Have you been told you need a circumcision?
You should always seek trained medical advice for any health concern, this page is intended for those who have been told that they need a circumcision. Information contained on the 15 Square website is intended to inform the public of viable alternatives to surgery and circumcision, however this does not replace medical advice.
There are alternatives to circumcision. If you have a health concern, or you have been told that a circumcision is necessary then please contact us as we may be able to help provide you with the advice you need.
Circumcision, like all surgery, carries risks and occasional complications. Generally speaking in the UK, healthcare has made progress in recent years with regards to circumcision. Unfortunately, medical practitioners have not always kept up to date with these advances in understanding.
Here is a list of after effects and the frequency as presented by The British Association of Urological Surgeons.
Find the BAUS information leaflet here.
If circumcision is necessary, it is important it is carried out by an experienced surgeon. In children, a paediatric surgeon ought to perform the procedure under a general anaesthetic, and in a fully equipped hospital. It is of course surgery and should be treated in the same way as any other surgical operation.
It is very rare that a child should need to undergo circumcision, however, if this is necessary then parents should encourage the surgeon to preserve as much tissue as possible. There are many nerve endings and receptors in the mucosal tissue, so removing this sensitive tissue ought to be avoided. There are also alternative surgeries that preserve the tissue (such as a preputioplasty), which we will discuss further on.
As much of the shaft skin as possible should be left intact. This will ensure mobility when the penis is erect. Removing too much tissue can cause ongoing discomfort, tightness, and issues during sexual activity. Some of these issues may not become apparent until later life if the procedure is performed on a young patient.
Foreskin issue & treatment in order of preference
Long foreskin: This is not an indication for circumcision and no treatment is required. This will not interfere with any part of penile function, and may even change throughout life.
Ballooning: ‘Ballooning’ of the foreskin is where the passing of urine causes a bulge in the foreskin. This is a healthy sign that the foreskin is beginning to separate from the glans (head of the penis), and is a natural developmental process. No extra care is necessary. For cleaning, only wash what is exposed when comfortably retracted. Over-retracting causes pain and scarring that can cause future problems.
Balanoposthitis/Balanitis: Aggressive chemical soaps should be avoided in favour of natural alternatives, or just clean water. Whilst further research is needed, there is a suggestion that Sodium Laurel Sulphate found in most shower gels may exacerbate this condition. A course of antibiotics, oral or topical should be the first course of treatment before surgery is considered.
Lichen Sclerosus/Balanitis Xerotica Obliterans: Referral to a specialist is essential, the earlier the better. Early cases may be resolved with potent steroid creams. Late diagnoses may make circumcision necessary.
Non-Retractable Foreskin: During ages 0-6 it is very common for the foreskin to be fused to the glans. By ages 16-17 most boys will have a retractable foreskin and 95%-97% will have no adhesions (parts of the glans that are fused to the foreskin). *See also – Further fate of the foreskin. – J. Oster
At ages, 13+ manual stretching can be used to gently retract the foreskin. This should never cause discomfort. If necessary, steroid creams can be used in later adolescence to assist retraction. This should be done under guidance from medical professionals. More information on physiological phimosis can be found at the end of this section.
Non-Retractable Foreskin Due to Infection: If other treatments do not help, then you should ask your doctor for a referral to a urologist or dermatologist (depending on your problem). Infections or skin conditions are generally quite noticeable as they cause irritation or pain. Several different infections can cause inflammation and problems with the foreskin. You will likely need to show a professional, and the earlier the issues are addressed the less invasive the outcome is likely be.
Minor Surgical Procedures are an Option.
If surgery is required to alleviate foreskin tightness, a preputioplasty can be performed as a first attempt. This involves making small minor incisions around the opening of the foreskin. This procedure preserves the tissue and foreskin, and the cosmetic result is generally agreeable with fewer impacts on sensitivity.
If the frenulum (the band of tissue that connects the foreskin to the glans) is short, a frenuloplasty can be performed. This will loosen the frenulum and prevent the pulling sensation and tightness caused by the short frenulum. If left untreated, a tight frenulum may eventually snap under pressure. A full circumcision is unlikely to be necessary.
Another procedure that can be performed is a dorsal slit. This refers to a single incision along the upper length of the foreskin can be an alternative to a full circumcision, though most patients prefer the outcome of preputioplasty’s as this procedure leaves skin hanging, and the cosmetic appearance is not generally preferred by patients.
