All About The Penis

Circumcision, the glans & the foreskin

It is estimated that there are currently in the world 650 million males who have been circumcised. think of what that means: the foreskin is removed from the penis without anesthetic. The most sensitive part of the body - the penis - is effectively mutilated for social or religious reasons. Do you think that this will have an impact on a man's pleasure?

Circumcision is a unique medical procedure in that the majority of circumcisions are not performed for medical reasons or by qualified medical practitioners. The historical origins of circumcision are unclear, but the practice is found throughout the world - in Native Americans, Australian Aboriginals, African and Middle Eastern tribesmen, and in the earliest Egyptian mummies. Almost all of these circumcisions were carried out for cultural or religious reasons, and in much of the world this continues to the present day, with circumcision a part of defining religious or tribal identity. A wonderful example of this can be found in the autobiography of Nelson Mandela, in which he describes his own circumcision as part of his rite of passage to adulthood. In the USA, circumcision remains the cultural norm, and 70-90% of all male babies are circumcised.

In this chapter we detail the medical indications for circumcision and the complications of surgery. Some of the issues that govern circumcision for religious purposes are discussed, and we examine the ethical and legal implications that are pertinent to the circumcision of minors. Medical practitioners need to be familiar with all these aspects of circumcision, to be able to advise on the wide range of questions that can arise when counseling parents and patients.

Religious circumcision

Amongst the major religions of the world, only in Judaism and Islam is circumcision an accepted religious rite. The origins of Christianity are found in Judaism and there are many similarities in the rites and laws of both religions, but there is no mandatory circumcision in Christianity. Similarly, there is no obligation for circumcision in the Buddhist, Sikh and Hindu religions.

Circumcision of a male neonate is an essential undertaking within the Jewish religion, and is performed by a specifically trained mohel (pt. mohelim). In the United Kingdom (UK), mohelim are trained according to strict guidelines under the auspices of the Initiation Society. It is a requirement that a mohel is a practicing Jew himself (it is generally accepted that a mohel has been circumcised, thus precluding women), attends around 50 circumcisions before actually performing one, and is examined through both written and practical assessments. Although the Torah states that circumcision occurs on the eighth day, the mohel visits the family a few days prior to this to ensure that the child is healthy. Jewish law allows for a delay in circumcision should the child be suffering from any ailment, since the welfare of the child is paramount. For the procedure itself the use of local anesthetics, though not routine, is not prohibited within the Jewish Talmud (an explanatory commentary and debate on the various biblical laws) and may occur at the request of the family. The cut edge of the prepuce is not sutured and haemostasis is achieved by means of bandaging. The mohel is required to visit at least once after the procedure to check the wound, and leaves aftercare instructions. Although no precise figures are available, the complication rates of Jewish circumcisions in the UK are thought to be low.

Given its place as part of the covenant of Abraham, it is likely that circumcision will remain a central part of Judaism and, as such, it may be of the utmost importance to a Jewish parent that their son be circumcised, even if the other parent is not a Jew.

Medical considerations in circumcision

Embryology and functional anatomy of the prepuce

The prepuce develops from ectoderm, neuroectoderm and mesenchyme to form a structure that is comprised of an inner epithelial-lined mucosa, a lamina propria, dartos muscle, with dermis and glabrous skin on the outer surface. The prepuce first appears at 8 weeks' gestation as an epithelial thickening that grows forward over the developing glans, covering the glans completely by 16 weeks.

During development, there is no plane of separation between the epithelium of the glans and that of the under-surface of the prepuce, and at birth the prepuce is almost always non-retractile. Separation of the two layers occurs as a result of spontaneous desquamation that commences in the distal prepuce at the end of gestation and proceeds proximally at varying rates. Hence, there is a considerable variation in the age at which the prepuce is fully retractile in different individuals, with 90% having a non-retractile prepuce at birth and 98% having a fully retractile prepuce at puberty. Importantly, even though a child may not have a fully retractile foreskin, partial retraction of the foreskin to its limit produces a characteristic 'flowering' appearance around the prepuce. The importance and significance of this are discussed later. The somatosenory innervation of the prepuce is by the dorsal nerve of the penis and branches of the perineal nerve. Additionally, the prepuce receives an autonomic innervation - parasympathetic visceral efferents and afferents from the sacral plexus and sympathetic visceral afferents from the lateral horns of T1 I-L2. Thus, neither a block of the dorsal penile nerve nor topical EMLA cream  completely relieve the pain of circumcision. Microscopically, the prepuce has a dense population of fine touch nerve endings (mainly Meissner's corpuscles). Conversely, the glans has very few such nerve endings and is instead innervated by those associated with pain and temperature sensation, with the exception of the corona and frenulum. During intercourse, the glans glides over the prepuce whereas in the circumcised male it slides directly against the vaginal wall resulting in considerably more friction. Interestingly, there is some suggestion that women having experience of intercourse with both circumcised and uncircumcised find the latter to be preferable.

