Circumcision is possibly the most frequently performed elective surgical procedure in men. It can simply be described as the excision of the preputium. There have been several studies about the association between circumcision and urinary tract infections (UTI). Many studies have demonstrated that the frequency of UTI increase in uncircumcised males, especially in the first year of life. This review discusses the embryology of the preputium, epidemiology, indications, complications and benefits of circumcision, as well as operation and anesthesiology techniques. It especially examines the association between UTI and circumcision and the importance of circumcision in congenital urinary system anomalies. In addition, this review examines the associations between circumcision and sexually transmitted diseases, including HIV, and the protective role of circumcision on penile cancer.
Keywords: Circumcision, urinary tract infections, sexually transmitted diseases, penile cancer
Circumcision can be defined as the excision of the foreskin. The relationship between circumcision and urinary tract infections (UTI) is confusing due to the lack of standardization of definitions in the literature. This becomes more challenging to interpret when the association between circumcision and serious urinary tract congenital problems are to be analyzed.
EMBRYOGENESIS AND HISTOLOGY OF PREPUTIUM
The skin of the penile shaft elongates during the 8th week of gestation, and the prep utium begins to develop from this ectodermal extension. Initially, there is an adherence between the squamous epithelium of the glans penis and the inner surface of the preputium, which generally continues into the postpartum period. The prepuce can be retracted in only 4% of newborns, but this ratio rises to 90% at three years of age and to 97% in uncircumcised men at 17 years of age. Retraction of the preputium involves splitting of the inner epithelium of the preputium from the glans. The separation generally occurs by desquamation of epithelial cells, which forms a caseous white structure called smegma. Nocturnal erections also play a role in the retraction of the preputium.
Circumcision is an ancient surgical procedure with a history of 15000 years, according to Egyptian mummies and wall reliefs, and has been performed for 5000 years in South Africa. The Middle East which presently contains the most crowded circumcised population has a slightly more recent history of 3000 years.
Twenty percent of all men worldwide are considered to be circumcised and this ratio may vary in different countries. For instance, the proportion of circumcised men is reported to be 48% in Canada, 24% in England, and 82% white men and 54% of African American men in the USA. Circumcision ratios may differ according to race and can also be performed for religious, cultural, and medical reasons as well as due to the request of the parents. Circumcision rate decreased from 90% in 1970 in the USA to 60% in 2000. Circumcision related expenses other than medical indications have not been paid since 1948 in England and since 1970 in Canada and Australia. Thirteen states of USA were added to these countries in 2004.
In previous decades, the American Academy of Pediatrics (AAP) declared different neonatal circumcision policies. In 1975 and 1977, the AAP advocated that there were no medical indications for routinely neonatal circumcision. In 1989, the AAP argued that neonatal circumcision might have potential advantages besides the known disadvantages and risks. In 1999, this argument was changed to, ‘Despite recent scientific proofs present the potential medical utilities of neonatal circumcision, these data are not sufficient for recommending routine circumcision.
Serious policies have been instituted recently against circumcision that depend on the idea that penile sensation diminishes nearly 50% after circumcision. Therefore, the decision should be left to the child when he gets older. The majority of anticircumcision movements refer to the procedure as, ‘genital mutilation.’ However, it has been shown that there is no difference between circumcised and uncircumcised men in their ability to sense extroceptive and tactile stimuli on the ventral and dorsal surfaces of the glans. This definitely counters the idea of loss of penile sensation.
However, there are also situations where circumcision becomes inevitable. These include phymosis, paraphymosis, balanopostitis, balanitis xerotica obliterans, preputium cysts, penile lymph edema, ammonia dermatitis, and the use of clean intermittent catheterization. However, topical steroids can be used for some of these indications as alternative treatment.
Although there are different theories about the accurate time of circumcision, it is generally not recommended between the ages of two and six years (phallic phase) to avoid the development of castration anxiety.