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Medical Concerns
Preventing Harm--1

 Medical Rationalizations    Anatomy    Here's What's Lost   >AAP   >CIRP  
Conversion of an Ob-Gyn   Psychological Aspects
   
    

--Top ten reasons physicians are sued--
includes circumcision.
___________________________________

The use of the term "medical" for this page is used loosely to refer both  (1) to conditions that are truly medical concerns and (2) to medical excuses and rationalizations for mistreating the genitals of children. These excuses are not acceptable when it comes to protecting females, but BOYS TOO deserve to be spared the genital damage resulting from quackery parading as medical care.

This page provides access to  research relevant to the genital integrity issues and advice from physicians. We do not, and cannot legally, offer medical advice. The contents of this website are for information only and are not intended to replace consultation with the appropriate medical practitioner. However, whether or not someone should circumcise, or allow someone else to circumcise, his or her son's normal penis, is NOT a medical question. No medical society in the world recommends circumcision on a normal, healthy infant or child as a therapeutic procedure. Even using circumcision as a "cure" for phimosis and balanitis (and most other conditions) is coming to be seen as inappropriate therapy given less invasive, nonsurgical procedures.


Care of the intact penis
Protecting the intact penis
Articles on Phimosis
Smegma's Value
Erectile Dysfunction
Post Traumatic Stress

____________________________________

Extract from the American Academy of Pediatrics ' pamphlet:

Newborns
Care of the Uncircumcised* Penis

Summary: Care of the uncircumcised boy is quite easy. "Leave it alone" is good advice. External washing and rinsing on a daily basis is all that is required. Do not retract the foreskin in an infant, as it is almost always attached to the glans. Forcing the foreskin back may harm the penis, causing pain, bleeding, and possibly adhesions. The natural separation of the foreskin from the glans may take many years. After puberty, the adult male learns to retract the foreskin and cleanse under it on a daily basis.

*["uncircumcised" means "intact." No one refers to someone who has all his or her fingers or toes as "unamputated." Wholeness is normal; circumcised is aberrant.]

Infant Smegma: Skin cells from the glans of the penis and the inner foreskin are shed throughout life. This is especially true in childhood; natural skin shedding serves to separate the foreskin from the glans. Since this shedding takes place in a relatively closed space--with the foreskin covering the glans--the shed skin cells cannot escape in the usual manner. They escape by working their way to the tip of the foreskin. These escaping discarded skin cells constitute infant smegma, which may appear as white "pearls" under the skin.

Adult Smegma: Specialized sebaceous glands--Tyson's Glands--which are located on the glans under the foreskin, are largely inactive in childhood. At puberty, Tyson's Glands produce an oily substance, which, when mixed with shed skin cells, constitute adult smegma. Adult smegma serves as a protective, lubricating function for the glans.

Foreskin Hygiene: The foreskin is easy to care for. The infant should be bathed or sponged frequently, and all parts should be washed including the genitals. The uncircumcised penis is easy to keep clean. No special care is required! No attempt should be made to forceably [sic] retract the foreskin. No manipulation is necessary. There is no need for special cleansing with Q-tips, irrigation, or antiseptics; soap and water externally will suffice.

Foreskin Retraction: As noted, the foreskin and glans develop as one tissue. Separation will evolve over time. It should not be forced. When will separation occur? Each child is different. Separation may occur before birth; this is rare. It may take a few days, weeks, months, or even years. This is normal Although many foreskins will retract by age 5, there is no need for concern even after a longer period. Some boys do not attain full retractability of the foreskin until adolescence.

_________________________________

How to Protect Your Intact Son 
from Unnecessary Post-Neonatal Circumcisions

Circumcisions later in life are frequently recommended by ill-trained medical doctors. Read what an informed M.D. says about this problem:

"Probably the only problem you will encounter with a foreskin is that someone will think that he has a problem. The foreskin is a perfectly normal part of the human body, and it has very definite purposes, as do all body parts, even if we do not readily recognize them. There's no need to worry about your son's intact penis...."

