National
Organization of Circumcision
Information Resource Centers
P.O. Box 2512, San
Anselmo, CA 94979
Tel: 415-488-9883 Fax: 415-488-9660 >www.nocirc.org
*****************
Avoiding
Circumcision After the Newborn Period
Alternatives to Circumcision
Overview
The
majority of childhood and adolescent circumcisions are performed
for misdiagnosis of foreskin “problems.”1
2 In the rare instances of true pathology, circumcision is often
utilized as treatment when effective, less invasive, and less expensive
non-surgical treatments are more appropriate.3 4 5
Appropriate Care of the Foreskin
Most foreskin
problems can be avoided with proper care of the intact penis.
During the first few
years of life, the inside fold of a male’s foreskin is normally attached
to the glans.6 7 8 The separation these two structures occurs
naturally over time - a process that should never be hurried.
The foreskin is
usually retractable by age 18.8 Even if the glans and foreskin
separate before then, the foreskin still may not be retractable because
the opening of the foreskin may be lax enough just to allow passage of
urine.9 10
The first person to
retract a child's foreskin should be the child himself.11
Forcing the foreskin back can be painful and can cause problems, such as
infection, adhesions, and/or acquired phimosis.11
Causes of a Reddened Foreskin:
When the tip of the
foreskin becomes reddened, it is doing its job of protecting the glans and
urinary meatus.12
Causes include:
·
Ammoniacal dermatitis (diaper rash) from lengthy exposure to soiled
diapers
·
bubble baths
·
highly chlorinated water (swimming pools, hot tubs)
·
use
of soap on the genitals
·
laundry soap or detergent on clothing
·
antibiotics (Microbial flora can be restored by bacterial replacement
therapy with internal and external Acidophilus culture)
·
concentrated urine from dehydration.
Increasing water
intake, soaking in warm baths, bacterial replacement therapy (liquid
Acidophilus culture ingested and applied to the foreskin 4-6 times daily),
and running around with a bare bottom all help healing.12
Criteria for Medically Indicated Surgery
According to the
Heath Care Financing Administration (HCFA), a medically indicated
circumcision requires a patient complaint, a diagnosis of pathology or
physical abnormality, and conservative treatment for a diagnosed condition
prior to surgery.13
Newborn circumcision
does not meet the criteria for a medically necessary surgery because there
is no documented pathology, physical abnormality, or complaint on the part
of the patient.14 15 16 Therefore, routine circumcision is
non-therapeutic. The American Medical Association says, “The term
‘non-therapeutic’ is synonymous with elective circumcisions that are still
commonly performed on newborn males in the United States."17
Male circumcision is
traumatic,18 destructive,19 removes erogenous
protective tissue,19 and therefore is not in the best interest
of the patient.20 Male post-neonatal circumcision is not
medically justified except in extremely rare circumstances, and only after
all less invasive alternatives have been attempted.21
Common Reasons Used Inappropriately to Justify Circumcision after
the Neonatal Period
Reasons
inappropriately used to circumcise children after the neonatal period:
Social Factors
So children resemble their peers, or
because immigrants adopt a “social norm.”
Phimosis
Most physicians in the United States
received little or no education about the structure, functions,
development, and care of the normal intact penis. Consequently, they may
diagnose a problem that simply does not exist. The non-retractile foreskin
is normal in childhood, and it becomes increasingly retractable with
maturity;8 22 usually requiring no treatment other than
reassuring parents that their child is normal.2 21 The American
Academy of Pediatrics guidelines state the foreskin may not retract until
age 18.23
Gairdner in 1949,7 reported
inaccurate information about the age that foreskin retraction occurs.
Wright (1994) calls Gairdner’s figures inaccurate;11 yet
practicing physicians learned this misinformation in medical school.
Consequently, many physicians do not properly understand normal penile
development.
Øster (1968)8 and Kayaba (1996)22
provide accurate data. According to Øster, 23% of boys in the
6-7-year-old-age group have fully retractable foreskins. By age 10-11,
retractibility increases to 44%; in the 14-15-year-old group, 75% are
retractable, and in the 16-17-year-old group, 95% are retractable.
Kayaba's figures are similar. Kayaba found that 16.7% of 3-4-year-old boys
had fully retractable foreskins. For the 11-15-age group, this figure
increased to 62.9%.
