CIRCUMCISION AND HIV/AIDS AS A CURE OR PREVENTIVE?–CONT. PART 5

CIRCUMCISION-THERAPEUTIC/NON THERAPEUTIC CONT.

Circumcision -The practice has been performed since ancient times, when it was done as a religious rite or as an initiation of boys into adulthood. Most Jewish and Muslim parents throughout the world today continue to have their sons circumcised for religious and cultural reasons. In the United States overall, the practice is somewhat less common today than it was 50 years ago, but is still done almost routinely with parental consent of course. In the 1800s, it was believed that circumcision helped prevent masturbation. Any circumcised man, however, will tell you this is not true.

Health Issues:

Researchers have attempted to learn more about whether circumcision prevents infection and certain types of cancer, but more studies need to be done to answer these questions. It is known that circumcision prevents infection and inflammation of the foreskin. It seems to decrease the risk of cancer of the penis. This disease occurs in less than one of every 100,000 men in the United States and probably in other countries too. But there has been a lot of argument in the medical community about circumcision and the risk of cancer.

Some reports quote studies having shown a greater risk of cervical cancer in female sexual partners of uncircumcised men who are infected with human papillomavirus. Circumcision might also have a role in reducing the risk of sexually transmitted diseases. But using a condom is a far more important factor in preventing these diseases than whether a man is circumcised or not!

Cleanliness

Some physicians say circumcision makes it easy to keep the end of the penis clean and easier for the parents of infant boys to keep them clean also. This may be one reason why so many parents were told to circumcise their sons. (This is nothing but, just another speculation)

Other Reasons

Circumcision is often chosen by parents so that their son will not "look different" from his father or peers. The belief is that an intact (uncircumcised) boy will feel uncomfortable if he does not "match" or look-like his others. Many parents say they don't want their son to feel "strange" or "weird" in the locker room at school.

Phimosis

Phimosis –a condition where the male foreskin cannot be fully retracted from the head of the penis. As most boys are born with a non-retracting foreskin, the term is confusing because it denotes both a normal stage of development, and a pathological condition (i.e. a condition that causes problems for a person). This confusion is particularly pronounced in regard to infants. Conflicting incidence reports and widely varying post-neonatal circumcision rates reflect looseness in the diagnostic criteria Phimosis has become a topic of contention in circumcision debates. It is normal for a baby's foreskin not to retract, but as the child grows the foreskin is expected to become retractable. Some have suggested that physiological infantile phimosis be referred to as developmental nonretractility of the foreskin to more clearly distinguish this normal stage of development from pathological forms of phimosis. Different management is appropriate. In other words, there are different degrees of phimosis, and treatment may vary on the degree of phimosis.
Women also can suffer from clitoral phimosis.

Infantile or congenital phimosis

For most of the Twentieth Century, most of the medical profession had recognized that most male infants have foreskins which are still attached to the epithelium of the glans penis and cannot easily be retracted. There have been four types of medical responses and attitudes toward this fact:

1.In the first half of the Twentieth Century, some physicians recommended that the foreskin be repeatedly retracted, if necessary with some force, to free it from the glans. It was thought that this could prevent later (pathological) phimosis and urinary problems in older boys by permitting washing of the glans and foreskin. Poor hygiene was thought to predispose to pathological phimosis. This approach has not been recommended by physicians for many decades.
2.Particularly in the middle of the Twentieth Century, some physicians promoted routine neonatal circumcision to avoid phimosis. While circumcision prevents phimosis, at least 10 to 20 infants must be circumcised to prevent each case of potential phimosis according to some incidence statistics. If one believes even lower phimosis incidence estimates, far more must be circumcised to prevent each case of phimosis. While some still promote this view, most pediatricians do not considered it a compelling argument for routine neonatal circumcision.
3.In the last three decades, as the circumcision rate in North America has declined, the most common official recommendations and guidelines from medical societies, as well as infant care books written by experts, have emphasized that it is normal not to be able to retract an infant's foreskin fully and that it need not be done. The American Academy of Pediatrics recommends gentle soap and water cleaning, but specifically recommends against forcible retraction. There is now some suspicion that forceful retraction that results in inflammation may actually contribute to pathological phimosis at an older age. Although the rate of surgical treatment of phimosis (usually circumcision) is falling, some pediatric urologists have argued that many physicians continue to have trouble distinguishing developmental non-retractility from pathological phimosis, and that phimosis is over diagnosed. Phimosis is sometimes used as a justification for circumcision, so that it will be covered by a national health system or insurance plan. The definition may be stretched by a physician for an older child; particularly where (as in North America), post-neonatal circumcision is usually outpatient surgery by a pediatric urologist, more expensive than the neonatal procedure. Most infantile phimosis is simply physiological.