The prepuce is therefore a specialized erogenous tissue, and surgical removal of the normal prepuce results in the loss of most of the fine touch receptors of the penis, and the glans itself becomes thickened and keratinized.

Medical indications for circumcision

The pathology that provokes the need for circumcision is different in infants and adults.

In infants there is often a dilemma whether a non-retractile prepuce is truly phimosed. The appearance of ballooning of the prepuce during micturition is often thought to indicate a significant degree of phimosis, but this is not so. The only absolute evidence in an infant that circumcision is essential is when, on attempted retraction, the prepuce takes on the appearance of a helmet. If the prepuce begins to open and to take on the appearance of a flower, then no true phimosis exists. There is seldom any contraindication to pursuing a conservative management policy, and reviewing the child after an interval of 6-12 months.

In an adult the only absolute indication for circumcision is true pathological phimosis, which is almost invariably due to balanitis xerotica obliterans (BXO, diagnosed on histological examination). This condition is essentially genital lichen sclerosis in males. It is characterized by hyperkeratinization, collagen deposition within the papillary dermis and lymphocyte infiltration into the inner dermis. Macroscopically, there is scarring of the preputial opening (with or without narrowing of the urethral meatus). Affected areas appear white, scarred and indurated. Attempts to retract the foreskin do not produce the normal 'flowering' of a developmentally incompletely retractile foreskin. The most florid cases of BX0 affect the whole of the preputial sac, resulting in a scarred prepuce that is densely adherent to the underlying glans. Although there has been the suggestion that BXO is a premalignant condition, this is not a universally accepted belief and a full consideration of this topic is beyond the scope of this chapter.

Other conditions such as balanoposthitis (inflammation of the prepuce) and paraphimosis can usually be managed without resorting to circumcision, which should be reserved for frequent troublesome recurrences (although circumcision does offer permanent cure).

Surgical technique and complications in circumcision

The operative procedure is similar in all age groups. Some form of topical analgesia is necessary, but without a general anesthetic the procedure will always be very uncomfortable. A dorsal penile block can be used to provide worthwhile postoperative analgesia. The adhesions between the glans and the inner layer of the prepuce must be broken down. This may leave the glans raw if there is a severe extent of BXO. The penile skin at the level of the corona should be marked circumferentially and incised cleanly. The two layers of the prepuce should be divided dorsally in the midline longitudinally between artery forceps from the preputial opening to 5 mm proximal to the corona. The inner layer of the prepuce should then be incised circumferentially, maintaining the 5-mm distance from the corona. Ventrally the frenular artery will be divided and must be ligated with a stitch ligature. The subcutaneous tissue by which the prepuce then remains attached should be divided, and any veins encountered should either be coagulated with diathermy or ligated with a fine absorbable ligature. If diathermy is used it is essential to use bipolar and not monopolar diathermy (see below). The penile and inner preputial layers of skin are then approximated with a fine absorbable suture material. Ventrally the inner layer of the prepuce should be closed longitudinally for a distance of a few millimetres, before commencing a circumferential closure. This will ensure that there is no tight band ventrally, which can be uncomfortable on erection and intercourse.

Recognized complications occur both early and late. If the frenular artery or a significant penile vein is not secured, significant bleeding can occur, necessitating ligation of the vessel under general anesthesia. Infection can develop, most commonly at the level of the corona, particularly if there has been balanitis at the time of the circumcision. Systemic antibiotics and cleaning the infected area with saline will usually result in an acceptable cosmetic and functional result, though this may take several weeks. In patients with BXO the external urethral meatus may be affected, resulting in meatal stenosis, which can be a difficult problem to resolve. Erections may be impaired if too much penile skin is removed. The most devastating complication of all can occur if the 'guillotine' technique is used for circumcision. The practitioner pulls on the end of the prepuce and with a swift motion cuts across what is thought to be prepuce, but which in reality is glans and prepuce. The resulting distal penile amputation is an irretrievable disaster.

Uncircumcision

Some men who were circumcised soon after birth request an operative procedure to reverse their circumcision. This is not at all easy to do. Some men attempt to lengthen the penile skin by attaching small weights to tapes attached to the skin of the penis. The lengthening process may take more than a year and the end result is often disappointing. Reconstructive surgical procedures have been described, but are risky. Descriptions of surgical technique have usually been anecdotal, and results of long term follow-up are virtually non-existent in the literature, but are probably poor.

