MediaCorp Mewatch: Circumcision

Circumcision - the medical reasons behind one and how it's done

Sonia: Hey guys, I am Mike and it's Sonia. Welcome to “We need to talk about this.” But I am going to be real with you guys, I never thought in a million years that I will be talking about this on a video right now on camera. But please, I want to welcome Dr. Tan. We are all about circumcision here today.

Mike: That's right. And I will tell you what I thought they are mostly about religious reasons. But apparently there are some health reasons for getting a circumcision. So, Dr. Tan, can you elaborate?

Dr Tan: You're absolutely right, when most people think about circumcisions, they think it's a surgery done for children. Very few people know that a lot of adults get circumcisions too, and most of the time it is for a medical reason or medical indication.

The commonest reason adults will get a circumcision is really for of balanitis or infection of the foreskin, and the most common cause of infection on the foreskin is actually a fungal infection, and the people who really are at risk of getting such an infection are people who suffer from diabetes. And you can see for yourself that a balanitis is not a very comfortable condition to have. It is swollen, it is painful, and when the patient tries to retract the foreskin, it cracks. It is just not a very nice experience to have.

Of course, we can treat it with creams and tablets, but the problem is because the patient has diabetes and because some medicines that patients take for diabetes make them urinate out sugar, this condition will recur. So really one of the best treatments we can give to fully prevent this would be to circumcise the patient. That is to remove the foreskin.

The next most common reason we circumcise patients for is this very fancy sounding condition called BXO, or Balanitis Xerotica Obliterans. So, it is a progressive disease where the skin gets harder, gets paler, gets stiffer to a point where the patient just cannot retract it anymore. And if he tries to do that again, the skin was split and causr a lot of discomfort. This condition also increases the risk of skin cancer on the foreskin. So, a very good reason to circumcise the patient.

Mike: What about sexually transmitted diseases? Does that have any effect with circumcision?

Dr Tan: There's a lot of data to show that circumcision reduces the risk of contracting a sexually transmitted infection.

Mike: No kidding, by a lot?

Dr Tan: By almost up to 60%.

Sonia: So, does this have any correlation with fertility, for example?

Dr Tan: So, some guys have had a tight foreskin since birth. That is what we call physiologic phimosis. And it can be so tight we actually call it pinhole phimosis. As the name implies, the opening of the foreskin is as small as a pin. You would understand that it can affect fertility because the expulsion of semen from the foreskin is actually retarded by this small opening.

Guys who suffer from this can have challenges getting their wives pregnant and doing a circumcision actually solves this problem.

Mike: This is personal to me because we just had a two-year-old. I am circumcised and I thought it was done for religious reasons. And so recently I thought, well, I do not need to circumcise my son because I don't need to do it for religious reasons. And if there's not huge health benefits, then let's just leave it. My wife agreed, but now I am just, my mind is blown. I mean, because now I am thinking, “I'm going to circumcise my son.” Is it too late for a two-year-old?

Dr Tan: Oh no, not at all. Circumcision can be done from newborns all the way to adults in their 60s or even 70s. Really, only when they needed. Now, there was a time where circumcision was recommended for almost everybody, whether they needed it or not. And we do know there is a lot of data to show that there is a lot of medical benefits to circumcision, like reducing the risk of infections. Of course, these days we are a lot more selective for our patients, so we just make sure that there is a real medical indication before we circumcise.

Sonia: So, doctor, how can we visualize this better without seeing the real images and pictures?

Dr Tan: Well, I have this little trick that I do with a glove.

Sonia: Oh, I was like, “What is he going to pull out of his pocket?”

Mike: I know. Yeah.

Dr Tan: For normal foreskin, it should be able to slip down.

Mike: This is uncircumcised, right?

Dr Tan: Yep, and it exposes the head quite easily. If the foreskin is tight, it can't expose the head.

Sonia: It has problems and trouble.

Dr Tan: And you find that even though it can slip down to expose part of the head, it is pinching the head, right? It is causing a lot of constriction. So, for a circumcision, what we simply do is we remove the foreskin

Mike: Just take the hat off.

Dr Tan: And there you go; the head is exposed.

Mike: Okay, and how many weeks, months does the recovery take?

Dr Tan: Two to three weeks.

Sonia: What's the recovery process like for some of these patients?

Dr Tan: The circumcision recovery process, you will be surprised, it is not as bad as you think.

Sonia: Oh.