This article is found at:  >http://www.nocirc.org/articles/fleiss2.php

____________________________________

The following article is written 15 July 2002 by the

National Organization of Circumcision
 Information Resource Centers

P.O. Box 2512, San Anselmo, CA  94979  
Tel: 415-488-9883 Fax: 415-488-9660 >www.nocirc.org


*****************

Avoiding Circumcision After the Newborn Period

Alternatives to Circumcision
 

Overview

The majority of childhood and adolescent circumcisions are performed for misdiagnosis of foreskin “problems.”1 2 In the rare instances of true pathology, circumcision is often utilized as treatment when effective, less invasive, and less expensive non-surgical treatments are more appropriate.3 4 5

Appropriate Care of the Foreskin

Most foreskin problems can be avoided with proper care of the intact penis. 

During the first few years of life, the inside fold of a male’s foreskin is normally attached to the glans.6 7 8 The separation these two structures occurs naturally over time - a process that should never be hurried. 

The foreskin is usually retractable by age 18.8 Even if the glans and foreskin separate before then, the foreskin still may not be retractable because the opening of the foreskin may be lax enough just to allow passage of urine.9 10

The first person to retract a child's foreskin should be the child himself.11 Forcing the foreskin back can be painful and can cause problems, such as infection, adhesions, and/or acquired phimosis.11

Causes of a Reddened Foreskin:

When the tip of the foreskin becomes reddened, it is doing its job of protecting the glans and urinary meatus.12

Causes include:

·         Ammoniacal dermatitis (diaper rash) from lengthy exposure to soiled diapers

·         bubble baths

·         highly chlorinated water (swimming pools, hot tubs)

·         use of soap on the genitals

·         laundry soap or detergent on clothing

·         antibiotics (Microbial flora can be restored by bacterial replacement therapy with internal and external Acidophilus culture)

·         concentrated urine from dehydration.

Increasing water intake, soaking in warm baths, bacterial replacement therapy (liquid Acidophilus culture ingested and applied to the foreskin 4-6 times daily), and running around with a bare bottom all help healing.12

Criteria for Medically Indicated Surgery

According to the Heath Care Financing Administration (HCFA), a medically indicated circumcision requires a patient complaint, a diagnosis of pathology or physical abnormality, and conservative treatment for a diagnosed condition prior to surgery.13

Newborn circumcision does not meet the criteria for a medically necessary surgery because there is no documented pathology, physical abnormality, or complaint on the part of the patient.14 15 16 Therefore, routine circumcision is non-therapeutic. The American Medical Association says, “The term ‘non-therapeutic’ is synonymous with elective circumcisions that are still commonly performed on newborn males in the United States."17

Male circumcision is traumatic,18 destructive,19 removes erogenous protective tissue,19 and therefore is not in the best interest of the patient.20 Male post-neonatal circumcision is not medically justified except in extremely rare circumstances, and only after all less invasive alternatives have been attempted.21

Common Reasons Used Inappropriately to Justify Circumcision after the Neonatal Period

Reasons inappropriately used to circumcise children after the neonatal period:

Social Factors

So children resemble their peers, or because immigrants adopt a “social norm.”

Phimosis

Most physicians in the United States received little or no education about the structure, functions, development, and care of the normal intact penis. Consequently, they may diagnose a problem that simply does not exist. The non-retractile foreskin is normal in childhood, and it becomes increasingly retractable with maturity;8 22 usually requiring no treatment other than reassuring parents that their child is normal.2 21 The American Academy of Pediatrics guidelines state the foreskin may not retract until age 18.23

Gairdner in 1949,7 reported inaccurate information about the age that foreskin retraction occurs. Wright (1994) calls Gairdner’s figures inaccurate;11 yet practicing physicians learned this misinformation in medical school.  Consequently, many physicians do not properly understand normal penile development.

Øster (1968)8 and Kayaba (1996)22 provide accurate data. According to Øster, 23% of boys in the 6-7-year-old-age group have fully retractable foreskins. By age 10-11, retractibility increases to 44%; in the 14-15-year-old group, 75% are retractable, and in the 16-17-year-old group, 95% are retractable. Kayaba's figures are similar. Kayaba found that 16.7% of 3-4-year-old boys had fully retractable foreskins. For the 11-15-age group, this figure increased to 62.9%. 

