Circumcision

The foreskin, or prepuce, is a double layer of skin and lining that covers the head of the penis, the glans, and normally slides back. Circumcision removes it with a circular cut, leaving the glans uncovered, and the edges of the skin are joined with fine dissolvable stitches or, in some techniques, sealed with tissue glue. In adults and older boys a conventional surgical technique is used, such as the sleeve method or a guided cut, and some surgeons use a disposable stapler device. In babies and young children a clamp or a plastic ring device may be used instead; the ring is left in place for several days until it falls off. A partial circumcision, which removes only part of the foreskin, or a foreskin-preserving procedure called preputioplasty, which widens a tight foreskin, may be options when the aim is to treat phimosis rather than to remove the foreskin completely.

Medical reasons include phimosis, a foreskin too tight to retract, when it causes problems such as ballooning during urination, pain on erection or difficulty keeping clean, and especially when it is caused by scarring from a skin condition called lichen sclerosus, also known as balanitis xerotica obliterans. In young boys a non-retractable foreskin is normal and usually loosens with time, so surgery is reserved for true scarring or repeated problems. Other medical reasons are repeated balanitis or balanoposthitis, infections of the glans and foreskin; paraphimosis, where a retracted foreskin becomes stuck and swollen behind the glans; recurrent urinary infections in some boys with urinary tract abnormalities; and, rarely, suspicious changes on the foreskin. Many people also choose circumcision for religious, cultural or personal reasons. A urologist or paediatric surgeon can help you weigh medical alternatives, such as steroid creams for a tight foreskin, before deciding.

For adults, circumcision is usually done under local anaesthesia, with an injection at the base of the penis that numbs the whole area within minutes, sometimes with light sedation. Children and some adults have general anaesthesia, often combined with a local nerve block for comfort afterwards. The surgeon marks the line of the cut so that the right amount of skin is removed, takes away the foreskin, seals small blood vessels with gentle heat and joins the remaining skin to the lining behind the glans with fine dissolvable stitches. A light dressing is applied. The operation takes about 20 to 45 minutes. In infants a clamp or ring device may be used under local anaesthesia, and the ring separates naturally after about a week. You usually go home within a few hours, once you have passed urine and any sedation has worn off.

Most healthy boys and men are candidates. Circumcision is postponed if there is an active infection of the foreskin, which is treated first, and it is not performed in babies with certain abnormalities of the penis, such as hypospadias, where the foreskin may be needed for later reconstruction. Bleeding disorders must be known in advance, so tell the team about any personal or family history of abnormal bleeding, and blood thinners are stopped or adjusted on medical advice. For general anaesthesia, you or your child fast for about six hours beforehand. Adults who want a particular appearance, such as a tighter or looser result, should discuss this at the consultation, because skin that has been removed cannot be added back. For children, the team explains anaesthesia and pain relief to parents. International families can usually share medical notes and the reason for surgery in advance for a remote review.

Swelling, bruising and tenderness are normal for the first week, and the head of the penis can feel very sensitive while it adjusts to being uncovered. Simple painkillers, supportive underwear for adults or loose clothing for children, and keeping the area clean are usually enough. Dressings are removed after a day or two, and showers are allowed soon after; swimming waits until the wound has healed. Dissolvable stitches fall out over about 2 to 3 weeks, and most wounds heal within 2 to 4 weeks. Adults usually return to desk work after a few days and to sport after about 2 to 4 weeks, and should avoid sexual activity, including masturbation, for about 4 to 6 weeks to protect the stitches. Children often go back to school or nursery within a few days. For travel, a stay of a few days to a week allows a wound check before a long flight; carry painkillers and spare dressings.

Circumcision is a common and generally safe operation, but complications do occur. The most frequent are bleeding from the wound, which usually stops with pressure but occasionally needs a small procedure, and infection, which is treated with wound care and sometimes antibiotics. Swelling can take several weeks to settle completely. Less common problems include an uneven or asymmetric scar, too much or too little skin removed, tight or tethered skin, and stitch tracks or small cysts along the scar, some of which may need correction. In boys, narrowing of the urinary opening, called meatal stenosis, can occur later. Sensation in the glans changes as the skin adapts, and views differ on how much this affects sexual feeling; most men return to a normal sex life once healing is complete. The result is permanent, with a scar line that usually becomes hard to see over the following months.