Circumcision – Is it always necessary? - NUH
Circumcision – Is it always necessary? - NUH
Circumcision – Is it always necessary? - NUH
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<strong>Circumcision</strong> <strong>–</strong> <strong>Is</strong> <strong>it</strong> <strong>always</strong><br />
<strong>necessary</strong>?<br />
Dr. Dale L. S. K. Loh<br />
Senior Consultant<br />
Department of Paediatric Surgery<br />
National Univers<strong>it</strong>y of Singapore<br />
<strong>NUH</strong>S
<strong>Circumcision</strong> - Overview<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
Natural history<br />
Absolute indications<br />
Relative indications<br />
When is <strong>it</strong> not <strong>necessary</strong>?<br />
Benef<strong>it</strong>s<br />
Risks<br />
Medical management of non-retractile<br />
foreskin<br />
Surgical options
Natural History:<br />
<br />
<br />
<br />
<br />
At 8 weeks of gestation, skin of the body of the<br />
penis starts to grow over the glans and eventually<br />
covers the entire organ<br />
Skin of the penile shaft becomes keratinized, but<br />
the surface of the foreskin adjacent to the glans<br />
does not<br />
At birth, the foreskin is firmly attached to the glans<br />
because separation of the ep<strong>it</strong>helial layers is not<br />
complete<br />
Separation of the foreskin from the glans takes an<br />
average of three years; 95% are separated by 5<br />
years of age
<strong>Circumcision</strong> <strong>–</strong> Absolute indications<br />
<br />
<br />
<br />
<br />
Religious reasons<br />
<br />
<br />
Judaism<br />
<strong>Is</strong>lam<br />
Balan<strong>it</strong>is Xerotica<br />
Obl<strong>it</strong>erans (B.X.O.)<br />
Phimosis/Paraphim<br />
osis<br />
Megaprepuce
<strong>Circumcision</strong> <strong>–</strong> Relative indications<br />
<br />
<br />
Recurrent<br />
balan<strong>it</strong>is/balanopos<br />
thisis<br />
Vesico-ureteric<br />
reflux/U.T.I
<strong>Circumcision</strong> <strong>–</strong> When is <strong>it</strong> not<br />
<strong>necessary</strong>?<br />
<br />
<br />
<br />
Social reasons<br />
<br />
<br />
‘Easier to keep clean’<br />
‘His father was circumcised’<br />
“Physiological” Phimosis<br />
<br />
Children under the age of 5 years<br />
Long/Redundant Prepuce
<strong>Circumcision</strong> - Benef<strong>it</strong>s<br />
<br />
<br />
<br />
<br />
<br />
Reduction of U.T.I<br />
Reduction of cancer<br />
<br />
<br />
Penile cancer<br />
Cervical cancer<br />
Reduction in penile inflammation<br />
<br />
<br />
Meat<strong>it</strong>is<br />
Balan<strong>it</strong>is<br />
Reduction in infection<br />
<br />
<br />
HPV, HSV-2, Trichomonas<br />
HIV<br />
Easier hygiene
<strong>Circumcision</strong> <strong>–</strong> Risks (2-5/1000)<br />
Bleeding<br />
Local infection<br />
Too much or too l<strong>it</strong>tle<br />
foreskin<br />
Buried penis<br />
Meatal<br />
ulceration/Meatal<br />
stenosis<br />
Amputation of glans<br />
Urethrocutaneous<br />
fistula<br />
Sexual dissatisfaction
Medical management of non-<br />
retractile foreskin:<br />
<br />
<br />
<br />
<br />
Topical steroids<br />
<br />
<br />
1% Hydrocortisone<br />
Betamethasone<br />
Apply twice daily for one month<br />
70% - 80% success rate<br />
Requires daily retraction
Surgical Options:<br />
<br />
<br />
<br />
<br />
Neonatal Plastibell<br />
<strong>Circumcision</strong><br />
Standard<br />
<strong>Circumcision</strong><br />
Carbon Dioxide<br />
Laser <strong>Circumcision</strong><br />
Preputioplasty
Conclusions:<br />
<br />
<br />
<br />
<br />
<br />
The American Academy of Paediatrics in 1999<br />
established a task force to look into neonatal<br />
circumcision<br />
They concluded that “existing scientific evidence<br />
demonstrates potential medical benef<strong>it</strong>s of newborn<br />
male circumcision, but the data was not sufficient to<br />
recommend routine neonatal circumcision. To make an<br />
informed choice, parents of all male infants should be<br />
given accurate and unbiased information and be<br />
provided the opportun<strong>it</strong>y to discuss this decision”<br />
This statement was reaffirmed in 2005 by the AAP<br />
Patient and parental education on hygiene is very<br />
important<br />
<strong>Circumcision</strong>s are not <strong>always</strong> <strong>necessary</strong>!
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