Balanitis Xerotica Obliterans (BXO)

Phimosis caused by balanitis xerotica obliterans (BXO) is recognizable by a whitish ring of indurated tissue near the tip of the foreskin and constriction prevents foreskin retraction.24 25 Diagnosis of BXO, an uncommon condition affecting 0.6% to 1% of boys by their fifteenth birthday, is confirmed by biopsy. BXO is treatable without surgery.26

Non-surgical Standard of Treatment of Foreskin Pathologies
 

Adult Phimosis

If a non-retractile foreskin (not BXO related) causes problems, such as pain with intercourse, retraction can be achieved by gentle stretching techniques27 and/or treatment with a topical steroid ointment (betamethasone valerate 0.05% or clobetasol proprionate 0.05%) for 30 to 60 days).3 4 5 

Those rare cases that are unresponsive to stretching techniques and/or medical treatment may be treated with preputioplasty, a conservative minimal surgery. This takes the form of a limited dorsal slit with transverse closure,28 29 30 or lateral slits with transverse closure.31  Trauma, pain, and morbidity are much lower than with traditional circumcision. 28 29 30 31

Recurrent Balanitis

Physical trauma, irritants, excessive washing, soap, bubble baths and chlorinated swimming pools or hot tubs may cause balanitis (inflammation). Infections may be protozoal, fungal, viral, bacterial, or amoebic in nature. The causative factor may be difficult to diagnose.  Escala & Rickwood recommend taking a swab;32 Birley and Edwards recommend biopsy.33

Correct diagnosis of the causative factor will determine appropriate treatment.32 33 34 If balanitis is caused by trauma, such as “foreskin fiddling” or premature forcible retraction, the traumatic action needs to cease.32 If recurrent washing and/or the use of soap or other irritants cause balanitis, the excessive washing should be stopped and the irritant avoided.34 If balanitis is caused by infection, the appropriate antibiotic should be selected for the specific organism.33 The proper treatment is medical, not surgical. The foreskin should be left intact so that its protective effect35 may aid in the treatment.

Escala & Rickwood advise circumcision of boys only “after recurrent attacks of balanitis which cause appreciable discomfort” [emphasis added].32 Birley and colleagues hesitate to recommend circumcision except in cases of plasma cell (Zoon's balanitis) and lichen sclerosus, but state that it may be helpful if the balanitis is recurrent.34 They note, however, that several of their balanitis patients were circumcised men, demonstrating that circumcision did not prevent balanitis.34 Edwards recommends circumcision only when the balanitis is Zoon's balanitis or the balanitis of Queyrat.33 Circumcision may not reduce the incidence of balanitis in boys. Preston states, “[B]alanitis is uncommon in childhood when the prepuce is performing its protective function.”15 Van Howe found increased incidence of balanitis in circumcised boys.36

There is absolutely no proof that circumcision for balanitis is an efficacious treatment. The proper treatment is accurate diagnosis of the cause of inflammation by inquiry, culture, or biopsy. Once the etiology of balanitis is determined, irritants must be eliminated and/or proper treatment provided.

Yeast infections with diabetes mellitus

Some non-circumcised males with diabetes mellitus have recurrent yeast infections caused by high sugar content in the urine. Careful control of blood sugar will reduce infections, as will ingestion and application of Acidophilus culture (bacterial replacement therapy). 

Valid Indications for Post-neonatal Circumcision

The following rare conditions may indicate treatment with circumcision:

Frostbite

If the foreskin is frostbitten to the point of necrosis, partial or full amputation may be required.

Gangrene

Individuals with diabetes or chronic alcoholism have been known to have circulatory problems that result in gangrene of the foreskin. Circumcision is indicated in this rare condition.

Malignancy

Should a foreskin malignancy develop, circumcision is indicated. Malignancies are extremely rare.

Conclusion

Good medical practice requires that doctors keep abreast of advances in the treatment of disease.21 The decade of the 1990s has seen appreciable advances in the treatment of disease of the prepuce. Adherence to outmoded treatment after better treatment becomes available creates medico-legal vulnerability.37 The information provided in this document will help doctors keep abreast of the changes in treatment modalities for common foreskin problems.

 
References

  1. Rickwood AMK, Walker J. Is phimosis over diagnosed in boys and are too many circumcisions performed in consequence? Ann R Coll Surg Engl 1989; 71(5): 275-7. URL:  http://www.cirp.org/library/treatment/phimosis/rickwood2/

  2. Griffiths D, Frank JD. Inappropriate circumcision referrals by GPs. J R Soc Med 1992; 85:324-325. URL: http://www.cirp.org/library/procedure/griffiths-frank/

  3. Van Howe RS. Cost-effective treatment of phimosis. Pediatrics 1998; 102(4)/e43. URL: http://www.pediatrics.org/cgi/content/full/102/4/e43

