Circumcision, the urgent mission of biomedicine in the 21st century
Circumcision is a simple and easy procedure to remove the excess foreskin that covers the head of the penis. According to statistics, an average of 25 men a minute undergo the procedure in the world today. When ancient man walked the earth naked, the foreskin served to protect the head of the penis, but when people put on clothes, this function of the foreskin ceased to exist and its disadvantages were gradually exposed, prompting people to remove it. In tropical regions near the equator, including countries such as Australia, the Middle East, Indonesia, and now the United States, most men are circumcised from birth. It is estimated that about 1.2 million newborns are circumcised each year in the United States, about 100,000 Jews and 10 million Muslims are circumcised each year in the Middle East, and about 9 million each year in Africa. The most dramatic benefit of circumcision in recent years has been the prevention of AIDS, however this is only one aspect, the benefits for both spouses are enormous. In other words, the risks of overcircumcision to human health are also enormous.
I. HIV infection
One of the main ways of transmission of AIDS is through sexual intercourse. The transmission of AIDS requires the virus to penetrate the epithelial tissue, and the inner surface of the prepuce provides this condition. The inner surface of the foreskin is a tender mucosal epithelium with a keratin protective layer that is significantly thinner than the outer plate of the foreskin. Histologically, this is similar to the nasal and vaginal mucosa, which is highly susceptible to the accumulation of pathogenic microorganisms. The long foreskin also causes the coronal groove of the penis to become an excellent “hiding place” for pathogenic bacteria, and the accumulated foreskin scale secreted in the coronal groove is also a good “breeding ground” for pathogenic bacteria.
The inner plate of the foreskin is rich in immune cells, significantly more than the urethral mucosa, the cervical mucosa, the outer plate of the foreskin, etc. HIV infects the body mainly through immune cells, which are resistant to the general pathogenic bacteria, but once they have engulfed HIV, they become a “Trojan horse virus” in the body. HIV must invade the immune cells in order to infect the body, and the immune cells in the inner foreskin are extremely close to the mucosal surface, thus making them vulnerable to HIV infection through various mechanisms. During sexual intercourse, the already thin inner foreskin plate is stretched even thinner by the erect penis and is directly exposed to the virus in the secretions of the partner, and the virus harbored in the coronal sulcus can also infect the subsequent partner. In 2007, the WHO called for circumcision to be used as a “vaccine” against HIV and emphasized its cost-effectiveness. Although condoms can protect against HIV transmission, the inner foreskin is still susceptible to various secretions during precoital intercourse. In contrast, circumcision has a more definite protective effect against HIV, which is even better if condoms are used in combination with circumcision.
Other Sexually Transmitted Diseases
Ulcerative sexually transmitted diseases: The warm and moist environment inside the foreskin is very conducive to the growth of syphilis spirochetes, herpes simplex virus type II, etc. The easily broken inner foreskin plate and ligament are also susceptible factors. Circumcision can effectively protect against the spread of these diseases.
Sexually transmitted diseases in the urethra: Studies have shown that the incidence of sexually transmitted diseases in the urethra is about 3.2 times higher after circumcision compared to those without circumcision, including chlamydia, genital warts, gonorrhea, non-specific urethritis, etc. Studies have shown that the incidence of sexually transmitted diseases in the urethra is reduced by 48% after circumcision.
Penile cancer
The pathological type is mostly squamous epithelial carcinoma, which has a high mortality rate and accounts for 0.3-0.6% of male malignant tumors in the United States. Studies have shown that the risk of circumcision is up to 22 times higher than normal in circumcised patients. Penile cancer is mostly due to human papillomavirus (HPV) infection, similar to cervical cancer in women. The importance of circumcision at an early age cannot be overstated. Circumcised patients with glans are at high risk for HPV infection, and numerous multicenter studies have shown significant reductions in HPV infection rates after circumcision. Compared to other factors, such as smoking, lack of hygiene, and sexually transmitted diseases, uncircumcised patients have the highest risk of penile cancer, and circumcised patients are more likely to have penile cancer. Condom use is negligible for protection against HPV. There is no scientific basis for the effect of hygiene on penile cancer protection for uncircumcised people.
