This leaflet is published by Circumcision Information Australia to complement the policy statement on circumcision issued by the Royal Australasian College of Physicians and to assist Australian and New Zealand parents care for their baby boys.
The media are full of confusing information about the benefits, harms and risks of circumcision. After a thorough examination of the evidence, Australian and New Zealand doctors have concluded that there is no medical justification for circumcising normal male infants and boys in Australia and New Zealand.
The circumcision policy statement issued by the Royal Australasian College of Physicians (RACP) in October 2010 states:
“After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.”
This means that Australian and New Zealand doctors do not recommend circumcision of normal infants and boys unless there is a definite medical indication or need. The genitals of healthy babies do not need surgical modification or correction. The RACP does not recommend that boys be circumcised as a precaution against the risk of future problems or diseases to which they may be exposed later in life.
Circumcision may be justified when there is a diagnosed disease or other problem that needs to be fixed, and it has not been resolved by non-surgical means after reasonable efforts. In these instances, medical treatment (with antibiotics or other medication) should always be tried first; surgery should be the last resort.
In Australia and New Zealand today circumcision of baby boys is rare, and the uncut penis is the normal thing among young people. But because both countries have a past history of widespread circumcision and many adult men are circumcised, parents are often anxious abut the subject. They may have heard stories from relatives that the uncircumcised penis is prone to problems or difficult to look after, or they may have been alarmed by media reports about epidemics in underdeveloped countries where circumcision is being deployed as a preventive health measure. There is no reason for these anxieties: the uncircumcised penis is very easy to look after, and health precautions that may be needed in underdeveloped countries are not relevant here.
Although most parents will not circumcise their boys, some parents prefer to have their boys circumcised for social reasons, usually because they belong to particular ethnic/religious groups in which circumcision is a traditional practice. This guide aims to assist the majority of parents who will not have their boys circumcised, and also the minority of parents who choose circumcision for cultural/religious reasons.
The penis is covered by a double fold of sensitive, and in adults mobile, tissue, known as the foreskin or prepuce. The foreskin is an integral and functional part of the genitals of all humans, male and female (in whom it is also known as the clitoral hood). It has several known functions, including the protection of the head (glans) of the penis in infancy, accommodation of erections and the facilitation of sexual activity in adulthood.
In baby boys the foreskin makes up a large proportion of the covering of the penis and usually ends in a tapering spout. Foreskin length is variable, but it is nearly always fused to the head of the penis (glans) in much the same way as the fingernail is connected to the nail-bed. As the boy grows, the two surfaces gradually separate and the foreskin is able to move freely back and forth over the glans. Like all organic processes, this can take time, and it is perfectly normal for a boy’s foreskin not to become retractable until puberty.
The foreskin should never be forced back over the glans. Premature or forcible retraction is very painful for the boy, and may result in serious injury to the penis, including scarring that can permanently fuse the foreskin to the glans, narrow the foreskin opening (phimosis) or lead to paraphimosis (explained below). The first person to pull a boy’s foreskin back should nearly always be the boy himself.
Rule 1: Leave it alone! The infant penis requires no special care. For cleanliness, just wash the outside of your boy's penis with warm water and mild (baby) soap when you bathe him, or wipe it gently with a soft damp cloth or tissue. Do not make any attempt to clean inside his foreskin, and never try to pull it back. Soaps can irritate the sensitive skin at the tip and the inside of the foreskin: you should avoid getting soap on these sensitive areas, just as you prevent soap from getting in a baby’s eyes.
Some boys produce a whitish, creamy material that builds up beneath the foreskin opening. This material, known as infant smegma, consists of skin cells shed by the inner foreskin and glans. Some parents become alarmed when they see smegma because they think it is pus and assume there is an infection that requires treatment. In fact, smegma is perfectly harmless and will work its way out of the foreskin opening, where it can be wiped away with a soft cloth or tissue.