  4. Dewan PA, Tieu HC, and Chieng BS. Phimosis: is circumcision necessary? J Paediatr Child Health 1996; 32:285-289. URL: http://www.cirp.org/library/treatment/phimosis/dewan/

  5. Berdeu D, Sauze L, Ha-Vinh P. Blum-Boisgard C. Cost-effectiveness analysis of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect. BJU 2001; 87(3): 239-244. URL: http://www.cirp.org/library/treatment/phimosis/berdeu1/  

  6. Deibert, GA. The separation of the prepuce in the human penis. Anat Rec 1933; 57:387-399. URL: http://www.cirp.org/library/anatomy/deibert/

  7. Gairdner D. The fate of the foreskin. Br Med J 1949; 2:1433-1437. URL: http://www.cirp.org/library/general/gairdner/

  8. Øster J. Further fate of the foreskin. Arch Dis Child 1968; 43:200-203. URL: http://www.cirp.org/library/general/oster/

  9. Spence J. On Circumcision Lancet 1964; 2:902. URL: http://www.cirp.org/library/general/spence1/

10. Catzel P. The normal foreskin in the young child. SA Mediese Tysskrif [South African Medical Journal] 1982; 62:751 URL: http://www.cirp.org/library/normal/catzel/

11. Wright JE. Further to the "Further Fate of the Foreskin". Med J Aust 1994; 160: 134-135. URL: http://www.cirp.org/library/normal/wright2/

12.  Questions about your son's intact penis. San Anselmo: National Organization of Circumcision Information Resource Centers, 1997. URL: http://www.nocirc.org/publish/pam4.php

13. Eileen Wayne, MD. Private Communication.

14. Leitch IOW. Circumcision - a continuing enigma. Aust Paediatr J 1970; 6:59-65.URL: http://www.cirp.org/library/general/leitch1/

15. Preston EN. Whither the foreskin. JAMA 1970; 213(11): 1853-1858. URL:  http://www.cirp.org/library/general/preston/

16. Grimes DA. Routine circumcision of the newborn: a reappraisal. Am J Obstet Gynecol 1978; 130(2): 125-129. URL: http://www.cirp.org/library/general/preston/

17. Council on Scientific Affairs, American Medical Association. Report 10: Neonatal circumcision. Chicago: American Medical Association, 1999.URL: http://www.ama-assn.org/ama/pub/article/2036-2511.html 

18. Boyle GJ, Goldman R, Svoboda JS, Fernandez E. Male circumcision: pain, trauma and psychosexual sequelae. J Health Psychology 2002;7(3):329-43. URL: http://www.cirp.org/library/psych/boyle6/

19.  Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-295. URL: http://www.cirp.org/library/psych/boyle6/

20. Re "J" (child's religious upbringing and circumcision) [1999] 2 FCR 34. URL: http://www.cirp.org/library/legal/Re_J/

21. Committee on Medical Ethics. Circumcision of Male Infants: Guidance for Doctors. London: British Medical Association, 1996. URL: http://www.cirp.org/library/statements/bma/

22. Kayaba H, Tamura H, Kitajima S, et al. Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol 1996;156(5):1813-1815.  URL: http://www.cirp.org/library/normal/kayaba/

23. Care of the Uncircumcised Penis, Elk Grove Village, IL: American Academy of Pediatrics, 1999. [leaflet]. URL: http://www.cirp.org/library/normal/aap1999/

24. Rickwood AMK, Hemalatha V, Batcup G, Spitz L. Phimosis in Boys. Brit J Urol 1980;52:147-150, URL: http://www.cirp.org/library/treatment/phimosis/rickwood/

25. Rickwood AMK. Medical Indications for circumcision. BJU Int 1999;83 Suppl. 1:45-51.

26. Jorgensen ET, Svensson A. Problems with the penis and prepuce in children: Lichen sclerosis should be treated with corticosteroids to reduce need for surgery. BMJ 1996;313:692. URL: http://bmj.com/cgi/content/full/313/7058/692

27. Beaugé M. Conservative Treatment of Primary Phimosis in Adolescents [Traitement Médical du Phimosis Congénital de L'Adolescent]. Saint-Antoine University, Paris VI, 1990-1991. URL: http://www.cirp.org/library/treatment/phimosis/beauge/

28. Cuckow PM, Rix G, Mouriquand PDE. Preputial plasty: a good alternative to circumcision. J Pediatr Surg 1994;29(4):561-563. URL: http://www.cirp.org/library/treatment/phimosis/cuckow/