Prostate Cancer
Prostate cancer is the second most common malignancy in men and is 1.6-2 times more prevalent in uncircumcised men. A recent study showed that the prevalence of prostate cancer in the United States dropped by 45,000-67,000 due to widespread circumcision, saving $800 million to $1.6 billion in medical costs.
Urinary tract infections
Urinary tract infections are more common in infants (especially those less than 6 months old) and are significantly more prevalent in uncircumcised boys. Global findings indicate that approximately 500-1.5 million urinary tract infections occur each year due to uncircumcision. Studies have shown that the incidence of urinary tract infections is 12 times higher in uncircumcised infants, and recent studies in older children have shown an 8 times higher incidence. Among febrile infants, bacterial urine was detected in about 36% of uncircumcised infants compared to 1.6% of circumcised infants. Urinary tract infections can infect the kidneys with the urinary tract and are more likely to cause kidney damage in infants. Studies have shown that 37-70% of urinary tract infections with fever can be accompanied by nephritis in infants and children, and 50-86% of these children with urinary tract infections with fever and nephritis have renal parenchymal damage on imaging. Surveys have shown that about 21% of uncircumcised children, 2% of circumcised children, and 5% of girls have fever due to urinary tract infections. Among uncircumcised boys over the age of 15, 82% could find mycobacteria, anaerobic bacteria, streptococci, etc. in the foreskin, and these pathogenic bacteria are also commonly found in the female vagina due to sexual transmission.
Sixth, inflammatory skin diseases
Foreskin penile head infection: can lead to itching, pain and is a surgical pointer. The disease occurs in about 11-13% of uncircumcised patients, and about 2% after circumcision.
Other penile skin diseases: psoriasis, lichen planus, seborrheic dermatitis, and plasmacytic foreskin penile head infection are common in the uncircumcised population. Plasmacytic foreskin penile head infection is due to mycobacteria in the foreskin scale, with typical symptoms of increased red blood cells, local swelling, exudation, difficulty urinating, bleeding, and ulceration. If the uncircumcised person is combined with diabetes, the foreskin penile head infection is more common.
VII. Physical problems
Circumcision: It accounts for about 10% of uncircumcised adults or adolescents and causes difficulty and pain in men during sexual intercourse. Circumcised individuals are susceptible to dry priapism, and although the incidence of the disease was once thought to be only 1% in boys, a recent census of a large sample showed that 40% of boys had dry priapism, with a high incidence between the ages of 9 and 11. Forty-six percent of these children were subsequently circumcised, and 27% of the boys had dry priapism near the urethra after surgery and required further surgical treatment such as urethral dilation and shaping. Circumcision is a necessary option for circumcised patients as they are prone to penile cancer.
Encrustation of the foreskin: The foreskin cannot be turned back after exposing the head of the penis, resulting in encrustation of the head of the penis, which may cause pain and difficulty in urination. After circumcision, there is no such hidden problem.
Painful erection: About 1/4 of uncircumcised men suffer from this condition, caused by a tethered belt that is too short, too thick or too tight, which pulls after erection and prevents the head of the penis from being exposed, causing pain during sexual intercourse or masturbation, or even tethered belt rupture, which then causes bleeding and infection.
Penile hygiene: In uncircumcised men it is more difficult to achieve penile hygiene and therefore the infection rate is higher. Circumcision is highly secreted at 20-40, and the accumulation over the years makes it contain a large number of epithelial cells, sebaceous secretions, pathogenic microorganisms, etc. A survey shows that about 82% of patients are circumcised to improve penile hygiene, and about 88% of pathogenic infections are attributed to circumcision. For parents, penile hygiene in children is easy to maintain after circumcision.
Psychological sequelae: The results of several post-circumcision surveys show that no psychological sequelae are produced, but on the contrary, inflammation and pain caused by circumcision can lead to psychological shadows.