When a boy is old enough to wash himself, he can rinse his own penis when he takes a bath or shower. Most boys learn how to pull their own foreskins back, but some may need to be shown how to do it. If, on the other hand, his foreskin is not yet retractable, he may need to be warned against forcing it.
Phimosis derives from the ancient Greek word for muzzled, and refers to a condition in which the foreskin cannot be retracted (pulled back) to expose the glans. Nearly all babies and young boys have a foreskin that will not retract, and this is perfectly normal. There is no definite age at which the foreskin is meant to become retractable. Most boys will be able to retract their foreskins by age 8, but it is a highly variable process, and quite a few wait until puberty, and some take even longer. Young boys naturally tug at their foreskin and play with their penis, and this helps the foreskin to separate from the glans and become mobile at the individual’s own pace.
No matter how long the process of foreskin separation takes, there is no need for any concern or anxiety unless the boy is experiencing pain or discomfort. Too many boys are needlessly circumcised between the ages of 3 and 7 because of a mistaken diagnosis of phimosis. In most cases they would have been perfectly all right if they had been left alone and allowed to develop naturally.
If a boy is experiencing regular pain or discomfort from a tight or short foreskin (for example, when he does a wee or gets an erection), or if his urine stream is very feeble, medical advice should be sought. In such cases the preferred treatment is application of steroid ointment (usually betamethasone valerate) as prescribed by a paediatrician or other medical specialist. Severe phimosis that does not respond to topical medication may require surgery. Apart from circumcision, there are several surgical operations that may resolve the problem without loss of tissue.
The most common cause of penis problems in infancy are attempts to stretch, dilate or forcibly retract the foreskin before it is ready. This is likely to cause tears in the foreskin tissue that may lead to infection; adhesion of the foreskin to the glans; and induced phimosis, when scar tissue resulting from tears and abrasion causes the tissue at the opening of the foreskin to harden and shrink. The most certain way to avoid foreskin problems in infancy and childhood is to leave the foreskin alone.
Like all body parts, the foreskin is liable to a variety of minor problems, most of which resolve themselves without the need for any treatment. None of these problems require circumcision.
Red or inflamed tip
This can have many causes, including exposure to soiled nappies, soap, chlorinated water, antibiotics, or concentrated urine resulting from not drinking sufficient fluids. It rarely indicates an infection. The treatment depends on isolating the cause, but measures such as rinsing or soaking without soap, letting him lie or run around naked, tossing a handful of salt into his bath or ensuring that he drinks more water may assist and will do no harm. In most cases the problem will resolve spontaneously, but if it does not you should seek medical advice.
Lumps under the foreskin
These are caused by an accumulation of smegma and will disappear spontaneously or be extruded through the foreskin opening, at which point the material can be wiped away. As mentioned above, smegma is quite harmless, and its presence indicates that normal separation of foreskin and glans is taking place.
Spraying
Quite a few boys go through a phase when their urine tends to spray out when they urinate. In most cases it does not last long and resolves itself, but some boys take delight in their capacity to spray a great distance and sometimes engage in contests with their mates. If the spraying persists or if it is accompanied by urinary accidents or abdominal pain, it may indicate a bladder or urinary tract problem, and expert medical advice should be sought.
Ballooning
Some boys find that their foreskin balloons out when they urinate. This is another passing phase that will resolve itself as the foreskin opening widens. Since the ballooning tends to stretch the foreskin, it helps to achieve separation and retractability. As with spraying, some (mainly older) boys amuse themselves by deliberately holding their foreskins shut so as to force their urine stream to reach further. As with spraying contests, such typically boyish behaviour comes under the general heading of good manners and discipline; it is not a medical issue.
Paraphimosis
This is a potentially serious condition in which the foreskin has been pulled back behind the glans, becomes trapped there and cannot be brought forward to cover it again. In most cases the problem can be resolved by gently compressing the glans by squeezing it and allowing the foreskin to fall forward, but in rare cases (where the condition has persisted long enough for the foreskin to become so swollen that it threatens to strangle the penis), urgent medical attention is needed. In the meantime ice may help.