29. de Castella H. Prepuceplasty: an alternative to circumcision. Ann R Coll of Surg Engl 1994;76(4):257-8. URL: http://www.cirp.org/library/treatment/phimosis/decastella/

30.  Saxena AK, Schaarschmidt K, Reich A, Willital GH. Non-retractile foreskin: a single center 13-year experience. Int Surg 2000;85(2):180-3.  URL: http://www.cirp.org/library/treatment/phimosis/saxena1

31. Lane TM, South LM. Lateral preputioplasty for phimosis. J R Coll Surg Edinb 1999;44(5):310-2. URL: http://www.cirp.org/library/treatment/phimosis/south1/

32. Escala JM, Rickwood AMK. Balanitis. Brit J Urol 1989;63:196-197.URL:  http://www.cirp.org/library/disease/balanitis/escala1/

33. Edwards S. Balanitis and balanoposthitis: a review. Genitourin Med 1996;72(3):155-9. URL: http://www.cirp.org/library/disease/balanitis/edwards1/

34.Birley HDL, Luzzi GA, Bell R. Clinical features and management of recurrent balanitis: association with atopy and genital washing. Genitourin Med 1993;69:400-403. URL: http://www.cirp.org/library/disease/balanitis/birley/

35. Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Inf 1998;74:364-367. URL: http://www.cirp.org/library/disease/STD/fleiss3/

36.  Van Howe RS. Variability in penile appearance and penile findings: a prospective study. Brit J Urol 1997;80:776-782. URL: http://www.cirp.org/library/complications/vanhowe/

37. Fisher TL. Outmoded treatment. Can Med Assoc J 1966;95:630. URL: http://www.cirp.org/library/legal/fisher1/

________________________________

Phimosis

[Note: The normal attachment of the foreskin to the glans is not a pathological condition. As the AAP pamplet above says, the separation will occur on its own and may not happen until after puberty. True phimosis, defined below, can be caused by premature retraction which can also bring on balanitis. It can also occur as a consequence of circumcision.]

"Cost-effectiveness analysis of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect," D. Berdeu1, L. Sauze1, P. Ha-Vinh1 and C. Blum-Boisgard* BJU International 87  (3), 239-244. 

Objective: To compare the cost-effectiveness of surgery and topical steroids as treatments for phimosis (defined as a clinically verifiable, pathological, cicatricial stenosis of the prepuce) and to evaluate the financial basis of these treatments.  

Methods: Data on treatment using topical steroids was obtained from published reports and those for circumcision from claims by private hospitals for children < 13 years old registered at the health insurance department of our facility. The estimate of the French national financial cost of the treatments for 1998 was calculated from public and private institutional information.  

Results: Treatment with topical steroids for 4 weeks was successful in 85% of patients (mean age 5 years) and had no side-effects; the remaining 15% were treated by circumcision. Topical steroid therapy costs (in French francs) F 360 per patient. For those primarily treated by circumcision (81 boys, mean age 4.3 years) and diagnosed as having phimosis, the cost was F 3330 per patient in the private sector. The total number of circumcisions performed in France, regardless of sector (public or private) for 1998 was estimated to be 51 080, which represents an annual cost of F 195.7 million.  

Conclusion: As topical pharmacological treatment avoids the disadvantages, trauma and potential complications of penile surgery, including anaesthesia-related risks, the use of topical steroids as a primary treatment appears to be justified in boys with clinically verifiable phimosis. This treatment could reduce costs by 75%, which represents a potential annual saving of 150 million.   

_______________________________________  

A conservative treatment of phimosis in boys

Eur Urol 2001 Aug;40(2):196-200
A conservative treatment of phimosis in boys.
ter Meulen PH, Delaere KP.
Department of Urology, Atrium Medical Centre, Heerlen, The Netherlands.

  OBJECTIVE: The aim of this study was to evaluate the efficacy of topical applications of clobetasol propionate cream in the treatment of phimosis in boys and a comparison of the results presented with an overview of the current studies. 

METHODS: In a prospective study, 94 boys (mean age 5.5 years [Why is anyone concerned with retraction at this age? D.V.]) were treated with topical applications of 0.05% clobetasol propionate cream twice daily. The prepuce was treated for 1 month, with an attempt at prepuce retraction after 14 days. The boys were evaluated after 1 month of treatment and every 3 months during follow-up. 