Sexually transmitted disease and circumcision

Although Islam and Judaism account for only a small proportion of religious identities within the USA, up to 90% of all newborn males are circumcised. One of the reasons for this practice is the longheld conviction that circumcision significantly lowers the risk of the development in adult life of a number of disorders of the penis, and of contracting sexually transmitted diseases.

There is variable evidence for such a 'protective' role for circumcision, but with little consistency in either the quality of different reports, or in the degree of attention given to different disorders. It is beyond the scope of this chapter to provide the reader with a full analysis of the merits and weaknesses of the evidence pertaining to each condition, and so a summary is presented.

A large population-based study from the USA found no clear association between circumcision status and hepatitis B, syphilis, gonorrhea or nongonococcal urethritis. In addition, there has been no consistent difference between circumcised and uncircumcised men for herpes simplex. Because of its association with penile and cervical carcinomas, the differing incidences of human papilloma virus (HPV) in circumcised and uncircumcised men have been closely examined. Although in the USA penile cancer has been reported to be more common in uncircumcised men, more recent evidence suggests that HPV infection is equally common. However, the results of population studies of circumcised and uncircumcised men are awaited to see if there is a corresponding change in the incidence of penile cancer.

Perhaps most interesting, and certainly most topical, is the suggestion that circumcision protects against human immunodeficiency virus (HIV) infection. Although large meta-analyses of this issue have reached vastly differing conclusions, in one study a very strong suggestion that circumcision is indeed protective against HIV has been shown. As part of a study on HIV infection in Africa in couples with disparate HIV status9 it was noted that, of the 60 couples where the mate was HIV negative and the female HIV positive, none of the circumcised males became infected whereas 17% of the uncircumcised males contracted HIV.

Legal and ethical issues surrounding circumcision

It is widely recognized internationally that circumcision (medically irreversible removal of a specialized erogenous tissue which confers no unequivocal prophylactic medical benefit and carries potential risks and long term consequences) is still accepted as a right within certain religious groups, is encouraged in many other societies, and is the norm in the USA. More recently, some have challenged the idea that circumcision is a pre-requisite for a newborn male to be accepted into Jewish religion and culture, and this has come from within the Jewish community - both in the USA and in Israel itself.

To fully examine this complex and highly sensitive issue, two concepts have to be considered: the right of an individual (adult or child) to be circumcised, and the right of a child to be protected from being circumcised until he is adequately competent to make a decision for himself.

The right to be circumcised

It would be difficult to argue that a competent adult requesting circumcision for religious, cultural or perceived medical reasons does not have the right to the procedure. Although UK law has found that consent from a competent adult does not guard against prosecution for extreme acts of sadomasochism through torture or genital mutilation, circumcision does not at present fall into this category and it would require a direct legal challenge to change this. The distinction as to when it becomes a matter for the individual concerned or for the parents of a minor depends on, in the UK, the child being 'Gillick competent'. This means that the child must have the mental capacity to make a decision for himself based on an analysis of the risk and benefits. Where a child lacks this ability, the decision rests with the parents and thus it is essential to be sure that they are acting in the child's best interests.

The argument that a child has the legal right to be circumcised for cultural or religious reasons, or put differently that the parents have a right to circumcise their child for their religious or cultural beliefs, relies on the assumption that not to do so would be to the detriment of the child's welfare. Whilst arguably not in the interests of the child's physical welfare at the time, ritual circumcision is part of long established practice and it is argued that denying this to a child excludes him from fully participating in his community or religious life. Thus it can be argued that failure by Jewish or Muslim parents to circumcise their child constitutes abuse as this would result in psychological harm from exclusion at school or in the community. The International Convention on the Rights of the Child states in Article 8 that 'States Parties undertake to respect the right of the child to preserve his or her identity', although the Article does not assist by defining or elucidating on the term 'identity'. Furthermore, Article 14 gives further support to a parent's right to bring up their child according to established ritual practices since States "shall respect the rights of and duties of parents ... to provide direction to the child in the exercise of his or her right in a manner consistent with the evolving capacities of the child", and thus circumcision can be argued to be consistent with 'direction'. Hence, when viewed in the long term, the best interests of Jewish and Muslim children and children from cultures where childhood circumcision forms a rite of passage require that parents allow them to undergo circumcision.