Paraphimosis in infants and young boys is often caused by forcible premature retraction of the foreskin, and can easily be prevented by observing the golden rule of foreskin care: leave it alone! Occasionally it is caused by the boy himself, such as when retracts his foreskin while his penis is flaccid, but then gets an erection and finds he can’t return it to the normal position. In these cases it is usually only a matter of waiting for the erection to subside. Again, ice may hasten the process.
Zipper injury
If the foreskin gets caught in a zipper it is very painful and the boy may be screaming. Urgent medical attention must be sought, but in the meantime application of topical anaesthetic cream or spray will dull the pain. It may also be possible to free the foreskin by cutting the zipper at the base and carefully separating the teeth. The vital thing is not to tug at the foreskin, as this will only increase the pain and enlarge the injury. Ways to minimise the risk are not to give boys trousers with zippers until they are old enough to dress themselves; always ensure that he wears underpants; and take care when dressing him. Circumcised boys can also get their penis caught in a zipper, and in these cases the same general rules should be followed.
There are several conditions which may require circumcision, but only after non-surgical treatments of the problem have been given a fair trial, and after expert medical advice. The conditions are
Balanitis xerotica obliterans (BXO)
BXO or lichen sclerosis is recognizable by a whitish ring of hardened and often cracked tissue, with redness around it, that develops at the tip of the foreskin. As this condition progresses, the ring constricts the foreskin opening and prevents retraction. The origins of the condition are obscure, and it is quite uncommon – rarely seen before the age of 5 years, and affecting no more than about 1 per cent of boys by age 15. Presence of the condition must be confirmed by specialist advice.
Conservative treatment, usually with steroid ointment or injections, should be attempted before surgery is considered. Minor surgery such as preputioplasty, which makes a small incision in the foreskin without loss of tissue, may be tried before circumcision is decided on.
Severe recurrent attacks of balanoposthitis (infections of glans and foreskin)
Balanoposthitis (from the Greek, balanos, meaning acorn, and posthe, foreskin) refers to inflammations of both the glans and foreskin. The condition may also feature dramatic swelling and reddening of the penis and foreskin, along with discharge, bleeding from the foreskin, difficulty urinating, and occasionally inability to urinate. The problem is quite rare, affecting no more than 4 per cent of boys between 2 and 5 years. The origins of the problem are unclear, but may be the result of infection or allergy. Although balanoposthitis may be recurrent, the episodes tend to become less frequent as the boy gets older, and usually disappear naturally.
Diagnosis requires specialist advice, and initial treatment should consist of bathing, topical or oral antibiotics, and steroids. Where these fail and the episodes continue to be both frequent and severe, circumcision may be considered.
Recurrent urinary tract infections (UTIs)
Most urinary tract infections clear up after treatment with oral antibiotics, but circumcision should be considered in the case of recurrent UTIs, with feverish symptoms, that have not responded to antibiotics, and where the urinary tract is abnormal. Again, specialist diagnosis and advice are required. The most effective preventive of UTIs is breast milk.
Severe traumatic injuries
Circumcision may also be necessary in the case of severe traumatic injuries, as well as gangrene, frostbite and cancer, where the tissue cannot be salvaged. Such cases are very rare.
NOTE: The decision to circumcise should not be taken lightly: the operation makes a permanent physical alteration to the body, and cannot be reversed. Since not all general practitioners are fully up to date with modern treatment options, specialist advice should always be sought in these cases, before such surgery is decided on.
Like all surgery, circumcision involves the cutting of tissue, nerves and blood vessels; and like all surgery it cannot be done without the risk of pain and complications, the most common of which are bleeding, scarring and various infections. Where anaesthetics are employed there may also be an adverse reaction to the anaesthetic used, and also to pain control drugs given after the operation. The severity of the risks and the requirements for after-care differ according to the age at which the circumcision is performed.