Though uncommon, phimosis can occasionally lead to urinary obstruction or pain. Causes of pathological phimosis in infancy are varied. Some cases may arise from balanitis (inflammation of the glans penis), perhaps due in turn to inappropriate efforts to separate and retract an infant foreskin. Other cases of non-retractile foreskin may be caused by preputial stenosis or narrowness that prevents retraction, by fusion of the foreskin with the glans penis in children, or by frenulum breve, which prevents retraction. In some cases a cause may not be clear, or it may be difficult to distinguish physiological phimosis from pathological if an infant appears to be in pain with urination or has obvious ballooning of the foreskin with urination or apparent discomfort. However, even ballooning does not always indicate urinary obstruction. There are several management approaches to infant phimosis. Most cases of simple physiological phimosis need no "management" but will disappear with time or simple stretching of the foreskin. Various topical steroid ointments have been effective at hastening separation without surgery. Several surgical techniques have been devised, which range from simple slitting of a segment of the foreskin to removal of it (circumcision).

Acquired phimosis

Phimosis in older children and adults can vary in severity, with some men able to retract their foreskin partially ("relative phimosis"), and some completely unable to retract their foreskin even in the flaccid state ("full phimosis").
Because of the "elasticity" of the diagnostic criteria, there has been considerable variation in the reported prevalence of pathological phimosis. An incidence rate of 1% to 2% of the uncircumcised adult male population is often cited, though some studies of older children or adolescents have reported higher rates. Relative phimosis is more common, with estimates of its frequency at approximately 8% of uncircumcised men. When phimosis develops in an uncircumcised adult who was previously able to retract his foreskin, it is nearly always due to a pathological cause, and is far more likely to cause problems for the man.
An important cause of acquired, pathological phimosis is chronic balanitis xerotica obliterans (BXO), a skin condition of unknown origin that causes a whitish ring of indurated tissue (a cicatrix) to form near the tip of the prepuce. This inelastic tissue prevents retraction. Some evidence suggests that BXO may be the same disease as lichen sclerosus et atrophicus of the vulva in females. Infectious, inflammatory, and hormonal factors have all been implicated or proposed as contributing factors. Circumcision is usually recommended though alternatives have been advocated.
Phimosis may occur after other types of chronic inflammation (e.g., balanoposthitis), repeated catheterization, or forceful foreskin retraction. Phimosis may also sometimes be brought on by diabetes, due to high levels of sugar being present in the urine of some diabetics, which creates the right conditions for bacteria to breed, under the foreskin.

Potential complications of acquired phimosis

Chronic complications of acquired (pathological) phimosis can include discomfort or pain during urination or sexual intercourse. The urinary stream can be impeded, resulting in dribbling and wetness after urination. Harmful urinary obstruction is possible but uncommon. Pain may occur when a partially retractable foreskin retracts during intercourse and chokes the glans penis. A totally non-retractable foreskin is rarely painful. There is some evidence that phimosis may be a risk factor for penile cancer. The most acute complication is paraphimosis (Paraphimosis image). In this acute condition, the glans is swollen and painful, and the foreskin is immobilized by the swelling in a partially retracted position. The proximal penis is flaccid. Paraphimosis is considered an emergency.

Treatment of phimosis

Phimosis in infancy is nearly always physiological, and needs to be treated only if it is causing obvious problems such as urinary discomfort or obstruction. In older children and adults phimosis should be distinguished from frenulum breve, which more often requires surgery, though the two conditions can occur together.
If phimosis in older children or adults is not causing acute and severe problems, nonsurgical measures may be effective. Choice of treatment is often determined by whether the patient (or doctor) views circumcision as an option of last resort to be avoided or as the preferred course. Some adults with nonretractile foreskins have no difficulties and see no need for correction.
•Circumcision is the traditional surgical solution for pathological phimosis, and is effective. Serious complications from circumcision are very rare, but minor complication rates (e.g., having to perform a second procedure or meatotomy to revise the first or to re-open the urethra) have been reported in about 0.2-0.6% in most reported series, though others quote higher rates. Preputioplasty, in which a limited dorsal slit with transverse closure is made along the constricting band of skin, can be an effective alternative to full circumcision. It has the advantage of only extremely limited pain and a very short time of healing relative to the rather more traumatic circumcision, together with no cosmetic effects.

