Ch. 7: Conservative Alternatives to Therapeutic Circumcision (DOC Genital Integrity Statement)

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Chapter Seven: Conservative Alternatives to Therapeutic Circumcision

Introduction

Male circumcision is an unnecessarily invasive operation that excises and destroys the prepuce1 and its multiple physiological functions (See Chapter Two),2,3 creates an abnormal physical appearance, leaves an annular scar, and violates the patient’s genital integrity. The Medical Ethics Committee of the British Medical Association (2006) advises use of conservative treatment whenever possible.4 The goal of conservative treatment should include preservation of the foreskin and its restoration to health.5

Phimosis

Phimosis (Greek for “muzzling”) is the term that designates a non-retractile foreskin. Circumcision is a traditional treatment for non-retractile foreskin. Non-retractile foreskin, however, is not a disease and does not necessarily require treatment, unless it causes problems.

Non-retractile foreskin is the normal condition in children and some adolescents.6-9 The foreskin usually becomes retractable with maturity, spontaneously and without treatment. (See Chapter Two.) Patiently waiting for nature to make the foreskin retractable is required.10 Thorvaldsen & Meyhoff (2005) report that the mean age of first foreskin retraction is 10.4 years.11 Physician ignorance of the normal development of the prepuce seems to be a worldwide problem.12-16 Physician education about the normal development of the foreskin should end improper diagnosis of pathological phimosis.10,13,14

If treatment of non-retractile foreskin is deemed necessary, there are three non-invasive or minimally-invasive alternatives to circumcision:

  1. manual stretching to accomplish tissue expansion
  2. topical application of steroid ointment with gentle stretching
  3. minimally-invasive preputioplasty

There have been numerous trials in several nations of topical steroid ointment for the treatment of non-retractile foreskin.17-30 Apparently, due to researcher ignorance, most have been carried out on very young boys, when the prepuce still is developing. Nevertheless, the treatment thins the skin21 and works in about 80 to 95 percent of cases. The procedure is safe20,24,27 and few, if any, complications have been reported. Topical steroid ointment now is the standard treatment of non-retractile foreskin in boys (if treatment is deemed necessary).24,27,29,30 Treatment with steroids avoids the psychological trauma of circumcision.31

Manual stretching also is effective for creating a retractile foreskin by tissue expansion.32-34 Manual stretching is suitable for adolescents and adults32-34 and is cost-free.

British and European surgeons have used minimally invasive plastic operations with great success for more than a decade.35-38 Plastic operations preserve the foreskin and its functions and have an easier and quicker recovery period with less pain.

Waiting for nature and maturity to make the foreskin retractable is the lowest-cost treatment of non-retractile foreskin in children. Manual stretching of the foreskin also is cost-free. After those cost-free treatments, topical steroid treatment costs less than preputioplasty, with circumcision being the most costly treatment for non-retractile foreskin.39,40

Scotland provides an example of what can be achieved. Better physician training on normal development of the foreskin, greater use of steroid medical treatment, and preputioplasty cut the number of circumcisions performed for phimosis in half over a ten-year period.41 With fuller use of conservative treatment, the number of circumcision operations for phimosis easily could approach zero.

Circumcision now is outmoded as a treatment for non-retractile foreskin and should be discarded, except when a competent adult patient insists on it, after he is completely and thoroughly informed of its certain injury, loss of penile sensation, sexual satisfaction, complications, and risks.42

Balanoposthitis

Balanoposthitis is inflammation of the glans penis and foreskin; balanitis is inflammation of the glans penis; and posthitis is inflammation of the prepuce. In this discussion, the word “balanitis” refers to all three conditions. Inflammation has many causes, including trauma, environmental irritants, and infection. Before treatment can be prescribed, the attending physician first must determine the cause of the inflammation. Diagnosis may include a patient history, swab and culture, and biopsy.43,44 There are many pathogens, including fungus, anerobes, aerobes, protozoa, and viruses, that may cause infection.43 Each requires different management.