Balanitis Xerotica Obliterans (BXO)
Phimosis caused by balanitis xerotica
obliterans (BXO) is recognizable by a whitish ring of indurated tissue
near the tip of the foreskin and constriction prevents foreskin
retraction.24 25 Diagnosis of BXO, an uncommon condition
affecting 0.6% to 1% of boys by their fifteenth birthday, is confirmed by
biopsy. BXO is treatable without surgery.26
Non-surgical Standard of Treatment of Foreskin Pathologies
Adult Phimosis
If a non-retractile foreskin (not BXO
related) causes problems, such as pain with intercourse, retraction can be
achieved by gentle stretching techniques27 and/or treatment
with a topical steroid ointment (betamethasone valerate 0.05% or
clobetasol proprionate 0.05%) for 30 to 60 days).3 4 5
Those rare cases that are unresponsive to
stretching techniques and/or medical treatment may be treated with
preputioplasty, a conservative minimal surgery. This takes the form of a
limited dorsal slit with transverse closure,28 29 30 or lateral
slits with transverse closure.31 Trauma, pain, and morbidity
are much lower than with traditional circumcision. 28 29 30 31
Recurrent
Balanitis
Physical trauma, irritants, excessive
washing, soap, bubble baths and chlorinated swimming pools or hot tubs may
cause balanitis (inflammation). Infections may be protozoal, fungal,
viral, bacterial, or amoebic in nature. The causative factor may be
difficult to diagnose. Escala & Rickwood recommend taking a swab;32
Birley and Edwards recommend biopsy.33
Correct diagnosis of the causative factor
will determine appropriate treatment.32 33 34 If balanitis is
caused by trauma, such as “foreskin fiddling” or premature forcible
retraction, the traumatic action needs to cease.32 If recurrent
washing and/or the use of soap or other irritants cause balanitis, the
excessive washing should be stopped and the irritant avoided.34
If balanitis is caused by infection, the appropriate antibiotic should be
selected for the specific organism.33 The proper treatment is
medical, not surgical. The foreskin should be left intact so that its
protective effect35 may aid in the treatment.
Escala & Rickwood advise circumcision of
boys only “after recurrent attacks of balanitis which cause
appreciable discomfort” [emphasis added].32 Birley and
colleagues hesitate to recommend circumcision except in cases of plasma
cell (Zoon's balanitis) and lichen sclerosus, but state that it may be
helpful if the balanitis is recurrent.34 They note, however,
that several of their balanitis patients were circumcised men,
demonstrating that circumcision did not prevent balanitis.34
Edwards recommends circumcision only when the balanitis is Zoon's
balanitis or the balanitis of Queyrat.33 Circumcision may not
reduce the incidence of balanitis in boys. Preston states, “[B]alanitis is
uncommon in childhood when the prepuce is performing its protective
function.”15 Van Howe found increased incidence of
balanitis in circumcised boys.36
There is
absolutely no proof that circumcision for balanitis is an efficacious
treatment. The proper treatment is accurate diagnosis of the cause of
inflammation by inquiry, culture, or biopsy. Once the etiology of
balanitis is determined, irritants must be eliminated and/or proper
treatment provided.
Yeast infections with diabetes mellitus
Some non-circumcised males with diabetes
mellitus have recurrent yeast infections caused by high sugar content in
the urine. Careful control of blood sugar will reduce infections, as will
ingestion and application of Acidophilus culture (bacterial replacement
therapy).
Valid Indications for Post-neonatal Circumcision
The following rare
conditions may indicate treatment with circumcision:
Frostbite
If the foreskin is frostbitten to the
point of necrosis, partial or full amputation may be required.
Gangrene
Individuals with diabetes or chronic
alcoholism have been known to have circulatory problems that result in
gangrene of the foreskin. Circumcision is indicated in this rare
condition.
Malignancy
Should a foreskin malignancy develop,
circumcision is indicated. Malignancies are extremely rare.
Conclusion
Good medical practice
requires that doctors keep abreast of advances in the treatment of
disease.21 The decade of the 1990s has seen appreciable
advances in the treatment of disease of the prepuce. Adherence to outmoded
treatment after better treatment becomes available creates medico-legal
vulnerability.37 The information provided in this document will
help doctors keep abreast of the changes in treatment modalities for
common foreskin problems.
References
1. Rickwood AMK, Walker J. Is phimosis over diagnosed in boys
and are too many circumcisions performed in consequence? Ann R Coll
Surg Engl 1989; 71(5): 275-7. URL:
http://www.cirp.org/library/treatment/phimosis/rickwood2/
2.
Griffiths D, Frank JD. Inappropriate circumcision referrals by GPs. J R
Soc Med 1992; 85:324-325. URL:
http://www.cirp.org/library/procedure/griffiths-frank/
3.
Van Howe RS. Cost-effective treatment of phimosis. Pediatrics
1998; 102(4)/e43. URL:
http://www.pediatrics.org/cgi/content/full/102/4/e43
4.
Dewan PA, Tieu HC, and Chieng BS. Phimosis: is circumcision necessary?
J Paediatr Child Health 1996; 32:285-289. URL:
http://www.cirp.org/library/treatment/phimosis/dewan/
5.
Berdeu D, Sauze L, Ha-Vinh P. Blum-Boisgard C. Cost-effectiveness analysis
of treatments for phimosis: a comparison of surgical and medicinal
approaches and their economic effect. BJU 2001; 87(3): 239-244.
URL:
http://www.cirp.org/library/treatment/phimosis/berdeu1/
6.
Deibert, GA. The separation of the prepuce in the human penis. Anat Rec
1933; 57:387-399. URL:
http://www.cirp.org/library/anatomy/deibert/
7.
Gairdner D. The fate of the foreskin. Br Med J 1949; 2:1433-1437.
URL: http://www.cirp.org/library/general/gairdner/
8.
Øster J. Further fate of the foreskin. Arch Dis Child 1968;
43:200-203. URL:
http://www.cirp.org/library/general/oster/
________________________________
Phimosis
[Note: The
normal attachment of the foreskin to the glans is not a pathological
condition. As the AAP pamplet above says, the separation will occur on
its own and may not happen until after puberty. True phimosis, defined
below, can be caused by premature retraction which can also bring on
balanitis. It can also occur as a consequence of circumcision.]
"Cost-effectiveness analysis of
treatments for phimosis: a comparison of surgical and medicinal
approaches and their economic effect," D. Berdeu1, L. Sauze1, P.
Ha-Vinh1 and C. Blum-Boisgard* BJU
International 87 (3), 239-244.
Objective: To compare the
cost-effectiveness of surgery and topical steroids as treatments for
phimosis (defined as a clinically verifiable, pathological, cicatricial
stenosis of the prepuce) and to evaluate the financial basis of these
treatments.
Methods: Data on treatment using
topical steroids was obtained from published reports and those for
circumcision from claims by private hospitals for children < 13 years
old registered at the health insurance department of our facility. The
estimate of the French national financial cost of the treatments for
1998 was calculated from public and private institutional
information.
Results: Treatment with topical
steroids for 4 weeks was successful in 85% of patients (mean age 5
years) and had no side-effects; the remaining 15% were treated by
circumcision. Topical steroid therapy costs (in French francs) F 360 per
patient. For those primarily treated by circumcision (81 boys, mean age
4.3 years) and diagnosed as having phimosis, the cost was F 3330 per
patient in the private sector. The total number of circumcisions
performed in France, regardless of sector (public or private) for 1998
was estimated to be 51 080, which represents an annual cost of F 195.7
million.
Conclusion: As topical
pharmacological treatment avoids the disadvantages, trauma and potential
complications of penile surgery, including anaesthesia-related risks,
the use of topical steroids as a primary treatment appears to be
justified in boys with clinically verifiable phimosis. This treatment
could reduce costs by 75%, which represents a potential annual saving of
150 million.
_______________________________________
A
conservative treatment of phimosis in boys
Eur
Urol 2001 Aug;40(2):196-200
A conservative treatment of phimosis in boys.
ter Meulen PH, Delaere KP.
Department of Urology, Atrium Medical Centre, Heerlen, The Netherlands.
OBJECTIVE: The aim of this study was to evaluate the efficacy of topical
applications
of clobetasol propionate cream in the treatment of phimosis in boys
and
a comparison of the results presented with an overview of the current
studies.
METHODS:
In a prospective study, 94 boys (mean age 5.5 years [Why is anyone
concerned with retraction at this age? D.V.]) were
treated
with topical applications of 0.05% clobetasol propionate cream twice
daily.
The prepuce was treated for 1 month, with an attempt at prepuce
retraction
after 14 days. The boys were evaluated after 1 month of treatment and
every
3 months during follow-up.
RESULTS:
Of the 94 boys, 91 were available for
follow-up,
of whom 42 boys (46.1%) achieved complete retraction of the prepuce,
24
(26.4%) had only preputial adhesions and 4 (4.4%) had partial
retraction.
Twenty-one
boys (23.1%) had no response. The treatment was continued in 13 boys
with
good results eventually. Seven boys (7.7%) had recurrence after a mean
follow-up
of 4.3 months (range 2-7). No side effects were noted. Circumcision
was
necessary in 24 of the 91 boys (26.4%). The mean follow-up was 11.0
months
(range
3-18). CONCLUSIONS: Local application of clobetasol propionate cream is
a
simple,
safe and effective treatment for phimosis in boys and avoids
circumcision
and its associated risks. It should be offered first instead of
circumcision.
PMID:
11528198 [PubMed - in process]
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Treatment
of childhood phimosis
with a moderately potent topical steroid
2:
ANZ J Surg 2001 Sep;71(9):541-54
Ng WT, Fan N, Wong CK, Leung SL, Yuen KS, Sze YS, Cheng PW.
Department of Surgery, Yan Chai Hospital, Tsuen Wan, Hong Kong.
BACKGROUND:
Recently, topical steroid application has been shown by a small
number
of studies to be an effective alternative to circumcision for the
treatment
of phimosis. However, only potent or very potent corticosteroids have
been
more thoroughly studied in this treatment option. A prospective study
was
conducted
to determine whether comparable results could be achieved using a
weaker
steroid cream.
METHODS:
Boys, 3-13 years of age [Why is anyone concerned with retraction at this
age? D.V], with non-retractable
foreskin
due to a tight ring at the tip were offered the regimen of twice-daily
preputial
retraction and topical application of 0.02% triamcinolone acetonide
cream.
The degree of preputial retractability was assessed at presentation and
at 4
and 6 weeks of treatment. Success was defined as full retraction or free
retraction
up to agglutination of the foreskin to the glans.
RESULTS:
Eighty-three
boys completed the treatment. Successful retraction was achieved in
48/83
(58%) patients after 4 weeks and 70/83 (84%) patients after 6 weeks of
application.
The overall response rate aggregated from six published series
using
0.05% betamethasone was 87% at 4 weeks and 90% on completion of
treatment.
Thus,
the results appear inferior when analysed at 4 weeks but compare
favourably with those reported for a more potent steroid on completion
of the
full
course of treatment. CONCLUSIONS: Even though the triamcinolone cream
used
in
the present study is less potent than the more commonly used 0.05%
betamethasone
valerate cream, it could effect comparable improvements in
foreskin
retractability after 6 weeks of treatment.
_____________________________________
http://www.reuters.com/newsArticle.jhtml?type=healthNews&storyID=8303274
Journal of Urology, April 2005.
Semi-Potent Steroids Treat Tight
Foreskin Problem
Tue Apr 26, 2005 05:23 PM ET NEW YORK (Reuters Health) -
Moderately potent topical steroids are just as
effective as highly potent ones for treating phimosis and offer a lower
risk of side effects, new research suggests. Phimosis is a condition in
which the foreskin opening is too small for it to be pulled back over
the head of the penis. Phimosis can affect 8 percent of boys between the
ages of 6 and 7. Although phimosis can resolve by itself, it is often
treated by circumcision, in which the foreskin is surgically removed.
While circumcision is an effective treatment for phimosis, various
complications can occur and topical steroid therapy has emerged as
alternative. The British National Formulary and other groups have
divided topical steroids into several potency categories. Most studies
looking at these agents as a treatment for phimosis have included only
ultra-high or high potency steroids. Thus, it is unclear if lower
potency steroids could achieve the same results with a better side
effect profile. To investigate, Dr. Chung Cheng Wang, from En Chu Kong
Hospital in Taipei, Taiwan, and colleagues assessed the outcomes of 70
boys who were randomly assigned to receive topical therapy with
betamethasone, a highly potent steroid, or with clobetasone, a
moderately potent steroid. The treatment response rates in the two
groups were not significantly different -- about 79 percent. The average
drop in the phimosis severity score was also comparable in each group --
about 2.2. No significant adverse effects were seen in either group.
Writing in the April issue of the Journal of Urology, the investigators
say that when topical steroid application is attempted to treat phimosis,
moderately potent steroids should be considered first to avoid adverse
effects that could, in theory, occur with higher potency agents.
____________________________________
Conservative Treatment of Paraphymosis
Ann R Coll Surg
Engl 2001 Mar;83(2):126-7
Modified puncture technique for reduction of [sic].
Kumar V, Javle P.
Department of Urology, Leighton Hospital, Crewe, Cheshire, UK.
vkumar3908@hotmail.com
PATIENTS AND
METHODS: A total of 45 patients underwent reduction of
paraphymosis at LN Hospital, Delhi, India and Leighton Hospital, Crewe,
UK from August 1991 to September 1999 using the multiple puncture and
glans squeeze technique. These were divided into 3 grades: grade 1,
paraphymosis without engorgement of glans; grade 2, paraphymosis with
engorgement of glans; and grade 3, paraphymosis with associated skin
changes (non-pitting oedema, cheese-cutting of the shaft of the penis or
erosions).
RESULTS: Grade 1 (6) patients were reduced by simply pulling
the foreskin back into the normal position. Grade 2 (37) patients were
reduced by the above-mentioned technique. Grade 3 (2) patients could not
be reduced by this technique and the band had to be divided.
CONCLUSIONS:
Difficult paraphymosis with gross engorgement of the glans
can be successfully reduced by this technique as long as the skin
changes are not marked.
_______________________________________________