Circumcision is the surgical removal of the skin covering the head of the penis in men. It is mostly grown in societies for religious/cultural reasons. In terms of religion, circumcision is important for Jews and Muslims. In some cases, circumcision becomes a medical necessity and must be done. Since it has many advantages in scientific studies, circumcision is also performed for religious reasons. In this article, I will give general information about circumcision, its importance, advantages, medical conditions and complications, which is a urological surgical application.

What is circumcision, what are the methods of circumcision?

Circumcision is the complete removal of the skin covering the head of the penis to the back of the head. In some countries it is a religious ritual. In some countries, such as the United States, it is an increasingly common surgical procedure in newborns for medical reasons.

Circumcision is done in different ways. These methods are:

• Classical medical circumcision
• Circumcision with laser or cautery
• Bell method

We prefer the medical, that is, the classical surgical method.

How is circumcision done?

Circumcision is a surgical practice. It should be performed in operating room conditions and under anesthesia. We also perform all children who will be circumcised in appropriate environments and under anesthesia.

In newborns, it is usually done 10 days after birth. The foreskin is cleaned with antiseptics, local anesthetic cream or gel is applied, then the foreskin is cut and removed. Then the glans is wrapped with antibiotic ointments so that it is not too tight.

It is necessary to prefer the operating room environment in the same way for older children and adults. If the child can be performed with local anesthesia, if not, the procedure is performed under anesthesia. In adults, surgery is performed under local or anesthesia. Bleeding vessels in older children and adults are cauterized or ligated. The incision is closed with thin, absorbable surgical sutures for proper skin closure.

How is the follow-up after circumcision?

Post-surgery is generally uneventful. There may be pain after the effect of the anesthesia wears off. Painkillers are given against pain. Since the procedure is performed under sterile conditions, the risk of infection is extremely low. After the procedure, the circumcision area is gently wrapped with antibiotic pomades and closed. Preventive antibiotics prevent future infections. Wound healing usually takes place within 7-10 days.

Why is circumcision done?

Circumcision surgery, which is generally performed for religious and cultural reasons, is also performed for health reasons. Circumcision is performed in societies around the world for two main reasons;

• Religious and cultural reasons: Circumcision is common among Jews and Muslims. Circumcision is obligatory in Judaism. Although it is not one of the basic conditions of religion in Islam, almost all Muslims have their boys circumcised.
• Medical reasons: For some medical reasons, circumcision becomes obligatory for boys, regardless of their belief system. In other words, circumcision is part of the treatment.

In which situations is circumcision medically obligatory?

In some cases, it is mandatory for boys to be circumcised. Otherwise, the disease cannot be cured. Situations in which circumcision is obligatory and must be done medically, that is, in terms of health, are as follows:

• Phimosis: Normally, the foreskin is easily pushed back from the glans and cleaned. The condition where the foreskin sticks to the head of the penis and cannot be pushed back is known as phimosis. In this case, children cannot urinate and urinary tract infections are common. In these patients, surgery must be performed as a treatment.
• Paraphimosis: Paraphimosis is the condition where the foreskin cannot be restored after being pushed back from the glans penis. This situation requires urgent urological intervention. Otherwise, the foreskin pushed back creates pressure behind the glans of the penis, disrupting the blood supply to the glans penis and causing gangrene. It should be corrected in a short time with emergency intervention and circumcision should be performed.
• Recurrent urinary tract infections: The skin surrounding the glans penis creates a serious problem for cleaning. Urinary tract infections often develop due to adhesions in this skin. If an uncircumcised boy has frequent urinary tract infections, circumcision should be performed.
• Trauma of the foreskin: Another medical condition that requires circumcision is that the foreskin is exposed to trauma for various reasons. In such cases, it is recommended to remove the foreskin completely instead of repairing it, that is, circumcision. In these patients, we surgically remove the foreskin to open the head of the penis.
• Balanitis and lichen sclerosis: It is also known as Balanitis xerotica obliterans (BXO).
• Inflammation of the glans penis is called balaniitis. Lichen sclerosis is a skin disease. In some patients, if they are not circumcised, there may be inflammation in the head of the penis and problems in the skin surrounding the head. BXO is among the 10% causes of phimosis in boys. In these cases, we recommend circumcision for definitive treatment.
• Vesicoureteral reflux: Vasicoureteral reflux is the backward flow of urine from the bladder into the urinary canals from the ureter. It happens in varying degrees, if the leakage continues up to the kidney, the kidneys will be damaged. There are different reasons. One of them is the situation where the foreskin sticks to the head of the penis for a long time. Vesicoureteral reflux may develop in boys as a result of the foreskin closing the urinary tract and urine not flowing easily. Circumcision must be performed to prevent recurrent urinary tract infections and kidney damage.
• Difficulty in urination: If the foreskin cannot be easily pushed back and pulled in boys, it means that there is adhesion. Because of these adhesions, infection and difficulty urinating occur. Children do not urinate completely, they have difficulty urinating and intermittent urination. In such cases, the definitive treatment is to remove the skin surrounding the head of the penis.

