One issue that I always encounter everyday with newborn males is the issue of circumcision. There is no one-day that I do am not asked questions. The most common questions are: Is it necessary? Will the baby feel it? Do you apply anesthesia? When is the best time to do it? What do you think about circumcision?

I do no less than two circumcisions a day. Considering that there is at least five working days in a week, that means ten circumcisions in a week, forty in a month and 480 a year. This is still very conservative. Of the number who does not go for circumcision is only a conservative one to two percent. The numbers are skewed to having circumcisions. My opinion of whether to do it or not is relative. I present the facts. The parents make the decision through knowledge, not ignorance. It is my belief that the ultimate responsibility of having it or not rests on the parents. The American Academy of Pediatrics takes the same stance though some years ago, their policy was that it was not necessary unless indicated or there was a reason. Why the change? It is for the same reason sited earlier. The decision rests on the parents. However, to complicate the issue, how about the baby’s rights to chose. Then if this were the case, circumcision should be postponed till the individual can make his own choices legally.

Circumcision, or removal of the foreskin, is an operation of great antiquity. As a magical or initiation rite it was introduced independently by aboriginal tribes in Australia, Africa and the Americas. Circumcision was practiced by the Egyptians of 3,000 B.C., at first as a privilege of the nobility, but it later became the custom for all males. Presumably what started as a religious rite was found to be a useful hygienic measure in a hot climate.

Circumcision is not just one type. The common type is when almost the whole entirety of the foreskin enveloping the head (glans) of the penis is removed. There is the dorsal slit where the foreskin is halved in parallel to the penis till the base of the glans. This means that no foreskin is actually removed. Eventually the remaining foreskin fans out exposing the head. There are variations between the two. Which again is better? Again the
decision rests on the parents. Of the ones mentioned, the former is more popular however among Asians especially Filipinos, the latter is the preferred procedure. A strong point with ACI Pediatrics is that we offer these forms of services.

The usual reason why circumcisions are done or not is whether dad or the male children are circumcised or not.

INDICATIONS FOR CIRCUMCISION

In order to show the relative importance of the various indications, or alleged indications, for circumcision they will be discussed under three headings:- Essential, Advisable and Optional. Each of these headings will be separated in three consecutive issues of this newspaper.

1. CIRCUMCISION IS ESSENTIAL

• Religion and culture The operation is obligatory for Jewish and Moslem males as a religious rite. Amongst some cultures like the Filipinos it is a ritual to manhood.
• Parental request. Routine circumcision at birth other than for religious reasons is a custom in several countries and in some families. Most males are circumcised soon after birth (within the first two weeks of life). Noteworthy for the reader to know is that most medical insurances cover the procedure only during this period (average first month of life) and thereafter, will consider it a cosmetic procedure unless medically indicated. So to haste on the decision to circumcise for a later date or when the baby or child is older may mean that the parent has to shoulder the costs. This is a big factor for most families.
• Desire to be circumcised. It is not uncommon for a man to be dissatisfied with the size or appearance of his penis. Quite a number of men have an intense desire to be circumcised which usually arises after seeing the circumcised organs of his brother or other men. In time, this initially simple wish to have the appearance of his penis improved becomes an obsession in which he feels that the continuing presence of his foreskin is affecting his sex life.
• Tight foreskin-“Phimosis” After infancy the foreskin should be loose enough to be drawn back so as to completely expose the whole penile head and to be pulled forward again without pain or difficulty. In the mature youth this action should be possible with the penis erect. If it cannot be retracted at all (known as -phimosis), personal hygiene and debris accumulate within the foreskin (smegma). Phimosis also makes sexual intercourse not pleasurable, causes the low deposition of semen in the vagina due to poor penetration and may cause infertility. Occasionally the opening becomes so small that urinating becomes difficult. If a tight prepuce is forcibly drawn back (e.g. during intercourse) it may become jammed and incapable of being pulled forward again (paraphimosis). In this painful condition the foreskin strangulates the glans and emergency treatment is necessary.
• Inflammation. In spite of adequate hygiene, one may suffer from persistent or recurrent soreness, itching or redness of the inner aspect of the foreskin and penile head -(a condition called balanities). Occasionally there may be an acute attack with a discharge of pus that resembles gonorrhea. Balanitis may also occur before the prepuce has fully separated from the glans in childhood when washing is not possible. A long prepuce tends to retain moisture predisposing to this condition which is often precipitated by warm weather (Summer Balanitis). Balanitis occurs especially among males who sweat a lot. One or more acute attacks or recurrent mild attacks heal with scarring of the foreskin and phimosis develops. Similarly, inflammation affecting the glans may heal with scarring and narrowing of the opening of the penis (meatal stenosis).
• Torn or tight frenulum. The frenulum is a band of skin containing a blood vessel and some sensory nerves which joins the inner aspect of the prepuce to the glans on the under surface of the penis. Drawing back the prepuce pulls upon the frenulum and in full penetration during sexual intercourse the frenulum is quite taut. If the frenulum is short or tight, full penetration may cause discomfort which may last for several days; or the structure may tear causing a painful wound for a longer period. Occasionally it tears and bleeds which requires emergency treatment. Surgical division of the frenulum usually cures the trouble and this can easily be done under local anesthesia. Sometimes circumcision has to be done as well to relieve the tension in this area.