There is a school of opinion among the medical profession that advocates and promotes a number of alternative methods where surgery, with all the attendant risks, can be avoided.

High rates of success have been reported with several nonsurgical measures:
•Application of topical steroid cream for 4-6 weeks to the narrow part of the foreskin is relatively simple and less expensive than surgical treatments. It has replaced circumcision as the preferred treatment method for some physicians in the U.K. National Health Service. Stretching of the foreskin can be accomplished manually, sometimes with masturbation, also known as the Beaugé method. The stretching can also be accomplished with balloons placed under the foreskin skin under anaesthesia, or with a tool. The tissue expansion promotes the growth of new skin cells to permanently expand the narrow preputial ring that prevents retraction.

Dilation and Stretching

Skin that is under tension expands by growing additional cells. A permanent increase in size occurs by gentle stretching over a period of time. The treatment is non-traumatic and non-destructive. Manual stretching may be carried out without the aid of a medical doctor. The treatment is inexpensive. Relief of phimosis by a stretching technique has the advantage of preserving all foreskin tissue and the sexual pleasure nerves. The Beaugé Method has proved successful for many and also this method was elected the most efficient method by several physicians.

Incidence

A number of medical reports of phimosis incidence have been published over the years. They vary widely because of the difficulties of distinguishing physiological phimosis (developmental nonretractility) from pathological phimosis, definitional differences, ascertainment problems, and the multiple additional influences on post-neonatal circumcision rates in cultures where most newborn males are circumcised. A commonly cited incidence statistic for pathological phimosis is 1% of uncircumcised males. When phimosis is simply equated with nonretractility of the foreskin after age 3 years, considerably higher incidence rates have been reported. Others have described incidences in adolescents and adults as high as 50%, though it is likely that many cases of physiological phimosis or partial nonretractility were included.

Phimosis in some historical references

•According to some accounts, phimosis prevented Louis XVI of France from impregnating his wife, Marie Antoinette, for the first seven years of their marriage. She was 14 and he was 15 when they married in 1770. However, the presence and nature of his genital anomaly is not considered certain, and some scholars (Vincent Cronin and Simone Bertiere) assert that surgical repair would have been mentioned in the records of his medical treatments if it had occurred
•US President James Garfield was assassinated by Charles Guiteau in 1881. The autopsy report for Guiteau indicated that he had phimosis. At the time, this led to the simplistic speculation that Guiteau's murderous behavior was due to phimosis-induced insanity.

Balanitis

Balanitis- is the inflammation of the glans penis. When the foreskin (or prepuce) is also affected, it is termed balanoposthitis. This may be due to the lack of aeration and irritation because of smegma and discharge surrounding the glans penis causes inflammation and edema.
Inflammation has many possible causes, including irritation by environmental substances, physical trauma, and infection by a wide variety of pathogens, including bacteria, virus, or fungus—each of which require a particular treatment.

Prevalence

Escala and Rickwood, in a 1989 examination of 100 cases of balanitis in childhood, concluded that the risk "in any individual, uncircumcised boy appears to be no greater than 4%.”Oster reported no balanitis in 9545 observations of uncircumcised Danish boys. Balanitis in boys still in nappies must be distinguished from the normal redness seen in boys caused by ammoniacal dermatitis. While any man can develop balanitis, the condition is most likely to occur in men who have a tight foreskin that is difficult to pull back, or who have poor hygiene. Diabetes can make balanitis more likely, especially if the blood sugar is poorly controlled.

Circumcision

Some studies indicate balanitis to be more common in uncircumcised boys but, Van Howe found balanitis only in circumcised boys. Van Howe's study has been criticized for the fact that few boys were uncircumcised.

Genital washing

Many studies of balanitis do not examine the subjects' genital washing habits. However, O'Farrell et al. report that failure to wash the whole penis, including retraction of the foreskin in uncircumcised men, is more common among balanitis sufferers. Birley et al., however, found that excessive genital washing with soap may be a strong contributing factor to balanitis.
Diagnosis
Diagnosis may include careful identification of the cause with the aid of a good patient history, swabs and cultures, and pathological examination of a biopsy.

Complications

Balanitis may cause edema, resulting in phimosis, or inability to retract the foreskin from the glans penis. Adherence of the foreskin to the inflamed and edematous glans penis is the cause.