Dr Tan: I know legend has it that patients have to wear sarongs for months and walk very gingerly. But these days with new and advanced surgical techniques, patients recover extremely quickly. In fact, I can discharge most of my patients two to three weeks after the surgery. Now, most patients will not complain about pain from the surgical wound.

For patients who have had tight foreskin since birth, what happens is once we remove the foreskin, the head, or the glans of the penis, is suddenly exposed to stimuli that has never been exposed to before. Even contact with clothing feels very foreign. So, patients feel a lot of sensitivity and discomfort from this rather than from the circumcision wound. Fortunately, the head of the penis or the glans penis naturally desensitizes very quickly. So, it is actually not such a big issue.

Mike: Alright, so right now we would like to have a demonstration on a model. Yeah. Not a real thing. Yeah. So come on over here.

Sonia: Alright, here we go.

Mike: Let us take a look. Maybe you can show us what is going on here.

Dr Tan: So, this model really helps us to picture what the foreskin looks like in 3D. I use this to demonstrate to patients who really want circumcision done for a more personal reason. There is not really a medical reason, but maybe they want to achieve a certain aesthetic look or outcome, or maybe they just want better hygiene.

For such patients, we can determine the kind of aesthetic outcome that we want for them. Now you notice this is a model of a penis with a foreskin covering it. Now, as we retract the foreskin, you would see that the inner lay of the foreskin, which we also call the inner mucosa, or the inner shield, becomes the skin that is just under the head.

Mike: It looks kind of raw. Is that healthy?

Dr Tan: Very good for noticing that. So that is absolutely intentional because that the inner mucosa is always a little bit smoother and a little paler than the skin on the outside. So, this model tries to illustrate that with a different color.

Sonia: Oh, okay.

Dr Tan: This red bit is what we call the inner mucosa, and it is just under the head. The skin that was on the outside of the foreskin or the outer shield, becomes the skin that is under this inner mucosa. So, for patients who are doing it for aesthetic purposes, we really can determine variables, namely how high and how tight the circumcision is.

A high circumcision would mean that the excision line would be very close to the head, so we remove most of the inner mucosa. And a low circumcision would mean the excision line is lower down, further away from the head, leaving most of the inner mucosa. So, the patients can choose how high or how low they want the circumcision to be.

Mike: And at this point, does that matter for health reasons?

Dr Tan: So, for health reasons, unfortunately, we cannot put this decision in the patient's hands. The doctor will decide what is best for the patient to resolve his medical problem.

Mike: But what I meant was if you are just, you have no problem and you want to get circumcised, is there a difference in the retraction here.

Sonia: Or sensation. I am curious to know as well.

Dr Tan: That is a brilliant question. Yes, the inner mucus is the part of the foreskin that causes most problems. So, most infections happen here. STIs getting through here. So, if you leave it up to the doctor, we will want to remove as much of this mucosa as possible.

Sonia: And then sensation-wise, I am just curious.

Mike: Yeah. That is important.

Dr Tan: Fortunately, a lot of published data that we have shown that most men report an improvement in their sexual performance after circumcision. So, I use that to reassure my patients. Now just a bit of technical detail. If you notice in the front of the penis, there is usually a small strip of thick skin known as the frenulum that connects the hip to the foreskin. This piece of skin is extremely rich in nerve fibers. So, what we try to do as surgeons is to make sure we keep this intact so that then the sensitivity of the head is preserved.

Mike: Is this what it would look like if it was not circumcised and erect?

Dr Tan: That is right. In most cases where the foreskin can retract easily, when the patient is erect, what happens is the foreskin retracts, and this is exactly what looks like when it's erect.

Sonia: What then is the, the ideal hygiene that we should go about? How should we clean this area properly and make sure that we are not prone to infections and stuff like that?

Dr Tan: Men who are not circumcised, I really make sure that they know how to keep the area clean. We make sure that they retract the foreskin and clean the area thoroughly, but do not use strong soaps. Strong antibacterial soaps can destroy the natural healthy bacterial micro-environment within the foreskin. And actually, intimate feminine cleansers are really a good kind of soap.

Mike: Like Summer’s Eve?

Dr Tan: It’s like gentle cleanser that men can use too. So, I tell my patients to steal some of their wives’ intimate cleansers and that's all they need to do.

Sonia: Okay. So, if you're at home and you're wondering why your container's going down in terms of liquid so fast. You know why?

Mike: All right, fantastic. Well, thank you so much, Dr. Tan. This has been a wealth of information for us here. And thank you guys for watching.

Sonia: If you like this content and you want more

Mike: Then be sure to catch the main series, “Let's talk about health” on Channel Five and Mewatch.