VIII. Cervical cancer
Cervical cancer is caused by human papillomavirus (HPV) infection, which is first manifested as squamous epithelial metaplasia. Women with cervical cancer or squamous epithelial metaplasia have sexual partners with HPV infection. Recent studies have shown that there is a clear correlation between uncircumcised men and cervical cancer in women, and the rate of HPV infection in the penis of uncircumcised men is about 20%, while that of circumcised men is only 5%. Men with HPV infection in the penis will be 4 times more likely to have HPV infection in their sexual partners, while women with HPV infection in the cervix will have a 77 times higher incidence of cervical cancer. HPV is skin-transmitted and highly contagious, and can be contracted without condoms in the foreplay of sexual intercourse, against which condoms offer little protection. A comparison of uncircumcised men who were cleaned after sexual intercourse with uncircumcised men who were not cleaned after sexual intercourse showed that the latter were more hygienic. For uncircumcised men, vaginal infections in their partners will make them susceptible, and if infected, they will be a source of infection for future partners. Therefore, the role of circumcision in preventing cervical cancer is huge.
IX. Chlamydia infection in women
A study showed that if a sexual partner is circumcised and not circumcised, the risk of Chlamydia trachomatis infection in women will be 5-6 times higher, while circumcision will reduce the risk by about 82%. Chlamydia trachomatis infection is the second most common sexually transmitted disease other than HPV infection, and is the most common bacterial sexually transmitted disease, with approximately 92 million new cases each year, and the trend is increasing. Pelvic inflammatory disease caused by chlamydia may cause infertility, ectopic pregnancy and pelvic pain, and in men it can lead to infertility, prostatitis and more. Chlamydia is also a synergistic factor for HPV and HIV infections.
X. Herpes simplex virus infection type 2 in women
A study showed that 25% of 1207 women aged 18-30 years were infected with HSV-2, and a history of sexual intercourse with uncircumcised men significantly increased the risk of the disease.
XI. Sensitivity, sensation and sexual desire
Sensitivity was not significantly different between circumcised and uncircumcised men, and a recent thermographic study showed no significant difference in penile sensation between circumcised and uncircumcised men. Studies have shown no correlation between circumcision and sexual desire, and no difference in erectile function scores or ejaculatory latency in adult men before and after circumcision. A survey of 1400 men in the United States showed that uncircumcised men were more likely to suffer from sexual dysfunction. An Australian survey of 16-60 year olds showed that uncircumcised people had more problems than circumcised people, including pain and erectile dysfunction (about 27% of people younger than 50 years). Circumcised people have increased confidence in their sex life and couples are more likely to be satisfied with their sex life.
Twelve, the timing of surgery
Considering the simplicity, speed, cost and cosmetic effect of post-operative recovery, newborns are the best time for circumcision. After adult circumcision, abstinence is needed for 4-6 weeks, and it takes several months to recover aesthetically after surgery, and complications such as postoperative infection, bleeding and edema increase accordingly.
XIII. Complications
Statistics show that about 1 out of 500 cases of infant circumcision has bleeding symptoms, about 1 out of 1000 cases may require reoperation, about 1 out of 4000 cases may have infection, and about 1 out of 5000 cases may require hospitalization due to serious complications. There are basically no more reported cases of penile defect or necrosis due to circumcision. However, patients with hemophilia need special treatment.
XIV. Outlook
The benefits of circumcision are unquestionable, and future studies will refine the current doctrine. Randomized controlled trials have established the susceptibility of the inner foreskin plate to HIV, so could randomized controlled trials be used to study the protective effect of circumcision on infections in any other situation, etc.? Urethral infectious diseases cannot be subjected to randomized controlled trials due to ethical considerations. Randomized controlled trials for penile cancer take many years to conduct. Randomized controlled trials are possible for prostate cancer, but repeat trials take many years to conduct. For women, randomized controlled trials are difficult to conduct.
So far, the benefits about circumcision have been gradually recognized, but the biggest problem is still education, so policy diffusion and publicity need to be increased.
XV. Conclusion
The inner plate of the foreskin makes men and their sexual partners much more at risk of contracting diseases, and men who are not circumcised will always face one or another problems caused by circumcision throughout their lives. Circumcision, on the other hand, requires only the risk of the procedure, which is minimal compared to the pain and risk of uncircumcised men. The procedure can be done under local anesthesia, and in newborns it can even be done without anesthesia.