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COMMENTARY
Year : 2014  |  Volume : 7  |  Issue : 3  |  Page : 293-295  

Circumcision or preputioplasty: What is the evidence?


Department of Surgery, Padmashree Dr D Y Patil Medical College, Hospital and Research Centre, Dr D Y Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India

Date of Web Publication18-Mar-2014

Correspondence Address:
Bharat Bhushan Dogra
Prof of Surgery, Padmashree Dr D Y Patil Medical College, Hospital and Research Centre, Dr D Y Patil Vidyapeeth, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Dogra BB. Circumcision or preputioplasty: What is the evidence? . Med J DY Patil Univ 2014;7:293-5

How to cite this URL:
Dogra BB. Circumcision or preputioplasty: What is the evidence? . Med J DY Patil Univ [serial online] 2014 [cited 2019 Dec 13];7:293-5. Available from: http://www.mjdrdypu.org/text.asp?2014/7/3/293/128961

Circumcision is one of the oldest and probably one of the commonest surgical operations worldwide. Although it is usually performed for a religious purpose, the main medical indication is organic-narrowing of the preputial orifice. [1]

To understand the genesis of phimosis, it is imperative to understand the development and growth of prepuce of normal male. This fact is greatly misunderstood both by the medical fraternity and by the public at large, which has led to many unnecessary circumcisions being performed on young boys. A newborn boy has a long prepuce with a narrow tip. Retraction is not possible in most of the infants because the narrow tip does not pass over the glans penis, since the inner mucosal surface of the prepuce is fused with the underlying mucosal surface of the glans-penis. Gairdner observed 100 newborns and about 200 boys of age group up to 5 years age and reported that only 4% of newborns had a fully retractable prepuce. [2] Oster reported progressive increase in the retractability of the prepuce with increasing age. [3] E. B. Grogono, observed that boys, with a non-retractile prepuce at age 11, have a fully retractile prepuce by age 14 or 15. Grogono further reported that the non-retractile prepuce caused no problems. [4] Kayaba recorded the findings in 603 Japanese boys and observed that only 40 percent of boys in the 8-10 age group are fully retractable, and rest of the 60 percent had varying degree of non-retractability. He also reported that only 62.9 percent of the boys in the 11- to 15-year-old age group had completely retractable prepuces. [5] Ishikawa and Kawakita investigated 242 Japanese boys and found that no boys had a retractable prepuce at birth but in the age group 11-15, 77% had a retractable prepuce. This confirms that, for many boys, the prepuce does not become retractable until after puberty. [6] Agarwal, Mohta, and Anand carried out a study in Delhi in boys up to age 12 and found that preputial retractability continues to develop through age 12. [7]

This normal developmental narrowness is improperly diagnosed as phimosis. In fact, the normal developmental narrowness is not phimosis. It is simply a normal stage of development. Pathological condition (Phimosis) is a fairly rare condition characterized by hardening of the tip of the prepuce, and a whitish ring of hardened tissue. A narrow non-retractable prepuce in boys is within the normal range of development and usually causes no problems. The prepuce usually will spontaneously widen until complete retractability is obtained by puberty.

Some boys experience ballooning of prepuce due to inflation of the prepuce during urination by the pressure of urine inside. This can occur if the inner layer of the prepuce is separating or has separated from the glans, before the prepuce has become fully retractable. Ballooning is a transient condition and an indication that the normal separation of the foreskin from the glans penis has occurred. Babu et al. [8] reported that ballooning does not interfere with voiding. Ballooning is not injurious, and it is not a cause for concern and is not an indication for circumcision. [8] Normal prepuce has an unscarred preputial orifice, while pathological phimosis is characterized by secondary cicatrization of the orifice, usually due to balanitis xerotica obliterans. This problem, the only absolute indication for circumcision, affects some 0.6% of boys, in age around 11 years of age, and is rarely encountered before the age of five. [9] Pathological phimosis as a result of chronic inflammation due to poor local hygiene may develop in older patients with diabetes or chronic balanitis. When infection develops, it can be managed by antimicrobial agents. Atilla et al. managed 32 cases of phimosis with non-steroidal anti-inflammatory ointment and noted improvement in 24. The other eight boys did not respond to therapy and six required circumcision. [10]

Several authors have noted that the foreskin is often removed unnecessarily, when there is no true fibrous phimosis. Children having this deformity can be managed by the lesser procedure of standard preputioplasty. It involves a short full thickness longitudinal incision on the dorsal aspect of stenotic prepuce exactly opposite the ventral raphe, to allow complete and easy retraction, a 'mini-dorsal slit'. Adhesions to the glans are broken down if present. The inner and outer layers of skin are sutured together transversely to produce permanent widening of the opening. [1] Castella reported carrying out this procedure in 60 patients having moderate to severe phimosis in 1-14 years age. At 5 years follow-up, 50 patients were happy with the appearance and no further surgery was required. [1]

