Circumcision

Circumcision is the surgical procedure in which the foreskin, known in medical terminology as the prepuce, which covers the glans penis (the tip of the penis), is removed to a specific shape and length, exposing the tip of the penis. In addition to being a tradition, circumcision is the most commonly performed surgical procedure in the world.

On average, 25% of all men worldwide are circumcised for religious, cultural, medical or family reasons. In the 19th century, routine circumcision of newborns began to be performed to protect against diseases, and it quickly gained acceptance, especially in English-speaking countries.

Today, neonatal circumcision is a very common operation in America.

In our country, circumcision is a religious and social requirement and is performed on all male children.

When should circumcision be performed?

Circumcision can be performed at any age; however, it is not recommended under local anaesthesia between the ages of 4 and 6 years, as it may cause psychological trauma, whereas in this age group it can easily be performed under general anaesthesia. Recently, the newborn period has been accepted as the most ideal age, due to the ease of the surgical procedure, the rapid healing of the wound in the baby, the ease of post-circumcision care, and because no personality has yet formed in the newborn, so no psychological trauma is caused. However, if frequent urinary tract infections occur due to the narrowing of the foreskin opening, which is called phimosis, circumcision is necessary regardless of age.

Who should perform circumcision?

In our country, circumcision may be performed by physicians, health officers, and even persons who have worked with a health officer for an appropriate period, as stated in the law that regulates the oldest medical practices. Today, it is most commonly performed by urology specialists, paediatric surgeons or general surgeons.

How and where should circumcision be performed?

For a surgical procedure on an organ that is of great importance to society, it will be the right choice to perform it under hospital conditions and in an operating theatre.

What are the methods?

Although there are several different methods for circumcision, the most reliable method with the fewest side effects, most frequently used by specialists today, is the surgical method, which is classically performed by surgically cutting the foreskin and suturing the edges together.

What should those who will be circumcised pay attention to?

Circumcision must absolutely not be performed in the presence of hypospadias, known among the public as being born circumcised or Prophet's circumcision, because in these patients the urinary opening is not where it should be. This condition needs to be corrected surgically, and foreskin is generally used in such operations. If there is a blood disease or a bleeding disorder in the family, the child should not be circumcised without consulting a doctor and without blood tests, even if the child has no complaints. Children with a history of prolonged bleeding after a fall or tooth extraction, those who develop bruising, swelling and bruises after an injection or after a blow, and children who occasionally have spontaneous gum or nose bleeding must definitely undergo blood tests before being circumcised. Chronic (persistent) diseases in the family, previously experienced significant illnesses (e.g., those requiring hospitalisation) and operations must also be known to the physician who will perform the procedure. In patients with problems, dangerous situations can be prevented by taking the necessary precautions before circumcision.

Definitively established benefits of circumcision:

• If the opening of the foreskin is narrow (phimosis), difficulty in urination and subsequent infection may occur, and at more advanced stages, significant problems in the upper urinary tracts may arise due to obstruction. This narrowing can be relieved by circumcision.
• Circumcision reduces the risk of penile cancer.
• It prevents the transmission of sexually transmitted diseases (such as AIDS, for example).
• It is claimed that the risk of cervical cancer decreases in the partners of circumcised individuals.
• Circumcision reduces urinary tract infections tenfold, because bacterial accumulation and multiplication under the foreskin is prevented.

What are the medical indications for circumcision?

Phimosis: Inability to retract the foreskin is physiological in young age groups. When an attempt is made to retract the foreskin, injury, tearing and bleeding of the foreskin occur along with pain, and excessive scarring forms at the tip of the foreskin. This scarred tissue ring is called phimosis. Other acquired causes include recurrent infection, poor hygiene, and excessive scar tissue after circumcision. Only 5% of phimosis is congenital. A narrow diameter at the tip of the foreskin and swelling of the foreskin during urination are meaningful for diagnosis.

Paraphimosis: If, in the presence of a circular scar at the tip of the foreskin that prevents retraction, the foreskin is forced back, the phimotic ring may constrict the head of the penis. This may cause secondary swelling of the penis, pain and inability to urinate, and may require urgent surgical intervention. This condition is often corrected manually, and circumcision is then performed under normal conditions. If it cannot be returned to its normal position manually, emergency circumcision is performed.

Balanoposthitis: It is an inflammatory condition involving both the glans and the foreskin at the tip of the penis. Along with a red, swollen prepuce, serous-purulent discharge is seen from the prepuce opening. Circumcision is recommended early, after treatment of the acute phase of the pathology.

Trauma: In cases of entrapment in a zipper or injury to the foreskin for other reasons, emergency circumcision is performed.

Urological anomaly: Circumcision is beneficial in patients who require frequent urine cultures or who have urine reflux into the kidney (vesicoureteral reflux) under conservative follow-up.

Circumcision is recommended in children with urinary system infections in whom no anatomical disorder can be detected. In circumcised children, the rate of urinary system infection is 0.1-0.2%, whereas in uncircumcised children it is encountered at a rate of 1.1-4.2%.

Complications and disadvantages

The problems that may arise in circumcisions performed by persons who are not specialists in the field are as follows:

Bleeding: Observed in circumcisions performed with inappropriate techniques or following trauma after circumcision, in normal children or children with a blood disease. While a second surgical procedure is sufficient in normal children, in children with a blood disease it may sometimes be too late.

Shape deformity: Observed in circumcisions performed with an inappropriate technique or by persons who are not specialists in the field. If the shape deformity is within acceptable limits or at a level that does not disturb the family or the child, it is waited on until adolescence. If the shape deformity has not decreased or disappeared after adolescence, re-circumcision is required.

Permanent disability: Observed if there has been excessive tissue loss or excessive burning with cautery. Although partial correction can be made with various cosmetic operations, functional losses are not corrected.

Poor scar tissue: Observed in children whose wound edges were not sutured and were left to heal on their own.

Infection and contagious jaundice: Seen more frequently in circumcisions performed at home, where the necessary antisepsis conditions cannot be provided, or in open areas in mass circumcisions. Especially in mass circumcisions, Hepatitis B, C and HIV infections may be seen.

Prophet's circumcision: Circumcising children whose urinary opening is located lower down may cause these children to lose their chance of a simple operation or to require several much more serious operations.

Glans penis injury: The glans penis may be injured partially or completely. Partial cuts can be easily corrected, while significant problems may be experienced in complete injuries.

Meatal stenosis: Meatal narrowing may develop due to cutting of the frenular artery, or due to meatal ulcers that may develop in children wearing diapers.

Urethral fistula: A urethrocutaneous fistula may develop as a result of injury to the urethra during circumcision. It needs to be corrected surgically.

Inadequate removal of the foreskin: In this case, the appearance intended by circumcision cannot be achieved.

Urinary retention: Because the dressing applied after circumcision may be too tight, difficulty in urinary outflow may be experienced, and this may lead to urinary tract infection and kidney damage.

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