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Circumcision
Circumcision (removal of the redundant prepuce) is one of the most frequently performed surgical procedures in the world. There is a wide variability in the rate of circumcision among different populations. A lack of consensus regarding the function of the foreskin and uncertainty regarding the benefits of circumcision has led to controversy regarding the appropriateness of elective circumcision. The most recent policy statement from the American Academy of Pediatrics (AAP) states, “Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it.”
Circumcision has been practiced since ancient times. A common reason for elective circumcision centers on religious beliefs. The Bible declares circumcision to be the sign of the covenant between God and the people of Israel. In the Muslim faith, circumcision is recommended, but not obligatory. Circumcision is common in the United States, areas of Africa, Australian aborigines, and portions of the Middle East. In contrast, routine circumcision is rarely performed in Europe, Asia, and Central and South America ( Fig. 60.1 ). This variation in incidence likely reflects religious and cultural differences.
This global map depicts the prevalence of male circumcision among various countries and continents. The countries marked in blue have a prevalence rate of circumcision between 0 and 20%, the countries marked in yellow have a prevalence between 20% and 80%, and the countries marked in orange have a prevalence rate >80%.
The Prepuce
The prepuce is the anatomic covering of the glans involving an outer and inner layer with attachments to both the shaft and corona ( Fig. 60.2 ). Contributing to the debate concerning the appropriateness of routine circumcision is a poor understanding of its function. The prepuce is specialized junctional mucocutaneous tissue that has both somatosensory and autonomic innervation. Innervation of the prepuce differs from the glans, which is innervated by free nerve endings with protopathic sensitivity. As a result of these differences, the inner mucosa of the prepuce is felt to be a part of penile erogenous tissue.
Given the possible relationship between the prepuce and sexual satisfaction, studies have looked into outcomes following circumcision. Problems with sexual dysfunction (inability to ejaculate, lacking interest, premature ejaculation, pain during sex, not enjoying sex) appear to be slightly more prevalent among uncircumcised men. For sexually active adult males undergoing circumcision, there does not appear to be any adverse, clinically important effects on sexual function or satisfaction. Other studies, however, have shown difficulty with sexual enjoyment, erectile function, and a decrease in masturbatory pleasure following circumcision. This is thought to be related to the keratinization of the glans and loss of specialized sensory tissue in the prepuce. A recent systematic review comparing perceived sexual function in circumcised and noncircumcised males, before and after circumcision, showed no inferior sexual function after circumcision. Additionally, using quantitative sensory protocols to assess touch and pain thresholds, penile sensitivity does not appear to differ across circumcision status. These mixed results hold true for homosexual men as well. The effects on female partners of adult males who are circumcised are similarly mixed. Some report dyspareunia, orgasm difficulties, and incomplete needs fulfillment, while others report no significant problems at all.
Medical Indications
The inability to retract the foreskin of a newborn is the result of incomplete keratinization of the glans and is not pathologic. Phimosis is the inability to retract the foreskin. True phimosis is associated with a white, scarred preputial orifice, most common just before puberty, and is an indication for circumcision. Balanitis xerotica obliterans is a ring-like distal sclerosis of the prepuce with whitish discoloration or plaque formation that may involve the prepuce, glans, or urethral meatus, and is also an indication for circumcision. Paraphimosis occurs when the foreskin has been retracted behind the corona and is unable to be brought back over the glans. This is also an indication for circumcision, though ardent opponents of circumcision would offer preputial stretching, plasty, or topical steroid creams as alternative therapy. Balanitis is an infection of the glans, and posthitis is an infection of the prepuce. Recurrent infection with scarring of the prepuce is also an indication for circumcision.
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