At birth, a baby’s foreskin and glans are usually fused to each other, in much the same way as the eyelids of a newborn kitten are sealed. Before circumcision can be performed, the foreskin must be forcibly separated from the glans, usually with a metal probe. The entire glans of the baby’s penis and the site of the incision then become raw wounds, liable to infection and bleeding, and extremely painful to touch. The open wound may also form an adhesion to the circumcision scar on the shaft of the penis. You should watch your baby very carefully for the first few days following circumcision to make sure that the wounds are healing.
Immediate complications
The following immediate complications of circumcision are most dangerous in the neonatal period (first month) and early infancy, but they are possible at any age.
Bleeding
Babies contain very little blood, and cannot afford to lose much. If the boy’s penis continues or starts to bleed following circumcision, you should seek urgent medical attention. Do not administer aspirin as pain relief in this situation, as this interferes with blood-clotting. Boys have died following circumcision because the nappies in which they were dressed absorbed the blood from the wound and parents did not notice they were bleeding until it was too late.
Infection
Infections can be communicated by the instruments used in the procedure, or from subsequent exposure of the raw surfaces to bacteria from medical personnel, dressings, nappies or the parents’ clothes or hands. Increasing redness, inflammation, swelling, oozing, or fever are all signs of infection. Infections spread rapidly in newborns, and serious diseases, such as meningitis, can quickly lead to death. If you see any sign of infection, medical attention must be sought immediately.
Retention of urine
Circumcision sometimes leads to blocking of the urethra (urine passage). If your baby goes longer than eight hours without doing a wee after being circumcised, the doctor should be notified immediately.
Urethral fistula
If your baby’s urinary opening (meatus) is not at the tip of his glans, or if urine comes out of any other opening in his penis, the doctor should be notified immediately.
Dislodged Plastibell circumcision device
If your baby has been circumcised with the Plastibell device, the plastic ring with a string tied around its rim on your baby’s penis should drop off within five to eight days. If it does not drop off within this period, or if it slips down from his glans and onto the shaft of his penis, or if you notice any swelling, the doctor should be notified immediately.
Complications from anaesthetics
The penile dorsal nerve block anaesthetic requires injections at the base of the penis. Needles puncturing tissue in this area are likely to cause bruising and may damage the dorsal nerve. Accidental puncture of the dorsal artery or vein can lead to internal bleeding and gangrene. If your baby has extensive bruising or swelling around the injection sites, the doctor should be notified.
Topical anesthetics such as EMLA cream are not fully effective against circumcision pain, and carry the risk of depleting the baby’s blood oxygen. Such creams are not approved for use on babies under one month. If your baby turns bluish or grayish after the application of such creams, or if he becomes lethargic, medical attention must be sought urgently.
Pain
Whether or not an anaesthetic is used, your baby is likely to be in pain following the procedure. Some doctors prescribe post-operative pain medication, but it is not always effective and is never 100 per cent effective. You can comfort your baby by holding him, nursing him frequently, sleeping with him, and being especially careful when changing his nappy. Older babies and children can safely be given pain relief, such as paracetamol or codeine, but be cautious about giving aspirin if there is any sign of bleeding.
Behavioural changes
Feeding Some babies feed readily soon after they are circumcised, but many do not. Circumcision often interferes with breastfeeding, and there is no known method of re-establishing contact except by persistence.
Sleep patterns
Many parents worry because their baby sleeps an unusually long time after being circumcised. The procedure is a stressful and exhausting experience for a baby, and sleep will help him to recover.
Dressing changes If your baby was circumcised with a Plastibell device, the plastic ring should be in place with no dressing on his penis. If your baby was circumcised with other devices, such as a Gomco or other forms of clamp, his penis may be bandaged with a gauze dressing to prevent the wound on his remaining foreskin and the open wound on his glans from sticking to each other or to a nappy. Some doctors recommend gently replacing this dressing when it is soiled; others recommend removing it after an hour or two. Some doctors recommend application of Vaseline to the wound with every nappy change for three weeks following the surgery so as to prevent the wound from sticking to the nappy. The yellowish crust on your baby’s glans forms part of the healing process and will fall off as the glans heals.
