Muslim boys after the circumcision ceremony.

By BRIGITTE ROZARIO

In the past, circumcision was only done by the Muslims and it was performed as a rite of passage for boys when they were about five to 11 or so. Today, people of other faiths are also having their sons circumcised and, in the big cities, it is something done right after birth.

According to upper GI & laparoscopic surgeon Dr Mohd Faisal Jabar, the majority who go for circumcision in Malaysia are Muslims. However, he does see a significant number of Buddhists and Hindus getting their children circumcised as well. And, it's even for older children, not just infants. The reason for this is that they believe it's more hygienic.

In certain parts of the world, particularly in Europe, the number of circumcisions is dwindling down. In North America, where they prefer their children circumcised, the number is pretty much the same. There, virtually everyone gets their babies circumcised within the first week of life.

“Culturally, the Malays want to have a ceremony, call the Tok Mudim, invite the family over to attend the ceremony of the rites of the boy becoming a man. However, I believe this is happening less within the Klang Valley. I suspect it's because the current generation have been abroad and seen their friends' children circumcised at birth. Or, they have been influenced by older brothers and sisters who have had their children circumcised.
 

Dr Faisal: 'There is a tendency nowadays in the Klang Valley for Muslim males to be circumcised within the first week.'

“There is a tendency nowadays in the Klang Valley to have Muslim males circumcised within the first week of their life. It's easier to be performed compared to a child who is 10 years old.

“I would say that two-thirds of male babies born here who are Muslim or of North American ancestry would get their babies circumcised. The other one-third would usually ask their elders and the mother or mother-in-law would say No,” says Dr Faisal.

He explains that the only medical reason to perform a circumcision is true phimosis - a medical condition where the foreskin narrows down to a pinhole. When the baby passes urine, the foreskin balloons up and the baby will cry because it stings.

In later adult life, the reasons to have a circumcision include a condition called BXO (Balanitis xerotica obliterans) or early cancer changes which require the foreskin to be removed but these are not very common.

Preparations for circumcision

There are several conditions that must be met before a baby can be circumcised. They are:

* Both parents must agree to the procedure.

* The baby must be of normal weight (preferably over 3kg, but definitely not under 2.5kg) and full-term.
If the baby is a pre-term or too small it would be unsafe to perform the circumcision and the baby's penis will not fit any of the standard-sized Plastibell circumcision devices. If the baby is too small, the parents will be told that it's not a suitable time and they would be advised to come back when the baby is bigger. Dr Faisal would also dictate a note to the paediatrician to send the parents back to him for the baby's circumcision when the baby is bigger.

* The baby's penis is not too sunken, there is reasonable shaft and no webbing of the penis.
If the penis is sunken, sometimes it's just the head that is visible and you can't perform a circumcision. One of the drawbacks of trying to do a circumcision in such a situation is that you can take off too much skin. It is more advisable to wait and do it at a later date.

* The baby should have normal genitalia (no hypospadias, epispadias or ambiguous genitalia) with both testes present.
Hypospadias is a medical condition whereby you do not offer circumcision because the foreskin is needed to repair the condition.

Dr Faisal has two preferred methods for doing the circumcision – the Plastibell method and the open surgery.

The Plastibell method is the most popular circumcision method in North America and in the Middle East. It is probably the most popular choice in hospitals in the Klang Valley as well.

Dr Faisal uses five sizes of Plastibell – from 1.1cm to 1.5cm in diameter. The common sizes for local infants would be 1.2cm and 1.3cm.

The surgery

Unlike other surgeries where the patient is asked to fast, this one requires the patient's stomach to be full.

Explains Dr Faisal:

“The fuller the patient is, the quieter they will be. I will insist on the mother being around or if the mother has just finished breastfeeding the baby, she can bring the baby down to the operating theatre.”

The baby is then exposed under a well-heated incubator so that they don't feel cold.

The surgeon would also have to duck under the incubator.
 

“I prepare the patient by cleaning with Povidone Iodine or something similar. Then I would put a dressing on top so that only the penis is visible. The baby would be held by a nurse to keep his hips abducted.

“What we would do next is to inject local anaesthesia – 1ml of Lignocaine but this is diluted four times. So, it will reduce to 0.25% Lignocaine. That's all you need to make it nice and comfortable for the baby. In terms of safety, it's very safe. We inject the anaesthesia in a few places in the area surrounding the penis and give them a dorsal block as well. Then we wait. We have to wait at least three minutes. I tend to wait five minutes because we don't want the baby to cry. It takes about two to three minutes for it to work properly.

“The next step would be to clean the glans. The skin of the penis doubles back on itself – the outer part of the foreskin is skin coloured and the inner one is pink. Babies are born with adhesions or sticky tissue adhering the pink skin to the head of the penis and some smegma as well.

“You need to clean all this off by peeling the foreskin all the way up to the recess of the corona of the glans of the penis.

“Using forceps, the foreskin is stretched a bit and a cut is made at the top – this is called the dorsal slit.

“I then clean by sweeping under the foreskin all the way to the recess. I then push the Plastibell over the penis so that the glans of the penis goes inside the Plastibell and quickly draw the rest of the foreskin over it all. Then I tie a ligature where there is a groove in the Plastibell. It must be snug. It must not be tied on the shaft of the penis.