A complete discussion of the diagnosis and treatment of the many causes of balanitis is beyond the scope of this statement. The British National Guideline on the Management of Balanitis (2001) provides specific directions and a flowchart for diagnosis of the cause of balanitis.45

Rickwood & Escala (1989) suggested that circumcision may be performed in cases of recurring balanitis,46 however, this was written before the development of specific guidelines for diagnosis. Balanitis should not recur if accurately diagnosed and appropriate treatment is administered. Recurrence of balanitis suggests that a different diagnosis and treatment is needed. Irritation, inflammation, and infection are treated with topical antibiotic ointment, steroid, or oral antibiotic.30

Fleiss (2000) reports that Acidophilus culture restores healthy bacteria and may be applied directly to the foreskin to promote healing.47

The foreskin, which has many immunological functions,2 is protective against balanitis. The foreskin maintains the subpreputial moisture, which contains oils and anti-pathogenic substances, and helps to protect against irritation and infection.2 More penile inflammation is found in circumcised boys,48 so circumcision should be avoided. The foreskin should not be retracted in young boys.48,50 It should be left in place to protect the penis. Soap may remove the oils from epithelial tissue and cause non-specific dermatitis that is mistaken for balanitis.51 Soap should be used sparingly or not at all.51,52

Balanitis Xerotica Obliterans/Lichen Sclerosus

Balanitis xerotica obliterans (BXO) is the same disease as lichen sclerosus et atrophicus (LSA).53,54 Traditionally, the term BXO has been used when the disease affects the male genital organs. The preferred term today, however, is lichen sclerosus (LS).

Edwards describes the disease as follows:

“The clinical appearance is of white plaques on the glans, often with involvement of the prepuce which becomes thickened and non-retractile. In active disease haemorrhagic vesicles may be seen. The changes only affect squamous skin, leaving atrophic areas which cause cicatritial shrinkage leading to urethral stenosis and phimosis. The condition affects all ages and circumcision specimens from children with phimosis often show the characteristic histological appearances. Histology initially shows a thickened epidermis, followed by atrophy and follicular hyperkeratosis. This overlies an area of oedema with loss of the elastic fibres and alteration in the collagen, which in turn overlies a perivascular band of lymphocytic infiltration. Haemorrhagic vesicles occur when the oedema causes detachment of the epidermis with a capillary erosion and extravasation of blood.”43

The disease, which is of unknown origin,43 commonly involves the genital organs.53 In males, the foreskin frequently is the target, but it may also involve the glans penis and the urethra.54 It usually is seen in boys from about age 4 to 11.56 Frequently, a whitish ring of hardened, non-elastic tissue is seen at the tip of the prepuce that prevents retraction.56-58 Diagnosis should be confirmed with biopsy.43

Rickwood et al. (2000) reported an incidence of 0.6 of one percent in British boys with a peak at age eleven.59 Kizer et al. (2003), who surveyed United States Army adult men, reported an incidence of 5.07 per ten thousand in white men and about twice that in black and hispanic men.60

BXO/LS once was considered to be an absolute indication for circumcision,57,58 but that is not the case today.55

Treatment with the carbon dioxide laser has been successful in removing the lesions of BXO/LS.61-65

Several studies have shown treatment with sub-lesional, intra-lesional, or topical steroids to be successful, especially in mild cases.17, 57, 66-71Vincent & MacKinnon (2005) report a 30 percent success rate with topical steroid cream.71

Treatment with topical steroid cream is now the first treatment for BXO/LS.55,56,69-70 Tacrolimus ointment may be a possible treatment option.73,74

Surgery, in addition to medical treatment, may be necessary in some cases. Meatotomy or urethroplasty may be required in severe cases to relieve obstruction and ease voiding.43 Dewan (2003) recommends preputioplasty instead of circumcision to relieve phimosis.72 Laser treatment may be useful in the treatment of meatal stenosis.55

BXO/LS has been identified as a risk factor for development of squamous cell carcinoma (SCC) in adults.43,55 The risk of SCC in children is unclear. Biopsy should be performed to rule out SCC.

Summation

Better understanding of the functions of the prepuce,2,3 the advent of the human rights era (see Chapter 9), and advances in medical ethics (see Chapter 11) have increased the demand for conservative alternatives to male circumcision, which preserve the patient‘s genital integrity, as a treatment. Advances in medical science make circumcision outmoded and obsolete as a treatment for phimosis and balanoposthitis. Newer medical and surgical treatments make circumcision as treatment for BXO/LS unnecessary in many cases.

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