Cosmetic success varies greatly with all surgical interventions, however, a preputioplasty and a frenuloplasty are less invasive alternatives than a full circumcision or a dorsal slit. The majority of these procedures can resolve issues, especially when addressed early.
Circumcision should really be viewed as a last resort.
“The term phimosis (from the Greek word for muzzling) is often incorrectly applied to any foreskin that cannot be retracted.” – (Gordon and Collin, 1993)
*To discourage unnecessary circumcision, a distinction needs to be made between physiological and pathological non-retractability for the foreskin. The foreskin develops early in development in the womb, it is the penile skin that grows forwards over the glans and adheres to it. Both glans and prepuce (foreskin) are protected by a membrane (stratified squamous epithelium), and separation of the membrane and retractable foreskin occurs at a variable time for all boys, this is a natural part of the development and infant circumcision disrupts this process.
Most people do not need a Circumcision
It is not the only treatment for most foreskin conditions. For many foreskin issues surgery can be avoided completely, or a more minor operation can be used without removal of tissue. These include stretching techniques, steroid creams, a frenuloplasty, or a preputioplasty. These surgical interventions have minor cosmetic changes however these can sometimes become unnoticeable with time and leave the sensation, protection and mechanical qualities of an intact foreskin.
Most cases of pathological phimosis result from BXO (balanitis xerotica obliterans), while the remainder may be due to a different, distinct fibrotic disease. (Clemmensen, Krogh and Petri, 1988) An underlying difficulty is the imprecision of the term phimosis, as this means general ‘tightness’ for the foreskin. This of course is a natural part of healthy development in early childhood. Pathological phimosis is very rare in children, as is BXO before age 5.
Circumcision is a last resort
Only after all other treatments have been considered should doctors necessitate circumcision. This is because there are recognised surgical complications as with all surgeries, and other issues unique to circumcision. Complications include –
– oedema leading to further surgery
– bleeding leading to further procedures
– infection
– permanent altered/reduced sensation in the glans,
– anaesthetic or cardiovasculare problems including chest infections, pulmonary embolus, stroke, deep vein thrombosis, heart attack and death.
The extent of the permanent changes to the functionality and sensation of the penis is also relevant, as are the psychological effects that interference with sex organs can cause. When there is a problem with the foreskin, we would like to see doctors exploring conservative treatment options before circumcision. These options ought to be offered to patients, with an explanation about their outcome.
Ballooning is not a reason for circumcision.
Any attempt to retract the foreskin forcibly before natural separation from the glans is harmful.
During boyhood, ballooning of the foreskin sometimes occurs during urination. This is because the flow rate is greater than through the foreskin’s opening; as a result, the urine starts to fill the preputial space. There is hardly ever a problem with an obstruction of the flow of urine, and it is an indication that the natural separation of the foreskin and glans is happening and ballooning will stop once the foreskin separates in due course.
Øster found that 8% of a group of boys had experienced phimosis during childhood. None were circumcised and all cases resolved themselves naturally. True phimosis does exist, but is rare in children.
The Best Treatment For Balanitis
Medical treatment of non-retractile foreskin with betamethasone valerate 0.05% ointment has a documented 90% success rate.(Orsola, Caffaratti and Garat, 2000)
Balanitis can be caused by excessive washing. It can usually be managed by correcting the overzealous hygiene, and by application of emollients. (Birley et al., 1993) Avoiding aggressive soaps may help in resolving balanitis.
We encourage the full implementation of conservative non-traumatic medical treatments of the nonretractile foreskin as this could cut the number of surgical operations needed by ten-fold. The percentage of boys who would actually need surgery we estimate is between 0.1% and 0.2%.
Furthermore, for those very few boys who do need surgery, non-traumatic, non-destructive dorsal slit with transverse closure (Arora, Arora and Arora, 2016) or lateral preputioplasty (Agarwal, D’silva, Sharma and Raina, 2008) may be effective and would preserve full anatomical function. Full application of newer non-traumatic medical and surgical treatments could eliminate the vast majority of circumcisions in medical practice.
Lichen Sclerosus/BXO. Balanitis Xerotica Obliterans
Often referred to as “true phimosis”.
Most UK doctors state that it is a reason for circumcision and will refer the patient to a surgeon.
Circumcision undoubtedly removes lichen sclerosus when it only affects the foreskin.
As such this is an option for adults willing to have the operation.
We do not think that this is justified in all cases. Some treatments are possible for early stage LS/BXO, which may be effective in some cases.
