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Surgical Procedures

Circumcision

Male circumcision is the surgical removal of some or all of the foreskin (prepuce) from the penis. The word "circumcision" comes from Latin circum (meaning "around") and cædere (meaning "to cut"). Early depictions of circumcision are found in cave paintings and Ancient Egyptian tombs, though some pictures are open to interpretation. Religious male circumcision is considered a commandment from God in Judaism. In Islam, though not discussed in the Qur'an, male circumcision is widely practised and most often considered to be a sunnah. It is also customary in some Christian churches in Africa, including some Oriental Orthodox Churches.

According to the World Health Organization (WHO), global estimates suggest that 30% of males are circumcised, of whom 68% are Muslim. The prevalence of circumcision varies mostly with religious affiliation, and sometimes culture. Most circumcisions are performed during adolescence for cultural or religious reasons; in some countries they are more commonly performed during infancy. Other reasons for circumcision include phimosis and paraphimosis. Circumcision reduces the risk of HIV infection in populations that are at high risk. Evidence among heterosexual men in sub-Saharan Africa shows a decrease risk of between 38 and 66% over 2 years and in this population it appears cost effective. Evidence of benefit for women is controversial and evidence of benefit in developed countries and among men who have sex with men is yet to be determined. Ethical concerns remain regarding the implementation of campaigns to promote circumcision. Medical associations of some developed countries have issued policy statements in which they do not recommend routine circumcision

Circumcision Surgery Information

Modern procedure. If anesthesia is to be used there are several options: local anesthetic cream (EMLA cream) can be applied to the end of the penis 60–90 minutes prior to the procedure; local anesthetic can be injected at the base of the penis to block the dorsal penile nerve; local anesthetic can be injected in a ring around the middle of the penis in what is called a subcutaneous ring block.

For infant circumcision, devices such as the Gomco clamp, Plastibell, and Mogen clamp are commonly used, together with a restraining device. With all these devices the same basic procedure is followed. First, the amount of foreskin to be removed is estimated. The foreskin is then opened via the preputial orifice to reveal the glans underneath and ensure it is normal. The inner lining of the foreskin (preputial epithelium) is then bluntly separated from its attachment to the glans. The device is then placed (this sometimes requires a dorsal slit) and remains there until blood flow has stopped. Finally, the foreskin is amputated. Sometimes, the frenulum band may need to be broken or crushed and cut from the corona near the urethra to ensure that the glans can be freely and completely exposed.

Plastibell Circumcision day 4 post operation With the Plastibell, once the glans is freed the Plastibell is placed over the glans, and the foreskin is placed over the Plastibell. A ligature is then tied firmly around the foreskin and tightened into a groove in the Plastibell to achieve hemostasis. Foreskin distal to the ligature is excised and the handle is snapped off the Plastibell device. The Plastibell falls from the penis after the wound has healed, typically in four to six days. With a Gomco clamp, a section of skin is dorsally crushed with a hemostat and then slit with scissors. The foreskin is drawn over the bell shaped portion of the clamp and inserted through a hole in the base of the clamp. The clamp is tightened, "crushing the foreskin between the bell and the base plate." The crushed blood vessels provide hemostasis. The flared bottom of the bell fits tightly against the hole of the base plate, so the foreskin may be cut away with a scalpel from above the base plate. With a Mogen clamp, the foreskin is pulled dorsally with a straight hemostat, and lifted. The Mogen clamp is then slid between the glans and hemostat, following the angle of the corona to "avoid removing excess skin ventrally and to obtain a superior cosmetic result" to Gomco or Plastibell circumcisions. The clamp is locked, and a scalpel is used to cut the skin from the flat (upper) side of the clamp. Adult circumcisions are often performed without clamps and require 4 to 6 weeks of abstinence from masturbation or intercourse after the operation to allow the wound to heal.[81] In some African countries, male circumcision is often performed by non-medical personnel under unsterile conditions. After hospital circumcision, the foreskin may be used in biomedical research, consumer skin-care products,[84] skin grafts, or β-interferon-based drugs. In parts of Africa, the foreskin may be dipped in brandy and eaten by the patient, eaten by the circumciser, or fed to animals.[89] According to Jewish law, after a Brit milah, the foreskin should be buried.