A child's right to protection from circumcision

As noted earlier, an adult has the capacity to give consent for circumcision for religious or cultural reasons, and certainly it cannot be argued that an adult cannot consent for circumcision for medical reasons. Thus it follows that in such situations, a medical practitioner has a legal defense against malpractice and a religious circumciser against actual bodily harm.

The legal position of involuntary circumcision (of children) is controversial, especially when considering religious circumcision. The argument by opponents of circumcision is that it is tantamount to child abuse. Such a claim potentially carries very serious consequences and its validity must be examined closely. Given that a child cannot give consent for circumcision, this must be obtained from a parent acting on behalf of the child. But for parents to give informed consent for a medical procedure, it is required that the child must be suffering from an illness or trauma that would result in injury, deformity, disability or death were treatment withheld. For non-emergency conditions, where delay would not endanger the child, it is now considered that treatment should be delayed until the child can make his or her own informed decision. Courts in both the USA and elsewhere have consistently ruled to uphold the bodily integrity of incompetent people, minors and adults. Likewise, the ability of parents to secure medical interventions for their children has been limited if the intervention could pose a risk to the health or safety of the child. A court in Texas prevented an incompetent girl from being put forward as a kidney donor, ruling that consent for surgical intrusions is limited to 'treatment'. All similar rulings have upheld that the removal of normal tissue or organs is not treatment.

Article 24.3 of the International Convention on the Rights of the Child, which has been ratified by all countries of the United Nations except Somalia and the USA, requires that all practices prejudicial to the health of the child be abolished. Article 19.1 requires that states ensure that no abuse or harm come to a child whilst in the care of parents or guardians. Article 16 requires that there be no unlawful or arbitrary interference with the privacy of children. Because of the persisting legality of corporal punishment, the UK has been found to be in breach of the Convention. Thus, the overriding importance of the child's best interest limits parental power. Parents must be seen to act in accordance with what children would wish for themselves. In a survey of American men circumcised as neonates, only 0.3% responded that they would have undergone the procedure later in life if given the choice. Hence, parental consent can only be valid if circumcision is required as the immediate treatment for a medical pathology, and it is hard to defend it on the dubious grounds of being a preventative measure.

It is further argued by some that involuntary circumcision cannot constitute child abuse because it is only a 'minor procedure' and, in neonates, causes only mild discomfort. Compare this with the observation that, although frequently a day case procedure in adults, circumcision is seldom performed under regional or local anesthesia. Although neonates exhibit reactions to painful stimuli that are different from those expressed by children or adults, there is no doubt that circumcision is a highly noxious stimulus. Certainly, the DSM-1V definition of trauma (an experience outside normal experience including torture, assault or threat to physical integrity) certainly applies to circumcision when looked at from the infant's point of view. Studies have in fact shown that there is a considerable rise in heart rate` and serum cortisol, and that children circumcised as neonates demonstrate a grossly exaggerated response to routine vaccinations compared to uncircumcised children. Additionally, there are many cases of mothers whose babies are circumcised in their presence (especially Jewish women) who report considerable psychological trauma arising from the experience.

Of the different cultural and religious groups that promote or require circumcision, Judaism has a very strong basis for the practice. It is perhaps significant therefore that there is growing cultural practice of 'anti -circumcision' arising from Jewish groups within both the USA and Israel. Their contention is that the sole requirement to a Jewish identity is to be born of a Jewish mother and that, contrary to popular belief, circumcision is not a necessity for this identity. They also contend that there is very little understanding within the Jewish authorities concerning the psychological harm arising from circumcision and that, despite the above evidence to the contrary, it is standard belief amongst mohelim and rabbis that neonatal circumcision is entirely harmless and pain free (or that there is 'mild discomfort' only). Whilst it is certainly not our intention to challenge thousands of years of religious practice, it is important to be fully aware of changing beliefs regarding circumcision, and to be able to advise and support parents accordingly.

Conclusion

Traditions dictate much of the behavior that occurs in society. Whether circumcision should remain a tradition will be strongly debated and any medical practitioner who has dealings with such patients or parents must be fully aware of the how ethical and social trends are changing. The operation, when performed for medical reasons, requires skill, care and time and patients should be aware of the need to arrange a period of convalescence.
 

Circumcision

Circumcision has been implicated in removing sexual sensitivity from the penis, although whether it is a contributory factor in delayed ejaculation is not entirely clear just yet. If you happen to be a man who suffers from delayed ejaculation, then you will want a treatment to help you ejaculate normally during sex which works swiftly, effectively, and is simple to try at home. There is no need to try and cope with the problem in a sexual relationship when a simple and effective treatment is available.