5 Things to Keep In Mind About Circumcision

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To tuli or not to tuli? It is a question that can leave many of us confused and uncertain about the entire procedure. Is it really necessary? When is the right time? How will it affect your child’s “manhood” as he grows older? What will happen if you decide not to have him circumcised?

Let's get this question out of the way first: Is it really important for boys to get circumcised?

It's actually a decision for the family, not the doctors. In a sense, circumcision is a cosmetic surgery—it is similar to having your ears pierced or getting a tattoo. The male genito-urinary system will function just as well even without the procedure. In fact, roughly 80 percent of males in the world are uncircumcised.

Surgeon Mario Adrian M. Zafra, M.D., FPSO-HNS, of Victor R. Potenciano Medical Center and Borough Medical Clinic, points out that that male circumcision is performed mostly for religious and cultural reasons. There are certain medical conditions, such as phimosis (where the opening of the penis’s foreskin is narrowed, preventing retraction) that call for it. There is also evidence that suggests specific health benefits (prevention of urinary tract infections is often cited) and is considered by some to be more hygienic, but the latter is not true.

The American Academy of Pediatrics (AAP) policy statement on circumcision states that “the preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure.” But AAP goes on to say that these benefits are not great enough to recommend routine circumcision for all male newborns. Thus, they leave the ultimate decision to the parents of the child.

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If you do decide to have your child circumcised, keep in mind the following: 

1 Circumcision can be done at any age.
It can even be performed on newborns. "Newborn circumcision, in my opinion, can spare the child of the anxiety and trauma that may happen when the procedure is done when he's an adolescent," Dr. Zafra says. "There are also studies that indicate early circumcision decreases the chances of penile cancer, a benefit not seen when postponing the procedure."

Filipinos, however, consider it a rite of passage into manhood. That's why it's done at the onset of puberty, around ages nine to 12. It's also traditionally performed in the summer when the boys don't have school. 

2 Healing can take up to three weeks. 
Physical activity should be limited while the wound heals. The surgical wound may be gently washed with mild unscented soap while bathing. The dressing should be changed and antibiotic ointment applied to the wound edges at least once a day. If the dressing gets wet, particularly during urination, it should be changed promptly. Oral antibiotics and pain medication may also be prescribed by your doctor.

Always refer to your surgeon if you note any problems such as new bleeding, pus draining from the wound area, the pain becoming severe or lasting longer than expected, or if the entire penis is red and swollen.

Healing time for newborns is usually about one week. Applying petroleum jelly on the area helps protect the wound during diaper changes. Some swelling and crust formation around the site is normal.  

3 Circumcision is an outpatient procedure.
The surgery takes no more than 15 minutes, and Dr. Zafra says doctors make it a point to keep it quick and painless as much as possible. The patient is laid down on the operating table with legs slightly apart. Antiseptic is applied to the area and sterile drapes are laid down, exposing the patient’s crotch. Local anesthesia is then injected at the base of the penis. The prepuce (foreskin) is then rolled down to expose the glans (head of the penis). The glans is gently cleaned with antiseptic, taking care to remove the smegma that often collects on the underside. The prepuce is again rolled out and surgical clamps or hemostats are then applied. The surgeon proceeds to cut the skin with his surgical scissors or scalpel (or electrocautery if available). The dorsal-skin incision is made long enough to expose the glans and the two resulting flaps of skin are retracted downward. The skin is sutured together—inner prepuce to outer prepuce—on either side, taking care to identify and close bleeding blood vessels along the way. Once suturing is complete and no more bleeders are seen, antibiotic ointment and dressing are applied.

4 The best cut is still a matter of debate. 
Or, we should add, preference. There are three basic techniques to circumcision, which Dr. Zafra discusses below:

• The dorsal slit or supracision is the most common. It involves making one straight incision on the foreskin on the top portion of the penis, and retracting both sides down to expose the glans. 
• The V-cut is usually done when the surgeon feels that there is too much foreskin. The V-cut involves removing a triangle shaped area of the foreskin in order to expose more of the glans. The remaining prepuce is sutured together and often bunches up at the lower part of the penis. 
• The German cut involves removal of the foreskin around the circumference of the penis, and then suturing the remaining skin back together. This technique may lead to more bleeding, as you are exposing and removing more tissue as compared to the other two techniques.

The dorsal slit and the V-cut are quick and easy procedures, and less bleeding is expected as you only cut only a small portion of the foreskin. This is why these techniques are employed during medical missions: only local anesthesia is used and many patients can be serviced as the procedure is quick. The remaining foreskin reorganizes itself as the child grows older. The German cut is slightly more complex and may require an operating room set-up as well as general anesthesia. It is also more apt for older patients, where the organ is larger and easier to handle.

5 You want a medical doctor to do the circumcision
The traditional tuli via pukpok method performed by the local albularyo is still quite prevalent in far-flung areas. Unsanitary conditions without consideration of aseptic techniques may lead to post-operative infections. Although chewed bayabas leaves do have some anti-bacterial properties, they may not be sufficient to fight off infection. Another problem is bleeding. The albularyo does not suture or close the wounds he makes, much less spend time looking for bleeding vessels. 

Interview by Ines Bautista-Yao. This article originally appeared on the April 2014 issue of Smart Parenting magazine. Minor edits were made by Smartparenting.com.ph editors.

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