Sexual effects

Main article: Sexual effects of circumcision The sexual effects of circumcision are the subject of much debate. The American Academy of Pediatrics points to a survey (self-report) finding circumcised adult men had less sexual dysfunction and more varied sexual practices, but also noted anecdotal reports that penile sensation and sexual satisfaction are decreased for circumcised males. A 2002 review by Boyle et al. stated that "the genitally intact male has thousands of fine touch receptors and other highly erogenous nerve endings—many of which are lost to circumcision, with an inevitable reduction in sexual sensation experienced by circumcised males." They concluded, "intercourse is less satisfying for both partners when the man is circumcised". In January 2007, The American Academy of Family Physicians (AAFP) stated "The effect of circumcision on penile sensation or sexual satisfaction is unknown. Because the epithelium of a circumcised glans becomes cornified, and because some feel nerve over-stimulation leads to desensitization, many believe that the glans of a circumcised penis is less sensitive. [...] No valid evidence to date, however, supports the notion that being circumcised affects sexual sensation or satisfaction." Payne et al. reported that direct measurement of penile sensation in the shaft and glans during sexual arousal failed to support the hypothesised sensory differences associated with circumcision status. In a 2007 study, Sorrells et al., using monofilament touch-test mapping, found that the foreskin contains the most sensitive parts of the penis, noting that these parts are lost to circumcision. They also found that "the glans of the circumcised penis is less sensitive to fine-touch than the glans of the uncircumcised penis." In a 2008 study, Krieger et al. found that 'compared to before they were circumcised, 64.0% of circumcised men reported their penis was "much more sensitive," and 54.5% rated their ease of reaching orgasm as "much more" at month 24'. Reports detailing the effect of circumcision on erectile dysfunction have been mixed. Studies have shown that circumcision can result in a statistically significant increase, or decrease, in erectile dysfunction among circumcised men, while other studies have shown little to no effect.

Complications

Complication rates ranging from 0.06% to 55% have been cited; more specific estimates have included 2-10% and 0.2-0.6%. According to the American Medical Association (AMA), blood loss and infection are the most common complications, but most bleeding is minor and can be stopped by applying pressure. A survey of circumcision complications by Kaplan in 1983 revealed that the rate of bleeding complications was between 0.1% and 35%. A 1999 study of 48 boys who had complications from traditional male circumcision in Nigeria found that haemorrhage occurred in 52% of the boys, infection in 21% and one child had his penis amputated.

One study looking at 354,297 births in Washington State from 1987-1996 found that immediate post-birth complications occurred at a rate of 0.2% in the circumcised babies and at a rate of 0.01% in the uncircumcised babies. The authors judged that this was a conservative estimate because it did not capture the very rare but serious delayed complications associated with circumcisions (e.g., necrotizing fasciitis, cellulitis) and the less serious but more common complications such as the circumcision scar or a less than ideal cosmetic result. They also stated that the risks of circumcision "do not seem to be mitigated by the hands of more experienced physicians". Meatal stenosis (a narrowing of the urethral opening) may be a longer-term complication of circumcision. It is thought that because the foreskin no longer protects the meatus, ammonia formed from urine in wet diapers irritates and inflames the exposed urethral opening. Meatal stenosis can lead to discomfort with urination, incontinence, bleeding after urination and urinary tract infections. Circumcisions may remove too much or too little skin. If insufficient skin is removed, the child may still develop phimosis in later life.[64] Van Howe states that "when operating on the infantile penis, the surgeon cannot adequately judge the appropriate amount of tissue to remove because the penis will change considerably as the child ages, such that a small difference at the time of surgery may translate into a large difference in the adult circumcised penis. To date (1997), there have been no published studies showing the ability of a circumciser to predict the later appearance of the penis." Cathcart et al. report that 0.5% of boys required a procedure to revise the circumcision. Other complications include concealed penis, urinary fistulas, chordee, cysts, lymphedema, ulceration of the glans, necrosis of all or part of the penis, hypospadias, epispadias and impotence. Kaplan stated "Virtually all of these complications are preventable with only a modicum of care" and "most such complications occur at the hands of inexperienced operators who are neither urologists nor surgeons." Another complication of infant circumcision is skin bridge formation, whereby a remaining part of the foreskin fuses to other parts of the penis (often the glans) upon healing. This can result in pain during erections and minor bleeding can occur if the shaft skin is forcibly retracted. Van Howe advises that to prevent adhesions forming after circumcision, parents should be instructed to retract and clean any skin covering the glans. Although deaths have been reported, the American Academy of Family Physicians states that death is rare, and cites an estimated death rate of 1 infant in 500,000 from circumcision. In 2010, Bollinger estimated a death rate of 9.01 per 100,000, or 117 per year in the United States. Gairdner's 1949 study reported that an average of 16 children per year out of about 90,000 died following circumcision in the UK. He found that most deaths had occurred suddenly under anaesthesia and could not be explained further, but hemorrhage and infection had also proven fatal. Deaths attributed to phimosis and circumcision were grouped together, but Gairdner argued that such deaths were probably due to the circumcision operation. Wiswell and Geschke reported no deaths in the first month of life after 100,157 circumcisions (in contrast with two deaths among 35,929 uncircumcised boys); they also reported finding no deaths in separate series of 300,000 US Army circumcisions, and 650,000 boys circumcised in Texas. King reported no deaths among 500,000 circumcisions. The penis is thought to be lost in 1 in 1,000,000 circumcisions.

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