What are the benefits of circumcision in boys?

Circumcision has many benefits for men. For these reasons, circumcision is performed in some countries for health purposes other than religious reasons. We can list the health benefits of circumcision as follows:

• Ease of hygiene (cleaning):
• Urinary tract infections are less common:
• Inflammatory diseases of the glans penis are rare:
• Less risk of penile cancer:
• Cervical cancer is less common in women
• Penile skin diseases such as phimoizis and paraphimosis are not seen in circumcised patients.
• Sexually transmitted diseases are less common: HPV, HIV (AIDS)
• Phimosis, paraphimosis, balanitis are not seen

Advantages/benefits of newborn circumcision

For health reasons, circumcision is sometimes performed in boys in the early period. It can be done in the first 24-48 hours after birth, or in the first 3 months. This decision should be made by the family and the doctor together. Circumcision in the newborn period has some advantages. We can list them as follows;

• Urinary tract infection is less common:
• It is done with local anesthesia
• Post-operative care goes more smoothly
• Wound healing takes place in a shorter time
• Children are not adversely affected psychologically

In order to perform circumcision in the newborn period, the baby’s health condition must be suitable.

Newborn circumcision is not performed in the following cases:

• Premature children
• If you have neonatal jaundice
• If there is a blood disease related to bleeding-coagulation in the family
• Hypospadias disease

What are the complications of circumcision?

Circumcision surgery is an application that does not have complications or is extremely small and insignificant if it is performed in appropriate environments and by a specialist. Complications that can be seen due to circumcision are as follows;

• Bleeding
• Deformity, irregularity
• Damage to the urinary tract
• Excessive or short cutting of the skin
• Re-correction surgery may be required

In the following cases, a doctor should be called?

Circumcision is not a serious problem if it is duly performed by an expert on the subject. However, some undesirable conditions may develop after surgery. After circumcision, the doctor who performed the surgery should be sought in the following cases;

• If there is excessive bleeding
• If there is an inability to urinate
• If there is a color change in the head of the penis
• If the discharge from the wound continues

Does circumcision prevent penile cancer?

Yes, circumcision prevents the development of penile cancer in men in advanced ages. It is known that a substance called smegma secreted by the foreskin causes penile cancer. Penile cancer is common among adult males in non-circumcised populations. Penile cancer is extremely rare in Jewish and Muslim societies due to circumcision.

Do circumcised people have sexual problems in the future?

There is information that there may be problems such as premature ejaculation in adulthood in boys who are circumcised due to the sensitivity of the foreskin. Or vice versa, there are thoughts that there will be no premature ejaculation in these people. There is no scientific study to support both of these conditions.

Is circumcision performed in those with coagulation factor deficiency?

In some people, factors that play a role in coagulation after bleeding and called coagulation factors may be missing. In these people, there is a problem in stopping the bleeding in case of any incision or trauma. If these people are to undergo an operation, these missing factors must be given to the patient and then the operation must be performed. In children who will be circumcised, if coagulation factors are missing, these factors can be given to the patient and surgery can be performed under normal hospital conditions. We did not encounter any bleeding problems in our patients who we performed in this way.

Can circumcision errors be corrected later?

Some people may experience simple cosmetic errors after circumcision. These are mostly skin problems such as excess skin and scar development. It does not pose a serious problem. If patients are not cosmetically satisfied, they can be corrected with surgery.

When / at what age should circumcision be done?

One of the most curious subjects is the most appropriate age for this surgery. If there is a medical necessity, age does not matter, circumcision is performed at any age. The importance of circumcision age in children is related to the psychological development process. Children begin to realize their sexual identity between the ages of 2-5. Surgery performed in an unsuitable environment and time affects children psychologically negatively, and they have a negative feeling that they will lose their genitals. If there is a medical necessity, surgery can be performed in this period under appropriate conditions.

In some developed western societies, boys are circumcised within the first 24-48 hours after birth due to hygienic concerns, regardless of religious and cultural reasons.

Abstract: Circumcision is generally performed religiously and culturally, as well as for health reasons in recent years. It has many benefits such as prevention of urinary tract infections, hygienic reasons, prevention of sexually transmitted diseases, and the development of penile cancer is extremely rare in circumcised patients. It is a very reliable and uncomplicated procedure when performed by specialists.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY