Circumcision is an ancient practice that dates back several thousand years. It involves removal of the distal part of the preputial skin that covers the glans penis. Photo: AFP
Circumcision is one of the oldest procedures recorded in the history of medicine, and the world’s most widely-performed surgery.
An estimated one-third of the world’s population are circumcised, the majority being the Muslims and the Jews. It is considered a tradition of the descendants of the Prophet Abraham, who was circumcised at the age of 80.
Circumcision for Muslims, as mentioned in the hadith (a collection of the sayings of the Prophet Muhammad), is a sign of fitrah, a natural inclination of humans, along with otherfitrah such as the clipping of nails, removal of hair in the armpits and genitals, and trimming of the moustache.
The Arabs usually circumcise their sons on the seventh day of life, a sunnah (the practices of the Prophet Muhammad) followed from the Prophet Muhammad, who was said to be circumcised at that age by his uncle Abdul Mutalib.
The Malays traditionally circumcise their sons much later, adding colourful traditions to the circumcision ritual. There are no Quranic verses that specify the circumciser’s gender, but traditionally, males are preferred and are chosen by the parents.
During the first year of life, there is physiological phimosis (a congenital narrowing of the opening of the foreskin so that it cannot be retracted). Babies are naturally born with a tight foreskin that is adherent to the glans and the inability to retract the foreskin at this age is normal.
As the child grows, the foreskin will separate from the glans and the opening will widen. For some, the foreskin opening grows wide enough to allow it to slide over an erect penis.
For others, the expansion of the foreskin never really catches up with the size of the glans and it remains adherent until adulthood. A tight foreskin secondary to physiological phimosis is usually not problematic – gentle stretching of the foreskin and sparing use of a steroid cream will usually allow the opening to widen.
A pathological phimosis, on the other hand, is usually a consequence of some medical condition, or occurs following injury to the foreskin.
For example, having a tight foreskin limits the ability to properly clean the child’s private part, hence, some residual urine may accumulate underneath the foreskin. This would predispose the child to infection of the glans penis, known as balanophosthitis.
This problem can lead to a vicious cycle, because after each infection, the foreskin will heal by fibrosis (the thickening and scarring of connective tissue), which will further shrink the tight foreskin. This would be a medical indication for circumcision to alleviate the problem.
If the preputial skin gets accidentally caught in the trousers’ zipper (a common presentation to the emergency room), it will usually end up with an unplanned circumcision.
Another medical condition that warrants a circumcision is recurrent urinary tract infections.
Preparing your child
It is very important that your child is mentally and physically prepared for the circumcision procedure.
Avoid saying that the procedure is not painful. Explore the fear that he has in his mind before undergoing the procedure. It also helps if your child has had previous experience of a local anaesthetic (LA) injection. They can then gauge the level of discomfort that they will encounter.
The first challenge is to convince your child that the most painful part is during the LA injection, and not during the circumcision procedure.
A child would perceive it differently. For the majority, the worse part is the “cutting”.
Circumcision can be done with LA alone, with the use of sedation, or under full general anaesthesia. The use of sedation or general anaesthesia avoids your child having to undergo the pain of LA injection.
They will first be given some sedation or anaesthetic gas before the LA administration. In all cases, a local anaesthetic injection is administered at the base of the penile shaft. This injection is painful. Depending on the type of LA used, the anaesthetic effect can last up to four hours.
Circumcision methods
Conventional method – The most common method used is the dorsal slit method. After the administration of the LA, the foreskin is retracted and cleaned with antiseptic solution. The foreskin is held before being trimmed off with scissors or diathermy (a method that cuts tissue using heat).
The inner and outer foreskin is then approximated with absorbable sutures, most importantly, at the underside of the glans. The sutured tissue is then covered with some topical antibiotic cream and dressing.
This method will require daily dressings and may cause daily discomfort. The sutures will be fully absorbed by the second or third week.
Clamp technique – There are many types of penile clamps, e.g. the Tara clamp and Mogen clamp. A penile clamp is defined as a medical device used solely for the purpose of circumcision.
After the administration of LA and cleansing with antiseptic, an appropriate-sized clamp is chosen and applied. A basic clamp unit consists of two parts: the inner and outer parts. These two parts will clamp the inner and outer foreskin together, effectively cutting off blood supply to the distal part of the foreskin.
This skin is usually excised during the procedure, leaving the clamp intact.
For most clamp techniques, the clamp will need removal with another administration of LA, usually done five to seven days later.
Sutureless circumcision – The sutureless circumcision technique using tissue glue was first introduced in early 2000.
The technique omits the use of a suture or a clamp, and relies heavily on tissue glue for tissue approximation.
After the administration of LA and excision of the distal foreskin, best done using diathermy, the tissues are approximated with tissue glue.
There are many types of glue available, 2-cyanoacrylate or histoacryl, but my personal preference is the former.
Sutureless circumcision was first introduced in Malaysia in 2008 and has since gained popularity.
There are great advantages documented with this method, the most obvious being the faster recovery rate and the ease of looking after the circumcision wound.
The tissue glue is waterproof, so your child is able to bathe as per normal.
The glue also has antimicrobial properties and gives better protection to the wound. There is no foreign body (e.g. penile clamp) attached to the surgical wound, hence, reducing the risk of infection.
Timing of surgery
In Malaysia, Muslims traditionally circumcise their children at school-going age.
Between a week until about three months of age, a baby’s physical activity is very limited. The sensory and pain receptors are still developing; the pain threshold is simply amazing. The majority of babies circumcised during this period will instantaneously show less or no distress in the hands of their parents.
Based on my experience, there is a healthy trend of requested neonatal circumcisions, especially from younger parents.
There are several known complications related to circumcision, the commonest being bleeding. In neonates and infants, the rate varies between 1.5% and 2%, while it is higher in older children. This is due mainly to the smaller-sized blood vessels of neonates and infants.
Other complication include incomplete or excessive circumcision, fistula formation, clamp failure, chordee (abnormal downward curving of the penis) formation, buried penis, and in the worse case scenario, penile amputation.
The practice of mass circumcision seems to be a fun event for the organiser, but definitely not for the child.
The children are paraded around, and will have to wait their turn to be circumcised, either by a medical doctor or a medical assistant.
I have been involved before in such events and have stopped doing so. The experience is not only traumatic for the child, but also for myself.
Although circumcision is compulsory for every Muslim, the child should experience it in the best way possible, and not be traumatised by the experience.
In many mass circumcision events, respecting a child’s right is often overlooked and overshadowed by the eagerness of the parents to complete the ritual and the organiser to call it a day.
The venue (not in a clinic or hospital setting) is usually suboptimal and non-conducive. Inavailability of proper sterilising equipment may increase the risk of infection, despite taking all the necessary antiseptic precautions.
Circumcision is an important surgery for a child. Dealing with a botched circumcision can be very costly, and will scar your child for life.
Consider safety issues rather than cost when planning circumcision for your child.
Source: http://www.star2.com/
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