Where lichen sclerosus (LS) affects any part of the body it should be treated first with a potent topical steroid. (Ledingham, Warrell and Ledingham, 2000) Once the condition has cleared, other treatments can be used to resolve any tightness of the foreskin. There are published clinical guidelines for the management of LS, confirming that topical steroids are an appropriate treatment. (Neill, Tatnall and Cox, 2002)
This should be the first choice for treating LS of the penis (aka “BXO”) The “gold standard” of proof of medical treatment is a Randomised Controlled Trial (RCT). There are RCTs to show phimosis due to LS can be treated with corticosteroid creams.
The most important information on foreskin conservative treament success is summarised in the table below
1. Vincent MV, MacKinnon E. The response of clinical balanitis
xerotica obliterans to the application of topical steroid-based
creams. J Pediatr Surg. 2005; 40(4):709-12.
2. Kiss A, Csontai A, Pirot L, Nyirady P, Merksz M, Kiraly L.
The response of balanitis xerotica obliterans to local steroid application compared with placebo in children. J Urol. 2001; 165(1):219-20
Lindhagen T. Topical clobetasol propionate compared with placebo in the treatment of the unretractable foreskin. Eur J Surg. 1996; 162:969.
4. Jorgensen ET, Svensson A. The Treatment of Phimosis in Boys, with A Potent Topical Steroid (Clobetasol propionate 0.05%) Cream. Acta Derm Venerol (stockh). 1993; 73(1):55-56.
Potent topical steroids and circumcision are not the only treatment options for penile lichen sclerosus.
Other treatments to be described include:
• sublesional or intralesional topical steroids
• carbon-dioxide laser treatment
• long term antibiotic therapy
• prepuceplasty with intralesional steroids
• topical tacrolimus
Why do we say '15 Square'?
In the average adult male, the length of the foreskin from its base to its tip is about 1 inch (4cm), while the circumference (the distance around) is about 5 inches (13cm).
The fold of the foreskin consists of two layers: an outer layer of epidermal tissue (like that of the rest of the body) and an inner layer of mucosal tissue (as in the vagina, mouth or inner eyelid). If laid flat, the upper amount of foreskin removed from an adult male would measure approximately 3 inches by 5 inches (8cm x 13cm); or about 15 square inches (104cm). or a surface area equivalent to that of a 3″ by 5″ inch index card. (Earp, 2016)
References
- Agarwal, P., D’silva, J., Sharma, D. and Raina, V., 2008. Bilateral Lateral Slit Preputial Plasty: A Technique Preferred over Circumcision in Primary Phimosis. The Internet Journal of Surgery, 18(1).
- Arora, B., Arora, R. and Arora, A., 2016. Dorsal slit preputioplasty for phimosis: a prepuce conserving surgery.
- Birley, H., Walker, M., Luzzi, G., Bell, R., Taylor-Robinson, D., Byrne, M. and Renton, A., 1993. Clinical features and management of recurrent balanitis; association with atopy and genital washing. Sexually Transmitted Infections, 69(5), pp.400-403.
- Clemmensen, O., Krogh, J. and Petri, M., 1988. The Histologic Spectrum of Prepuces from Patients with Phimosis. The American Journal of Dermatopathology, 10(2), pp.104-108.
- Earp, B., 2016. Circumcision and Sexual Function: Bad Science Reporting Misleads Parents | Journal of Medical Ethics blog. [online] Journal of Medical Ethics blog. Available at: <https://blogs.bmj.com/medical-ethics/2016/04/22/circumcision-and-sexual-function-bad-science-reporting-misleads-parents/#:~:text=The%20adult%20foreskin%20has%20on,that%20respond%20to%20tactile%20stimulation.> [Accessed 2 September 2021].
- Gordon, A. and Collin, J., 1993. Save the normal foreskin. BMJ, 306(6869), pp.1-2.
- Ledingham, J., Warrell, D. and Ledingham, J., 2000. Concise Oxford textbook of medicine. Oxford: Oxford University Press.
- Neill, S., Tatnall, F. and Cox, N., 2002. Guidelines for the management of lichen sclerosus. British Journal of Dermatology, 147(4), pp.640-649.
- Orsola, A., Caffaratti, J. and Garat, J., 2000. Conservative treatment of phimosis in children using a topical steroid. Urology, 56(2), pp.307-310.
- Werker, P., Terng, A. and Kon, M., 1998. The Prepuce Free Flap: Dissection Feasibility Study and Clinical Application of a Super-Thin New Flap. Plastic and Reconstructive Surgery, 102(4), pp.1075-1082.
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