December 24th, 2013
Reasons for Circumcision in infant boys could be cultural or religious. When male teenagers or adults are medically required to undergo a circumcision, the procedure ultimately requires the removal of the foreskin.
In this article we would like to only discuss medical conditions that would require a circumcision in male infants, teenagers and adults. Some of these conditions are initially treated with topical or oral medications which tend to limit the conditions; a recurrence is then eventually and potentially cured by the removal of the diseased foreskin. Most commonly reported indications for circumcision include phimosis, paraphimosis, balanitis without phimosis, condyloma, redundant foreskin, Bowen disease, carcinoma, trauma, disease prophylaxis (e.g., HIV infection), and patient choice.
Phimosis is a condition where the foreskin is or becomes tight enough to prevent a retraction of the same over the glans penis. This condition can be very painful especially during an erection and result in severe foreskin and glans irritation, skin tearing, and possible infection. The removal of the foreskin can help to solve this issue.
Paraphimosis is a condition where the foreskin is pulled back underneath the glans of the penis and becomes trapped, not being able to be returned to its original position over the penile head. This entrapment of the foreskin causes a band like stricture caused by swelling located around and right underneath the glans penis. If not treated, the lack of blood supply will cause tissue ischemia and the tissue of the penis will begin to die.
Paraphimosis can possibly occur as a complication of a medical procedure that involves a retraction (pushing back) of the foreskin for a prolonged period of time. Such procedures may include examination of the penis, cystoscopy, urinary catheterization, and other. Paraphimosis is usually almost an induced condition; Raman et.al. report coital paraphimosis during sexual activity leading to penile tissue necrosis and Koenig et.al. reported piercing associated paraphimosis.
In most cases, paraphimosis can be treated using medication to reduce the swelling, or minimally invasive surgery to return the foreskin to its original position (dorsal slitting without the removal of the foreskin). While a dorsal slitting will resolve the tightness and allow the blood to flow, a later circumcision is usually required for medical and aesthetic reasons.
While rare in children and easily treatable with medication, paraphimosis in adults usually requires circumcision when medication and surgery fail and could be one of the reasons for circumcision. Circumcision is also usually recommended if someone has repeated episodes of paraphimosis. According to Hayashi et.al. the best way to ensure that paraphimosis will not recur is to perform circumcision.
Balanoposthitis is inflammation of the foreskin and the glans penis, usually caused by a bacterial infection. The foreskin covers most parts, especially the ridge (corona), of the glans, causing a moist and hard-to-reach area where bacteria can sit and grow causing infections. Initially starting as a mild irritation, the infection can eventually grow and cause dysuria (pain when urinating), a discharge of pus from the penis, and inflammation of the shaft of the penis
Balanoposthitis is usually treated using locally applied antibiotics. Most cases resolve with antibiotics without further complications or recurrences. Repeated infections (recurrent balanoposthitis) which do not respond well to local antibiotics may require a circumcision with the removal of the foreskin.
Genital warts are a sexually transmitted disease that appears externally on the genitalia, in the anal area, internally in the upper vagina or cervix, and in the male urethra. The reappearance of the warts, especially under the foreskin, may require a circumcision.
Urinary tract infections (UTIs) are usually less common in male compared to female due to anatomical and physiological differences. In fact, only 4% of boys have at least one UTI before they are 16. These UTIs are thought to be caused by bacteria that gather inside the foreskin before spreading to the urinary system.
Circumcision with the removal of the foreskin can be an effective way to reduce UTIS in boys, especially if UTIs become recurrent.
Research shows that circumcised boys are 10 to 14 times less likely to catch a UTI than uncircumcised boys.
However, most UTIs are mild and do not cause serious damage. Circumcision is usually only recommended if a boy has a risk factor that increases the likelihood of repeated UTIs.
By providing a clean environment with reduced pathogen infestation, circumcision is known to reduce the risk of catching three sexually transmitted infections (STIs):
Research studies conducted in Africa show that heterosexual circumcised men are 38-66% less likely to contract HIV than uncircumcised men. The efficacy of circumcision as preventative measure in homosexual men who have unprotected anal sex has not been clearly studied.
While having some protective advantages, circumcision is not as effective as condoms in preventing STIs. If used correctly, condoms are 98% effective in preventing STIs.
Research have shown that men who were circumcised in childhood are three to four times less likely to develop penile cancer than men who are uncircumcised. This is because many cases of penile cancer develop in the foreskin.
Bowen disease is a squamous cell carcinoma (SCC) in situ with the potential for significant lateral spread. Larger lesions can reach several centimeters in diameter. Infections such as HPV and chronic mechanical or chemical skin irritation and damage belong to the causative mechanisms.
Overall, penile cancer is rare and circumcision as a preventative measure would not be justified. However, in some rare cases a person may be more at risk, for example if they have a family history of penile cancer or a weakened immune system. In such cases, circumcision is recommended as a preventative measure.
Balanitis xerotica obliterans (BXO) is a skin condition that can only be cured with circumcision. However, the condition is rare in children and usually affects adults.
Circumcision after the age of 13, late circumcision, or uncircumcised male are believed to be at higher risk for developing this condition which is believed to be due to chronic foreskin irritation and favorable milieu for causative agents.
BXO can cause hardening and inflammation of the penis, usually affecting the foreskin and tip of the penis causing difficulties and pain when passing urine and itchiness and soreness of the penis.
BXO can initially be treated with local steroids or other medications. In cases of BXO that primarily affect the foreskin, circumcision is usually the most effective treatment, and often results in a complete cure and is definitely indicated in cases of urethral stenosis with lower urinary tract symptoms.
As previously discussed, circumcision in older boys or adult men may be indicated if no other treatment is effective for the above discussed conditions, or if a patient has reasons for circumcision for personal or aesthetic reasons. Discussions about ethical and medical justification of male circumcision are widely spread over the World Wide Web, and while uncircumcised male argue about the barbaric nature of circumcision, circumcised men might provide contra arguments. The effectiveness of circumcision in the treatment or prevention of certain conditions has been studied, so has the effects of circumcision on male sexual performance and satisfaction. And despite the vast body of evidence, the question about “circumcision, yes or no” will remain a hot subject of discussion. Objective findings will continuously be argued upon based on personal subjective ideas. At the end, if no medical reason is given, circumcision in adult male will remain a personal choice and reasons for circumcision could be a personal matter.
We have discussed a lot about circumcision, its advantages and disadvantages in our previous blog posts. You may find them here:
Medical Reasons For Circumcision
Circumcision Effects on Male Sexual Satisfaction
Circumcision Advantages and Disadvantages
Circumcision Benefits in Adults
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