Posthitis, Balanitis and Circumcision

Routine circumcision remains controversial.

Although 80% of the world’s population does not practice circumcision, the operation is done either for “health reasons” or as a religious ritual by Moslem, Jews, most black Africans and others. According to some, one reason that circumcision is prevalent in the United States is that medical and popular literature abounds in errors of judgment and obfuscation.

Boys are not usually born with a retractable foreskin and the physiologic process of penile skin dehiscence from the glans takes place over a period of months or years. At birth, 5% of boys have a retractable foreskin, whereas at 5 years of age most boys will have a retractable foreskin. Physiologic neonatal phimosis therefore is the rule rather than the exception.

Routine foreskin retraction is often suggested for “cleaning” and to remove smegma. Sometimes smegma can be seen as small deposits under the foreskin or sometimes it egresses from the edge of the glans. Smegma consists of secretions from the glands of Tyson and desquamated epithelial cells. This material is not pus and rarely leads to infection, and there is no place for instructing mothers to retract the infant’s foreskin on the pretext that removing this physiologic secretion improves hygiene. In fact, forcible retraction of the foreskin may lead to complications. Such force may lead to tearing, bleeding and secondary scarring, bringing about a true phimosis. Our recommendation then, is that in the uncircumcised infant external cleaning of the penis is all that is necessary until separation of the prepuce is complete and retraction possible. Of course, appropriate separation for easy retraction will not occur in all boys, and some will require a circumcision.

Circumcision is the most frequently performed operation in the United States. Most neonatal circumcisions are performed with the use of clamps or devices (Plastibell, Gomco, Mogen) and without any form of anesthesia. The incidence of complications following neonatal circumcision varies in the literature from about 0.2% to 5%. The majority of circumcision complications occur with devices and clamps and rarely when performed through formal surgery (sleeve resection).

The sleeve resection circumcision is performed as an outpatient under a general anesthetic. After also placing a local anesthetic block for added pain control, the sleeve of foreskin is excised, the bleeding is stopped with cautery, and the skin defect is closed with absorbable sutures.

Most circumcision complications are minor, and the risks can be immediate or delayed. Immediate risks include: hemorrhage, excessive skin excision, separation of skin edges, glans amputation and urethrocutaneous fistula formation. As the foreskin is often asymmetric in boys with a penile anomaly, excess skin may be removed from the ventral penile surface inadvertently when using a clamp or device. When circumcision is desired and no other reconstructive procedure is anticipated, we perform formal surgical circumcision in boys under anesthesia to better allow for this asymmetry.

Delayed risks include: infection, skin bridges, urinary retention and lymphedema. Excessive skin (inner preputial) removal can lead to concealed penis and/or penile webbing. Some degree of meatal stenosis (due to meatitis) is common but meatotomy is rarely required. Insufficient skin removal can lead to redundancy or adherence of the skin margin to the glans. The cutting current should never be used during circumcision, as current spread can lead to devascularization, necrosis and penile loss. Deaths are very rare and most often due to sepsis.

One risk for uncircumcised boys is urinary tract infections, which are 10 to 20 times more common in uncircumcised than in circumcised boys. Opponents of circumcision have argued, however, that it would take 98 circumcisions in order to prevent 2 urinary tract infections. The presence of a urinary tract infection in an uncircumcised boy, however, still mandates radiological investigation because of possible underlying developmental causes such as reflux. Other risks in uncircumcised boys include: posthitis, balanitis, phimosis and paraphimosis.

Cancer of the penis occurs almost exclusively in the man who has not been circumcised. However, despite mediocre studies that attest to a cause and effect relationship between smegma/poor hygiene and increased risk of penile cancer, convincing data are not yet to hand. Such data are also awaited regarding the claimed epidemiologic relationship between prophylactic circumcision and diminished risk of penile cancer.

Human papilloma virus (HPV) Type 16 and Type 18 have also been found in association with women who have cancer of the cervix. Again, despite the association of the HPV virus with cancer of the penis and cervical cancer there is still no strong evidence associating the uncircumcised male with increased risk for harboring these viruses. Also, there are no solid data associating sexually transmitted diseases with the uncircumcised male.

The main medical contraindications for circumcision are low birth weight, bleeding diathesis, or any genital deformities such as hypospadias where the foreskin may be necessary for urethral reconstruction.

The main medical indications for circumcision are paraphimosis or phimosis. An alternative to this procedure may be the dorsal slit. Rarely a tight frenulum can compromise retractability, and this can be incised if parents wish to preserve the prepuce and it is appropriate.

It is important that parents understand the potential risks, alternatives and benefits of circumcision with or without anesthesia through informed consent. Circumcision when properly performed may have potential medical benefits. When the circumcision is done through formal surgery (as opposed to that done with a clamp or device) we usually wait until the infant is at least 3 months of age, after which the risks of general anesthesia are minimal. Like any procedure, however, there are associated disadvantages and risks. Surgery for ritual and cultural reasons may be indicated because of the parent’s/patient’s beliefs, but physicians should take care not to misconstrue these indications for ones that are based on sound medical principles.