RESULTS: Of the 94 boys, 91 were available for follow-up, of whom 42 boys (46.1%) achieved complete retraction of the prepuce, 24 (26.4%) had only preputial adhesions and 4 (4.4%) had partial retraction.

Twenty-one boys (23.1%) had no response. The treatment was continued in 13 boys with good results eventually. Seven boys (7.7%) had recurrence after a mean follow-up of 4.3 months (range 2-7). No side effects were noted. Circumcision was necessary in 24 of the 91 boys (26.4%). The mean follow-up was 11.0 months (range 3-18). CONCLUSIONS: Local application of clobetasol propionate cream is a simple, safe and effective treatment for phimosis in boys and avoids circumcision and its associated risks. It should be offered first instead of circumcision.

  PMID: 11528198 [PubMed - in process]

  ___________________________________________

 Treatment of childhood phimosis
 with a moderately potent topical steroid

2: ANZ J Surg 2001 Sep;71(9):541-54
Ng WT, Fan N, Wong CK, Leung SL, Yuen KS, Sze YS, Cheng PW.
Department of Surgery, Yan Chai Hospital, Tsuen Wan, Hong Kong.

BACKGROUND: Recently, topical steroid application has been shown by a small number of studies to be an effective alternative to circumcision for the treatment of phimosis. However, only potent or very potent corticosteroids have been more thoroughly studied in this treatment option. A prospective study was conducted to determine whether comparable results could be achieved using a weaker steroid cream. 

METHODS: Boys, 3-13 years of age [Why is anyone concerned with retraction at this age? D.V], with non-retractable foreskin due to a tight ring at the tip were offered the regimen of twice-daily preputial retraction and topical application of 0.02% triamcinolone acetonide cream. The degree of preputial retractability was assessed at presentation and at 4 and 6 weeks of treatment. Success was defined as full retraction or free retraction up to agglutination of the foreskin to the glans.

RESULTS:
Eighty-three boys completed the treatment. Successful retraction was achieved in 48/83 (58%) patients after 4 weeks and 70/83 (84%) patients after 6 weeks of application. The overall response rate aggregated from six published series using 0.05% betamethasone was 87% at 4 weeks and 90% on completion of treatment.

Thus, the results appear inferior when analysed at 4 weeks but compare favourably with those reported for a more potent steroid on completion of the full course of treatment. CONCLUSIONS: Even though the triamcinolone cream used in the present study is less potent than the more commonly used 0.05% betamethasone valerate cream, it could effect comparable improvements in foreskin retractability after 6 weeks of treatment.

_____________________________________

http://www.reuters.com/newsArticle.jhtml?type=healthNews&storyID=8303274
Journal of Urology, April 2005.
Semi-Potent Steroids Treat Tight Foreskin Problem
Tue Apr 26, 2005 05:23 PM ET NEW YORK (Reuters Health) -

Moderately potent topical steroids are just as effective as highly potent ones for treating phimosis and offer a lower risk of side effects, new research suggests. Phimosis is a condition in which the foreskin opening is too small for it to be pulled back over the head of the penis. Phimosis can affect 8 percent of boys between the ages of 6 and 7. Although phimosis can resolve by itself, it is often treated by circumcision, in which the foreskin is surgically removed. While circumcision is an effective treatment for phimosis, various complications can occur and topical steroid therapy has emerged as alternative. The British National Formulary and other groups have divided topical steroids into several potency categories. Most studies looking at these agents as a treatment for phimosis have included only ultra-high or high potency steroids. Thus, it is unclear if lower potency steroids could achieve the same results with a better side effect profile. To investigate, Dr. Chung Cheng Wang, from En Chu Kong Hospital in Taipei, Taiwan, and colleagues assessed the outcomes of 70 boys who were randomly assigned to receive topical therapy with betamethasone, a highly potent steroid, or with clobetasone, a moderately potent steroid. The treatment response rates in the two groups were not significantly different -- about 79 percent. The average drop in the phimosis severity score was also comparable in each group -- about 2.2. No significant adverse effects were seen in either group. Writing in the April issue of the Journal of Urology, the investigators say that when topical steroid application is attempted to treat phimosis, moderately potent steroids should be considered first to avoid adverse effects that could, in theory, occur with higher potency agents.

