rare. Other observations include watching for signs of infection, difficulty in urination, and jaundice. A sterile gauze dressing with ointment is usually placed over the penis when surgery is completed. The dressing is changed each time the diaper is changed, or, in young children and adults, after each urination. When the Plastibell method of circumcision is used, the penis and attached ring is cleansed with sterile water each time the diaper is changed. Healing usually takes place in five to seven days.
 Circumcision using the Plastibell. The specialist places the Plastibell, a plastic ring, over the glans, draws the prepuce over it, and ties a suture around the prepuce and Plastibell. This procedure prevents bleeding when the excess prepuce is removed. The handle is removed, leaving only the ring in place over the glans. The Plastibell falls off in 5 to 8 days. From McKinney et al., 2000.

cir·cum·ci·sion

(ser'kŭm-sizh'ŭn),
1. Operation to remove part or all of the prepuce.
2. Cutting around an anatomic part (for example, the areola of the breast). Synonym(s): peritectomy (2)
[L. circumcido, to cut around, fr. circum, around, + caedo, to cut]

circumcision

/cir·cum·ci·sion/ (ser″kum-sizh´un) the removal of all or part of the foreskin of the penis in males; see also female c.
female circumcision  any of various procedures involving either excision of a portion of the external female genitalia or infibulation.
pharaonic circumcision  a type of female circumcision comprising two procedures: a radical form in which the clitoris, labia minora, and labia majora are removed and the remaining tissues approximated, and a modified form in which the prepuce and glans of the clitoris and adjacent labia minora are removed.
Sunna circumcision  a form of female circumcision in which the prepuce of the clitoris is removed.

circumcision

(sûr′kəm-sĭzh′ən)
n.
1. The act of circumcising.
2. A religious ceremony in which a boy or man is circumcised.
3. Circumcision Christianity A feast observed on January 1 celebrating the circumcision of Jesus. Used with the.

circumcision

[-sizh′ən]
Etymology: L, circum, around, cadere, to cut
a surgical procedure in which the prepuce of the penis or the prepuce of the clitoris is excised. Circumcision is widely performed on newborn boys. The operation is performed on newborns with penile block anesthesia, using one of several kinds of clamp. It is sometimes performed on adult males in the treatment of phimosis and balanitis. Ritual circumcision is required by the religions of approximately one sixth of the world's population.

circumcision

Surgical removal of the foreskin, either by an obstetrician or as a part of a religious rite (e.g., a bris, performed by a rabbi in the Jewish religion at birth and Moslems in pre-adolescence).

The American Academy of Pediatrics recommends circumcision, as it decreases the incidence of balanitis, phimosis, colonisation by Escherichia coli and other bacteria, and urinary tract infections, which are 10- to 20-times greater in uncircumcised boys. The lifetime risk for penile cancer in uncircumcised males is 600-fold greater than that of circumcised males; the risk for cancer of the uterine cervix is closely linked to HPV infections (HPV-16 in 50% and HPV-18 in 10%) in uncircumcised males partners. The incidence of STIs (e.g., genital herpes, syphilis, gonorrhoea, chancroid and HIV-1) is decreased in circumcised males.

circumcision

Urology Surgical removal of the foreskin/prepuce, either by an obstetrician, or as a part of a religious rite–eg, a bris, performed by a rabbi in Judaism at birth and Moslems in preadolescence. See Sunna circumcision. Cf Female circumcision.

cir·cum·ci·sion

(sĭr'kŭm-sizh'ŭn)
1. Operation to remove part or all of the prepuce.
Synonym(s): peritomy (2) .
2. Cutting around an anatomic part (e.g., the areola of the breast).
Synonym(s): peritectomy (2) .
[L. circumcido, to cut around, fr. circum, around, + caedo, to cut]

circumcision

Surgical removal of the male foreskin (prepuce) or of parts of the female external genitalia. Male circumcision is mostly done for ritual purposes, as in Jews and Muslims, but is occasionally necessary for medical reasons. Female circumcision is a culturally-determined but barbaric practice causing pain, mutilation and distress to millions of women. The procedure may be limited to removal of the clitoris or may also involve removal of all the external genitalia and stitching together of the raw surfaces so that they heal across and make sexual intercourse impossible (infibulation).

circumcision

surgical removal of part of the prepuce. Performed only to repair a prolapse of the prepuce, encountered in all species but especially in Bos indicus cattle. Called also posthioplasty.