The Battle to Defend Banana

This is the 4829th article of Da Yi Xiao Hu

Many parents come to the clinic with their children to consult about circumcision, especially during the winter vacation. What is foreskin? What is phimosis? What is circumcision? Although this topic is relatively private and a bit embarrassing to talk about, it is a common and unavoidable question. Because circumcision is one of the most common surgical operations.

In fact, the foreskin is the layer of skin on the boy's penis. Sometimes, the foreskin of a boy may grow too long or too tight. At this time, the doctor may recommend a surgery called "circumcision" to solve the problem, that is, to cut off part of the foreskin, which can be cleaner and healthier (Figure 1).

Figure 1 Schematic diagram of circumcision (Source: The Penis Book)

What is the problem with foreskin being too long?

In the third month of pregnancy, the foreskin of a boy begins to develop, and then grows like a collar until it covers the head of the penis. If the foreskin can still be turned up and the external opening of the urethra can be seen, it is called prepuce. If the foreskin cannot be turned up and the external opening of the urethra cannot be seen, it is called phimosis. Prepuce and phimosis are congenital. The foreskin of infants and young children often have epithelial adhesions with the penis. With growth and development, the epithelial adhesions are gradually absorbed, and the foreskin is separated from the penis. When growing up, some people will have prepuce disappear on their own, but a considerable number of people still have it.

Current Status of Circumcision

Circumcision is one of the most common surgical procedures, with about one-third of men worldwide undergoing the procedure, according to the World Health Organization. Most boys born in Israel, Australia, Central Asia, Bangladesh, Pakistan, Turkey, Indonesia, the Philippines, South Korea, and much of the Middle East are circumcised. In the United States, the distribution varies by race, with more white people than African Americans, who in turn are more likely to be circumcised than Hispanics. Africans are also more likely to be circumcised, and studies have shown that circumcision reduces the risk of HIV infection. There are also many circumcised men in China, of all ages.

History of circumcision

Circumcision is also one of the oldest known surgical procedures. Circumcision was found in mummies around 1300 BC and was also depicted in Egyptian murals. In Judaism, circumcision is called "circumcision" and is regarded as a religious ritual. Male babies must undergo "circumcision" on the eighth day after birth.

Even according to the religious text "Genesis", circumcision was used as a "military tactic". Shechem, the prince of Hittite, had an ignoble relationship with Dinah, the daughter of the Jewish patriarch Jacob, but Shechem was not Jewish, which was opposed by Dinah's Jewish brothers. They hatched a conspiracy and said to Shechem: "We can't give our sister to an uncircumcised man. It is a shame for us. But we are willing to reach an agreement with you. As long as you circumcise your subjects, we can eventually become one nation through marriage." Prince Shechem agreed, and he and his subjects acted in unison and circumcised their foreskins on the same day. Three days later, when all the men in the kingdom were still recovering from surgery, Dinah's brothers suddenly launched an attack, attacked the defenseless city, and took Dinah back.

How is circumcision performed?

Circumcision is generally not complicated and can be performed in an outpatient surgery room in a hospital. Before the operation, the doctor will conduct a detailed examination and evaluation of the patient to determine whether the patient is suitable for circumcision. Before the operation, the area needs to be cleaned to remove the smegma, which is the dirt in the foreskin. If there is an infection in the foreskin fossa, the infection should be controlled first.

There are many ways to perform a circumcision. For example, in a traditional circumcision, the doctor will anesthetize the patient before the operation begins so that it will not feel pain. The doctor will then use his hands or an instrument to turn the foreskin back and use a scalpel to remove the excess foreskin. The doctor will then carefully stop the bleeding and suture the wound. The operation usually takes about 30 minutes, and after the operation is completed, the doctor will bandage the patient's incision.

There are also methods that use circumcision devices. For example, one device is to place a small safety "helmet" on the head of the penis to separate it from the foreskin. A circle of thread is tied around the foreskin, and the "helmet" and the thread are strangled to cause tissue ischemia and necrosis. When the necrotic tissue falls off, a healed wound will be left.

What should I pay attention to after the operation?

It usually takes some time to recover after a circumcision. Oral antibiotics are generally required for several days after surgery to prevent infection. You also need to take good care of the wound, keep it clean and dry, wear comfortable and loose clothes, and avoid exercise and heavy lifting until the wound heals well, which may take 3-4 weeks. In the first few days after surgery, the wound may be a little painful and bleed a little, but these will gradually subside and generally get better in about a week. But if these problems persist for several days or get worse, you should see a doctor. Children may experience pain when urinating after surgery, or even refuse to urinate because of this. A small amount of lidocaine (a local anesthetic) can be used as a wash to relieve it as appropriate. Local edema may occur in the penis after surgery, but it generally disappears over time.

To cut or not to cut?

Circumcision has been a topic of debate for centuries. To cut, or not to cut? Male circumcision certainly has its benefits, as it can reduce the occurrence of local infections. Over time, smegma can form in the foreskin sac, which is where dirt is stored, and bacteria also like to grow in the moist environment under the foreskin. If these are not removed in time and accumulate under the foreskin, they can stimulate and cause balanitis. Bacteria can also decompose the smegma and produce a strong odor. Even repeated inflammation over time can lead to tumors. However, an excessively long foreskin generally does not affect the development of a boy's external genitalia.

Circumcision also has risks, such as bleeding, wound infection, and wound scar formation, but under the operation of experienced doctors, the risk rate is already quite low. Whether to perform circumcision on children should be decided with caution. Parents need to weigh the pros and cons before making a decision. Of course, they must also fully consider the opinions of the children and obtain their consent. For those who have repeated infections and phimosis, surgical treatment is recommended. For children who can easily turn up their foreskin without any obstruction, if they do not undergo surgery, remember to regularly turn it up and wash it during bathing, instead of just washing the outside.

Acknowledgements: We would like to thank Wang Luxuan from Xinsong Middle School in Minhang District, Shanghai for his revisions and suggestions for the readability of this article.

Department of Urology, Shanghai Fifth People's Hospital, Fudan University

Department of Surgery, Fudan University

Wang Wei, Chief Physician, Doctor