____________________________________

Conservative Treatment of Paraphymosis

Ann R Coll Surg Engl 2001 Mar;83(2):126-7
Modified puncture technique for reduction of  [sic].
Kumar V, Javle P.
Department of Urology, Leighton Hospital, Crewe, Cheshire, UK.
vkumar3908@hotmail.com

PATIENTS AND METHODS: A total of 45 patients underwent reduction of paraphymosis at LN Hospital, Delhi, India and Leighton Hospital, Crewe, UK from August 1991 to September 1999 using the multiple puncture and glans squeeze technique. These were divided into 3 grades: grade 1, paraphymosis without engorgement of glans; grade 2, paraphymosis with engorgement of glans; and grade 3, paraphymosis with associated skin changes (non-pitting oedema, cheese-cutting of the shaft of the penis or erosions).

RESULTS: Grade 1 (6) patients were reduced by simply pulling the foreskin back into the normal position. Grade 2 (37) patients were reduced by the above-mentioned technique. Grade 3 (2) patients could not be reduced by this technique and the band had to be divided.

CONCLUSIONS: Difficult paraphymosis with gross engorgement of the glans can be successfully reduced by this technique as long as the skin changes are not marked.

_______________________________________________

Balanitis Xerotica Obliterans:
Conservative Treatment Options.
>http://www.cirp.org/library/treatment/BXO/

Introduction. Balanitis Xerotica Obliterans was first described by Stühmer in 1928 in Germany.1 Balanitis Xerotica Obliterans (BXO) and Lichen Sclerosus et Atrophicus (LSA) are two names for the same disease.  BXO/LSA is a skin disease of unknown etiology.[2] It occurs in both males and females. LSA is the name applied when the disease appears in a female or a male in other than the genital organs. BXO is the name traditionally used when the disease afflicts the male sexual organs. An older name is kraurosis glandii et praeputii penis.... For information on the disease in females see >Lichen Sclerosus.

BXO is a rare disease that affects only 6 of 1000 males (.6 of 1 percent).[19] It can affect males of any age. The traditional treatment has been radical circumcision. However, many conservative treatment options are now available.

BXO is a relatively serious disease. It can cause urethral stricture and retention of urine.[2] Malignant tumors have (rarely) been reported to develop from BXO. A person with BXO or suspected BXO should be under the care of a medical doctor....

Complete statement at >CIRP Library.

_________________________________________

  Smegma's Value

Dr. Dean Edell, MD, National radio host:

A major reason for the idea that the natural penis is difficult to clean is a small, but feared word: "smegma". It even sounds ugly, so who wouldn't believe what they might hear about it and the non-circumcised penis? Actually, the word itself comes from the Greek smegma translated as "detergent", "cleansing medicine",and "soap". Smegma can be found between the glans and the foreskin and between the clitoris and its hood, as well as between the labia. (Both the penis and the clitoris form as the >same tissue in the womb during the first trimester of pregnancy.) In both sexes, its job is to lubricate and cleanse. If it is washed away too frequently, the mucous membranes of these parts can become dry and irritated. The picture that is sometimes given of smegma is of a flowing, cheesy substance which smells. (I picture feta cheese, myself, when I hear this comparison!) Frankly, if smegma were to be allowed to build up to this amount, the man or >woman would surely know about it before it began to smell, as going that long without washing would make one itch - and not only in the genital area either! In actuality, it is a whitish, pasty substance which doesn't really have much of an odor. It does not "flow" and is easily removed with a rinse with water, or soap and water if one prefers [soap may be an irritant].
 

Marilyn Milos, RN:

The male and female prepuce require no retraction and cleansing prior to puberty. Neither does a young girl need to have a douche or a Q-tip clean her out. What is called "debris" is the very same thing that ends up on the crotch of a woman's underwear -- and why she buys new ones every few years. It's nothing more than the sloughed vaginal cells. The prepuce operates the same way. Nothing will cause increased smegma production (as a way of defense) more than to use soap on the mucous membrane of the inner prepuce and glans of an intact boy.

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Circumcision and Erectile Dysfunction
>http://www.mind.org.uk/information/factsheets/M/mental/MEN'S_MENTA L_HEALTH4.asp

Excerpt:
Circumcision is practiced on some male infants as a routine, and on
others as a result of religious or cultural tradition. It is also practiced on adult males as a result of certain medical conditions.

  There is strong evidence that circumcision can be overwhelmingly painful and traumatic. The physical and sexual loss resulting from circumcision is gaining recognition, and some men have strong feelings of dissatisfaction about being circumcised.