Zoon's balanitis

Zoon's balanitis also known as Balanitis Circumscripta Plasmacellularis or plasma cell balanitis (PCB) is an idiopathic, rare, benign penile dermatosis for which circumcision is often the preferred treatment. Zoon's balanitis has been successfully treated with the carbon dioxide laser and more recently Albertini and colleagues report the avoidance of circumcision and successful treatment of Zoon's balanitis with an Er: YAG laser. Another study, by Retamar and colleagues, found that 40 percent of those treated with CO2 laser relapsed.

Circinate balanitis

Circinate balantitis (also known as balanitis circinata) is a serpiginous annular dermatitis associated with Reiter’s syndrome.

Frenulum Breve

Frenulum Breve – is the condition in which the frenulum preputii penis, which is an elastic band of tissue under the glans penis that connects to the prepuce (foreskin) and helps contract the prepuce over the glans, is short and restricts the movement of the prepuce. The frenulum should normally be sufficiently long and supple to allow for the full retraction of the prepuce so that it lies smoothly back on the shaft of the erect penis. The frenulum is comparable to the small band between the tongue's lower surface and the lower jaw.

Frenulum breve is often complicated by tearing of the frenulum during sexual activity. The torn frenulum results in healing with scar tissue which is less flexible after the incident causing further difficulties.

The diagnosis of frenulum breve is frequently confounded with that of phimosis (an occurrence as well as phimosis is however possible). The condition may be easily treated without major surgery by threading a suture through the lower membrane, and then tying a tight knot around the frenulum itself. After a few days the frenulum will weaken and eventually break apart to allow the prepuce to fully retract. Stretching exercises and steroid creams may also be helpful. Alternatively, it may be treated by a reparative plastic surgery operation called a frenuloplasty, or by complete circumcision including removal of the frenulum (frenectomy).

Masturbation:

It was once believed that circumcision would prevent masturbation, in the 1800s when masturbation was not looked upon as a healthy thing to be doing. Circumcision does not prevent masturbation or increase fertility. The belief that circumcision enhances the sexual experience for men or for their sexual partners may not necessarily be true, either. I can't confirm or deny this as I am not the only one born with a penis, but many men would say or attest to the fact that they believe they are more 'sensitive' because of having a foreskin.

Cancer Risk

It is widely and falsely believed that uncircumcised men stand a greater risk of penile cancer. A big surprise- to many in the medical community who thought otherwise. But, In March of 1999, the American Academy of Pediatrics revised its circumcision policy statement and concluded that there is not sufficient data to support the supposed potential health benefits of circumcision. The organization no longer advocates routine neonatal circumcision. And after the analysis of almost 40 years of available medical research on circumcision in the US, the American Academy of Pediatrics (AAP) issued new recommendations stating that the benefits are not significant enough for the AAP to recommend circumcision as a routine procedure.

The new policy statement was published in the month's issue of Pediatrics, the journal of the AAP. “Circumcision is not essential to a child's well-being at birth, even though it does have some potential medical benefits. These benefits are not compelling enough to warrant the AAP to recommend routine newborn circumcision. Instead, we encourage parents to discuss the benefits and risks of circumcision with their pediatrician, and then make an informed decision about what is in the best interest of their child,” says Carole Lannon, M.D., MPH, FAAP, chair of the AAP's Task Force on Circumcision. The policy concluded, however, that it is legitimate for parents to take into account cultural, religious and ethnic traditions, in addition to medical factors, when making this decision. It states that to make an informed choice, parents of all male infants should be given accurate information and be provided the opportunity to discuss this decision with their pediatrician.” That was their conclusion at that time.

Either way, the eyelid/foreskin is naturally designed to protect the head of the penis from abrasion and infection. Its surface represents 50 percent of all penile skin, and folds around the opening of the penis. Its inside surface is composed of a soft mucosa that secretes antibacterial and antiviral lubricants called smegma, which further protect the glans from friction and infection. Because the glans is sheathed in this moist envelope, it retains its sensitivity. During sex, the foreskin glides along the penile shaft, providing lubrication and stimulation. And some spouses married to uncircumcised husband would say- “There’s a big industry in this country selling lubricants and jellies to enhance sex, but they’re unnecessary for those of us lucky enough to have married an uncircumcised man. An intact man’s glans is naturally moist and juicy.”

*****WHY CIRCUMCISION MAY NOT BE THE ULTIMATE SMOKING GUN ON HIV/AIDS-GIVEN IT'S HISTORY? TO BE CONTINUED**********