Tim Lane et al in 2003 reported that in 40% of the children the main indication for circumcision was asymptomatic phimosis without a history of either recurrent balanoposthitis or voiding dysfunction. They preferred management of symptomatic patients by lateral preputioplasty. This procedure involves two laterally placed vertical incisions over the stenotic preputial bands, which are subsequently closed horizontally. It provides excellent symptom relief and avoids the unsightly cleft left by a single dorsal incision over a stenotic preputial band. [11] Earlier Hoffman et al described their method in which multiple Y-V-plasties relieve the phimosis without resecting any preputial tissue. [12] They employed this method in 44 cases with good functional and cosmetic results in all except one case who had balanitis xerotica obliterans. Wahlin (1992) used his technique of three longitudinal incisions over the preputial band and sutured them transversely to obtain retraction of prepuce. He had a series of 63 consecutive patients with good results. [13]

Barber et al carried out a retrospective study by sending questionnaires to the parents of 23 boys who had undergone standard dorsal slit preputioplasty, 20 months earlier. Replies were received from 22 parents. There had been no postoperative complication and all but 2 boys had been back to normal activities within ten days and success rate was 77%. [14]

Circumcision happens to be most commonly performed operation for phimosis worldwide but there are good reasons to avoid circumcision keeping in mind the evidence available today. On the one hand circumcision does carry substantial morbidity in the form of hemorrhage, meatal ulceration and stricture. Moreover, it also has adverse effect on sexual function. Prepuce is important not only for male sensation but also of female enjoyment of intercourse. [14]

Taylor et al (1996) described the prepuce as a structural and functional unit, a combination of smooth mucosa and true skin, which act together to allow a specialized 'ridged band' to be deployed onto the shaft of the penis, providing a sensitivity to the glans and the penile shaft, possibly mediating the afferent limb of the ejaculatory reflex. [15] During erection, the double-layered foreskin provides the skin necessary to accommodate a normal erection and to allow movement of this skin over the shaft and glans. During sexual intercourse the mucosa of the foreskin facilitates smooth and gentle movement between the penis and the mucous membrane of the vagina.

Thus circumcision should not be carried out indiscriminately sacrificing the vital preputial tissue. Circumcision is indicated only in clinically scarred prepuce (because of recurrent infection or balanitis xerotica obliterans), the remainder are suitable for more conservative treatment. [15]

 
  References Top

1.deCastella H. Prepuceplasty: An alternative to circumcision. Ann R Coll Surg Engl 1994;76:257-8.  Back to cited text no. 1
    
2.Gairdner D. The fate of the foreskin. Br Med J 1949;2:1433-7.  Back to cited text no. 2
    
3.Oster J. Further fate of the foreskin: Incidence of preputial adhesions, phimosis, and smegma among danish schoolboys. Arch Dis Child 1968;43:200-3.  Back to cited text no. 3
    
4.Grogono EB. The case against circumcision. Br Med J 1979;1:1423.  Back to cited text no. 4
[PUBMED]    
5.Kayaba H, Tamura H, Kitajima S, Fujiwara Y, Kato T, Kato T. Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol 1996;156:1813-5.  Back to cited text no. 5
    
6.Ishikawa E, Kawakita M. Preputial development in Japanese boys. Hinyokika Kiyo 2004;50:305-8.  Back to cited text no. 6
    
7.Agawal A, Mohta A, Anand RK. Preputial retraction in children. J Indian Assoc Pediatr Surg 2005;10:89-91.  Back to cited text no. 7
    
8.Babu R, Harrison SK, Hutton KA. Ballooning of the foreskin and physiological phimosis: Is there any objective evidence of obstructed voiding? BJU Int 2004;94:384-7.  Back to cited text no. 8
    
9.Rickwood AM, Kenny SE, Donnell SC. Towards evidence based circumcision of English boys: Survey of trends in practice: BMJ 2000;321:792-3.  Back to cited text no. 9
    
10.Atilla MK, Dündaröz R, Odabaº O, Oztürk H, Akin R, Gökçay E. A nonsurgical approach to the treatment of Phimosis: Local non-steroidal anti-inflammatory ointment application. J Urol 1997;158:196-7.  Back to cited text no. 10
    
11.Lane T, South M. Preputioplasty. J R Soc Med 2003;96:619.  Back to cited text no. 11
[PUBMED]    
12.Hoffman S, Metz P, Ebbehøj J. A new technique for phimosis: Prepuce-saving technique with multiple Y-V plasties. Br J Urol 1984;56:319-21.  Back to cited text no. 12
    
13.Wahlin N. Triple incision plasty." A convenient procedure for preputial relief. Scand J Urol Nephrol 1992;26:107-10.  Back to cited text no. 13
    
14.Barber NJ, Chappell B, Carter PG, Britton JP. Is preputioplasty effective and acceptable? J R Soc Med 2003;96:452-3.  Back to cited text no. 14
    
15.Taylor JR, Lockwood AP, Taylor AJ. The prepuce: Specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-5.  Back to cited text no. 15
    




 

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