2. CIRCUMCISION IS ADVISABLE

• Climate and occupation Balanitis and its complications occur in individuals who live in a warm climate or work in environments that are hot and humid. In hot and humid countries the inhabitants are aware of the problem and practice routine circumcision in childhood as a preventative measure.
• Redundant foreskin. Over half the male population the prepuce shortens during development leaving the glans partially or completely exposed but in the remainder the long infantile form persists. The persistence of a long foreskin must be regarded as a failure of normal development because of the greater incidence of troubles associated with this state. Foreskin length is an inherited characteristic. It retains moisture so that the inner aspect of the prepuce and the glans become white, sodden and malodorous. Balanitis develops in the devitalized tissues and even if the inflammation is mild, phimosis may follow in a few years. A long prepuce may be an anatomical cause of premature or early ejaculation. It seems that the glans is too sensitive due to over-protection from an excess of foreskin.
• Very loose foreskin. Having shown that a tight prepuce is a definite indication for circumcision one would expect that a rather loose one would be an advantage. A loose, short foreskin usually causes no trouble during sexual intercourse but it may ride to-and-fro during everyday activities trapping pubic hairs. A long, loose foreskin may be a nuisance if it will not remain retracted as a collar behind the glans during sexual intercourse but tends to slip forward re-covering the glans. The man virtually self stimulates inside his foreskin during intercourse and his partner complains of lack of stimulation.
• Physical or mental handicap. Severely physically handicapped males may be unable to wash their own genital area, while the mentally handicapped may be incapable of learning and appreciating the need to do so daily. Thus circumcision is advised in this occasions as a preventive measure.
  

3. CIRCUMCISION IS OPTIONAL

• Prevention of cancer of the penis. Cancer of the penis affects men in the 40-70 age group and being fairly rare only causes 80-100 deaths every year. Note again that it is RARE but as you will realize the disease is devastating to men. The joke goes- "it is better to be a female with breast cancer because your chances is better as compared to male with penile cancer". It is treated by partial or complete amputation of the penis and about half of the victims survives for 3 years. Men who develop this cancer give a history of phimosis (tightness of the prepuce or foreskin) and/or balanities (infection of the foreskin) over a period of years. Smegma (materials accumulated inside the foreskin which is not regularly cleaned) seems to be the cancer producing agent which accumulates before the foreskin becomes retractable in the child, or later in life when hygiene is not practiced. Complete circumcision in the first three years of life completely prevents this disease and a lesser degree of protection is afforded if circumcision is incomplete or done later in life.
• Prevention of cancer of the prostate gland. The prostate gland lies at the base of the bladder and supplies part of the liquid that forms the semen. Cancer of the gland may occur in later life. Circumcision may be a preventative measure.
• Hygiene. Those who argue that soap and water are all that is required for penile hygiene and that circumcision is quite unjustified are ignoring the evidence that many males that forget or ignore this part. Parents must show the boy how to retract his prepuce at bath time until he is old enough to do this for himself. This is better said than done. Circumcision renders the penis permanently clean and avoids the washing and inspection which may draw unnecessary attention to his penis at an early age. In the physical and mental handicap, this is a preventive procedure.
• Aesthetic considerations or "looks" Many cultures and individuals are in the opinion that circumcised penises look better.
• Delays orgasm. One of the contentions of doing this procedure is to delay the orgasm of the male. This is however relative. It is said that circumcised penises are lesssensitive because of the destruction of nerve endings by removal of the foreskin. This is the reason why the "dorsal slit" circumcision is recommended and is becoming popular. In this circumcision, no foreskin is removed. As mentioned in part one of this article, this is the desired procedure of Filipinos.
• Improved stimulation during intercourse because of better contact between the glans (head of the penis) and the vagina
• Circumcision increases the efficiency of a small penis.
• Reduces the risk of some sexually transmitted diseases- herpes, fungal infections, warts

In conclusion, currently in the United States, most males are being circumcised. The decision of whether to circumcise or not is entirely dependent on the parents. It is however emphasized continually that if ever a parent is to circumcise his child or not, they should do it because of knowledge of the advantages or disadvantages of each and not ignorance. They take the responsibility to educate their male offspring's with proper hygiene. More so for their children who are not circumcised because of the problems related to non-circumcision. 6

By Joseph C. Nacion, M.D. Medical Director, ACI Pediatrics 

For your comments and suggestions, write me at ACI Pediatrics/ Seven Hills Pediatrics, 2545 S. Bruce St. Suite 8-10, Las Vegas, Nevada, 89109, (702) 733-0744. We have other clinics to serve the valley: • 3815 S. Jones Suite 1A, Las Vegas, Nevada, 89103, (702) 362-6608, • 10001 Eastern Ave., Suite 106, Henderson, Nevada, 89052, (702) 896-6606.