Bathing Following circumcision the penis will be extremely sensitive to pain and care must be taken not to allow any abrasive materials to touch it. After he has done a poo, the circumcision area should be gently rinsed with warm running water. It is best to wait until the wound has healed (seven to ten days) before touching it or using a wash cloth or “baby-wipes.”
Preventing adhesions Adhesions and skin bridges may form when the raw surfaces of the glans and remaining penile skin fuse together as they heal. This can be prevented by pulling the penile shaft skin behind the line of the incision gently away from the glans once a day and applying petroleum jelly for the first three weeks. Gentle retraction should be done regularly until your baby is a year old to ensure that the deeper layers of the wound heal without fusing to adjacent tissue.
Meatitis In the absence of the foreskin, the urinary opening (meatus) may become inflamed and ulcerated. As ulcers heal, scar tissue forms, constricts the meatus and causes a condition known as meatal stenosis.
Meatal stenosis Constriction of the meatus impedes and sometimes blocks the flow of urine. Urine retained in the bladder may allow the growth of bacteria, which can lead to infections. If you notice anything irregular about your baby’s urine flow, the doctor should be notified. Surgery may then be required to enlarge the urinary opening.
Preputial stenosis As it heals, the circumcision scar sometimes forms as a tight, constricted, inelastic ring, trapping the glans behind it. This condition may require corrective surgery.
Buried penis Following circumcision, the penis may become entrapped by scar tissue and retract into the pubic fat. This condition may correct itself naturally but sometimes requires surgery. Boys whose buried penis is noticed before circumcision should not be circumcised.
Excessive skin removal A common complication of circumcision is excessive removal of tissue, but it rarely becomes apparent until the penis reaches its full adult size at puberty. One important function of the foreskin is to provide the slack skin necessary to accommodate the enlargement of the adult penis when erect, meaning that a tight circumcision will make erections painful, and that a very severe operation may inhibit them. Both foreskin length and penis size vary immensely from one male to another, but before puberty it is impossible to know either of these details. There is not much that can be done in cases where there has been excessive skin removal, but a boy may be able to achieve some relief by utilising the stretching techniques developed for foreskin restoration.
Scarring The size, colour and shape of circumcision scars vary from male to male, and some are more noticeable than others. Many circumcised males feel self-conscious about the scar on their penis, and some scars may be painful.
Desensitization The foreskin is erogenous tissue – now understood to be the most sensitive part of the penis – and its loss tends to desensitizes the penis and affect sexual function. Circumcision also causes the surface of the glans to dry out, thicken, and become dull instead of glossy, and lighter in colour.
Resentment and anger Increasing numbers of men are angry and resentful at having been circumcised in infancy or childhood without their agreement, and in some individuals the resentment leads to serious psychological and behavioural problems, and even suicide in rare cases. Parents should bear this risk in mind when considering whether to have their child circumcised.
Circumcision Information Australia
www.circinfo.org
February 2011
Full RACP policy statement on circumcision
British Association of Paediatric Urologists, Management of Foreskin Conditions
British Medical Association, The Law and Ethics of Male Circumcision
American Academy of Pediatrics, Care of the Uncircumcised Penis: Guidelines for Parents
Simpson ET, Barraclough P. The management of the paediatric foreskin. Aust Fam Physician 1998;27(5):381-3
Thomas B. McGregor, John G. Pike, Michael P. Leonard. Pathologic and physiologic phimosis: Approach to the phimotic foreskin. Canadian Family Physician 2007(March);53:445-448
Dewan PA. Treating phimosis. Med J Aust 2003 178 (4): 148-150
Camille CJ, Kuo RL, Wiener JS. Caring for the uncircumcised penis: What parents (and you) need to know. Contemp Pediatr 2002;11:61