Studies into the practice of circumcision often refer to the practice as “traumatic”.[29] [30] Research suggests that some boys, and adult males, may experience post-traumatic stress disorder as a result of circumcision. [31] Examples of PTSD symptoms include recurrent thoughts and dreams about, and avoidance of the topic of circumcision.

Other symptoms include emotional numbing and inappropriate anger which may increase with time after the traumatic event. Both infant and adult circumcision can result in a loss of sexual sensitivity and, in some cases, can result in impotence.[32]

Negative feelings about the penis are related to the idea of body image. This includes value judgments about how the body is thought to appear to others, and can have a great impact on how men live their lives.

  Erectile dysfunction, or impotence, is one of the most common chronic medical disorders in men over the age of 40 years. One study found that 35% of men aged 40-70 reported moderate or complete impotence, with 52% of the group reporting some degree of erectile dysfunction.[33] The prevalence and severity of this disorder increases with age, and is a major quality-of-life issue for older men. Erectile dysfunction can lead to depression and relationship problems.  

Additional References:
1.  Palmer JM and Link D. Impotence Following Anesthesia for Elective Circumcisions. JAMA. 1979; 241:2635-6.
2.  Stinson JM. Impotence and adult circumcision. J Natl Med Assoc. 1973; 65:162-179.
3.  Glover E. The `Screening' Function of Traumatic Memories. Int J Psychoanal. 1929; 10:90-93.
4.  Ozkara H, Asicioglu F, Alici B, Akkus E, Hattat H. Retrospective analysis of medicolegal cases and evaluation for erectile function. Am J Forensic Med Pathol. 1999; 20(2):145-9.
5.  Stief CG, Thon WF, Djamilian M, Allhoff EP, Jonas U.  Transcutaneous registration of cavernous smooth muscle electrical activity: noninvasive diagnosis of neurogenic autonomic impotence. J Urol. 1992; 147(1):47-50.
6.  Anon. Circumcision botched: suit, National Post (Canada), 8 March 2001.  

________________________________________

BULLETIN OF SCIENCE, TECHNOLOGY & SOCIETY,
 Volume 21, Number 4, Pages 297-311, August 2001.
"Below the Belt: Doctors, Debate, and
the Ongoing American Discussion
of Routine Neonatal Male Circumcision"
>http://www.cirp.org/library/general/dritsasl/

___________________________________________

Post Traumatic Stress
BESSEL A. VAN DER KOLK and JOSE SAPORTA
Harvard Medical School
>http://www.cirp.org/library/psych/vanderkolk2/

 CONCLUSIONS: A rapidly expanding knowledge of the effects of traumatization on the functioning of the Central Nervous System, the dawning awareness that memory functions are central in understanding the nature of PTSD, combined with the availability of animal models for PTSD, makes the psychobiology of trauma one of the most promising areas in psychiatry. As long as the most effective therapy of PTSD has not been firmly established, a greater understanding of the biochemical and physiological correlates of traumatization should provide important clues about appropriate intervention. A variety of psychopharmacological agents that affect the physiological arousal system, including clonidine, benzodiazepines, monoamine oxidase inhibitors, and tricylic antidepressants decrease the long term effects of inescapable shock in animals, and seem to have varying degrees of use in the pharmacotherapy of PTSD. The recent discovery that serotonin reuptake inhibitors seem to act by quite a different mechanism and may be extremely effective in reducing both the intrusive and the numbing effects of PTSD needs to be carefully documented and understood. Further exploration during the coming decades of how trauma affects neuroendocrine emergency systems, neuromodulation, and memory should provide us with a much greater understanding about the interplay between soma and psyche in coping with potentially overwhelming experiences. It seems to me that the pain associated with the stressful event need not be consciously remembered to evoke the PTSD symptoms.

_______________________________________________

The PIAA top ten reasons that Pediatricians are sued
>http://www.aapca1.org/aapca1/nl972.html

Submitted by George Thomasson, MD to AAP of California

       1.  Failure to diagnose meningitis
       2.  Brain damaged infant
       3.  Routine infant and child health checks
       4. Congenital dislocation of the hip
       5.  Failure to diagnose appendicitis
       6.  Premature infant
       7.  Asthma
       8.  Cerebral palsy
       9.  Circumcision's adverse outcomes
     10.  Respiratory problems of the newborn

 

 

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