Circumcision: a surgeon’s perspective

The foreskin in small boys causes much anxiety in our society. It develops during the second half of gestation, and in premature infants may appear relatively deficient. By term, however, it has grown and protruded to well beyond the glans penis. The inner layer of the foreskin is densely adherent to the surface of the glans and cannot be retracted until it is fully separated, which occurs during the first few years of life. Prior to that time the distal opening of the foreskin is narrow, but because of its adherence there is no significant pocket under the skin to allow accumulation of urine or debris. Later in childhood, after the foreskin is fully separated, urine and dirt can accumulate between the foreskin and the glans, leading to infection and inflammation (balanitis). With recurrent balanitis, and/or tearing of the delicate foreskin, phimosis or scarring may constrict the distal foreskin.

Circumcision has a long history in ancient societies of the Middle East, and is likely to have arisen as an early public health measure for preventing recurrent balanitis, caused by sand accumulating under the foreskin. Circumcision is a major part of the ritual for such religions as Judaism, Christianity, and Islam, and it is probably no accident that all of these arose in the Middle East. By contrast, in religions arising outside the arid Middle East (Hinduism, Shintoism, Buddhism), there is no ritual circumcision. In aboriginal society in Australia, circumcision is practised also.

The importance of preventing recurrent balanitis and secondary phimosis in arid, sandy regions was confirmed by the Australian army medical corps in two world wars. During both wars, Australian soldiers were stationed in North Africa and the Middle East, and the incidence of recurrent balanitis caused by sand under the foreskin reached “epidemic” proportions, leading to large numbers …