“If it is tied beyond that point it will be too loose and the Plastibell will come off and there will be bleeding. It must be just right. Before tying the ligature it is important to check if there is adequate skin on top and below. You don't want to take off too much skin, which is very easy to do.

“After tying the ligature, just trim the remaining foreskin. It's just a very small bit of skin. And, then I remove the handle of the Plastibell.”

The skin is kept in a bottle and the parents will be asked if they want it. Muslim parents will want to bury it according to religious rituals. The non-Muslim parents usually don't want it.

The Plastibell method takes about 15 minutes to complete.

Post surgery

What is the after care like?

“Now, you have the raw edge of the foreskin, the plastibell and the glans of the penis has just seen the light of day for the very first time. This will be rather painful and pretty sensitive once the local anaesthesia wears off, just like any surgery,” explains Dr Faisal.

He recommends that parents, for the first 48 hours, give the baby regular paracetamol syrup. The dose is 15mg per kilogram (according to the weight of the baby), every four to six hours, up to four times a day.

Because the glans of the penis is rather sensitive, he also advises parents to apply some antibiotic ointment on top of it so that it becomes more lubricated.

Basically, the baby goes home with the Plastibell still attached. They wear nappies and behave in exactly the same fashion as any other baby. The Plastibell has a little hole in it that allows them to pee through.

They can poo and pee in their nappies. It will not make any difference at all. Dr Faisal says the risk of infection is very low.

“Eventually, the part of the foreskin in front of the ligature will become black and dry and it will come off at the same time as the umbilical cord (if you do a neonatal circumcision). The idea is for us not to put stitches in but to ligate it and allow for the skin to dry up and fuse together. The umbilical cord takes five to seven days and the plastibell takes about seven to 10 days to fall off.

“You don't have to worry about it at all. Treat the baby in exactly the same way. After the second day usually parents don't bother giving the paracetamol syrup anymore but they do diligently apply the antibiotic ointment; not so much for the antibiotic properties but for the oil properties,” says Dr Faisal.

The main risk of circumcision is bleeding. Infection is much less common compared to bleeding.

Exaplins Dr Faisal:

“It might bleed if the ligature comes off too early if it gets snagged, or for whatever reason. They might leave the hospital fine and return two or three days later saying the Plastibell has come off and there is bleeding. It shouldn't come off when it is tied so snugly.

“If it comes off too early, that means it hasn't had time to become dry and atrophy yet and it will bleed. In such a case we would have to take the baby back into the operating theatre for an open circumcision and a stitch repair.

“However, this very rarely happens.”

If there is any bleeding or fever (indicating infection), the parents need to bring the child back to the hospital.

Bigger children

For bigger children whose penis can't fit into the Plastibell, then open surgery is the only other method of choice, says Dr Faisal.

“We cut a bit of the foreskin and then stitch it. We use a micro surgery technique. We would use that for all bigger children. We can't use the Plastibell for children over the age of four. Firstly, their skin is too thick. It'll take ages for it to come off and you're just inviting infection that way.

“For bigger children, surgery is easier to manage, there is no Plastibell and the stitches are absorbable. It'll take 10 to 14 days for the stitches to absorb. I don't put any dressing on.

“It might bleed when you cut the foreskin. It would mainly bleed from the dorsal vein. It may also bleed at the frenulum. You cannot use electrical cauterisation equipment that you would use for regular open surgery. You have to use bipolar or laser equipment. So, there will be no current coursing through the child or through his penis.

“Theoretically, if you have electricity coursing through the penis it can damage the nerves, arteries and veins and cause thrombosis and problems later on in life like the inability to have an erection,” he says.

The open surgery takes 30 to 40 minutes.

Post surgery

There is no dressing and the patient just has to apply the antibiotic ointment. However, they are given a styrofoam cup. So that when they cover themselves with a sarung or blanket it won't land on the penis. They can even wear baggy trousers and still use the styrofoam cup.

“I insist on them keeping the styrofoam cup for at least two days, if they can,” informs Dr Faisal.

He sees patients 10-14 days after the surgery unless there are problems and the parents bring them back.

The boys can eat any food after surgery, including eggs and peanuts (unless they have a food allergy), clarifies Dr Faisal.

As with the Plastibell method, if there is any bleeding or sign of infection, the child needs to be brought back to the hospital.

Don't blame the foreskin

Contrary to popular belief, uncircumcised children are not more prone to getting UTI (urinary tract infection), informs Dr Faisal.

“UTI may not necessarily come from the foreskin; you can get urethral valves. This means that you get valves within the shaft of the penis where the passage of urine comes up. You can develop UTI that way.

“Or it could be that the child is born with abnormal anatomy in the first place.

“Don't blame the foreskin for UTI.”

Conclusion

Dr Faisal says he performs one circumcision every other day.

However, the vast majority of circumcisions in this country are not conducted by surgeons. They're done by general practitioners, Tok Mudim (circumcision experts) and nurses.

Is it safe if the circumcision is not conducted by a surgeon?

“At the end of the day, we're just removing some foreskin. I think for best results perhaps you should see a surgeon. It's not cheap – it can come up to over RM1,000. But it does come with a guarantee.”