Dr Syariz: 'When Planning Circumcision for Your Child, it is Crucial to do it Right'

Every year in Malaysia, thousands of parents of Muslim boys look for circumcision services as a matter of course. For Muslims, it is a religious obligation that every male child will have to undergo to address health and hygiene issues as well as to symbolize the rite of passage before they reach puberty. For this reason, Muslim boys in Malaysia are circumcised during their school-going age before they reach the age of 12. Circumcision Across the World The general notion about circumcision is that it is practiced only for religious reasons. However, this perception cannot be further than the truth as circumcision is also widely performed for non-religious reasons. The topmost non-Islamic countries that routinely opt for the procedure citing health and medical reasons, are the USA, South Korea and the Philippines. “The strange truth is that the US is the sole country in the world where a large majority of its male population is routinely circumcised at birth for non-religious reasons,” writes science writer Mathew Tontonoz on his own website. As for South Korea, Wikipedia says it was their contact with the American military during the Korean War that influenced this country to have this procedure done. In a study in 2002, it was found that 86.3% of South Korean males aged 14–29 have been circumcised. In the Philippines ─ a largely Roman Catholic country ─ 92.5% of males are circumcised. It is believed that they circumcise due to tuli ─ a cultural tradition, rather than a religious one. Health Reasons And then there are the health reasons. The World Health Organisation (WHO) has made the stand that circumcision prevents the transmission of HIV in adult males. “There is compelling evidence that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%,” they say in their website. Furthermore, a study published in the Canadian Medical Association Journal reported by Time.com, states that Uncircumcised Boys Have a Higher Risk of UTI (Urinary Tract Infection) than circumcised boys ─ a condition that could lead to kidney damage and scarring if left untreated. And, NCBI ─ the site for the US National Library of Medicine additionally states that the procedure protects against aggressive penile cancer among other infections. Whether it is for health or religious and cultural reasons, suffice to say that circumcision is a controversial topic, especially among those who argue against it. Despite that, it is the most widely practiced surgical procedure in the world today, and especially so in Malaysia. In fact, it is so common and so sought after in the country that there are surgical centres set up in the Klang Valley specifically for circumcision. Many clinics and hospitals countrywide also offer the procedure alongside mass circumcision events often organized by mosques. Because of this, parents are confronted with an array of choices and a sea of questions when they seek circumcision for their sons. What does the procedure entail, how much will it cost, how should they care for their child post-surgery, what sort of technique is best, and what should they be looking at or asking the doctor or clinic before choosing where to have the procedure done on their children? To answer all these questions, Motherhood talks to Dr Syariz Izry Sehat (MS Paeds Surg (UM), MBBCh BAO BMedSc (Ireland) Fellow European Board of Paediatric Surgery (EBPS) – a Paediatric Surgeon at Prince Court Medical Centre (03-2160000) and AVISENA Women’s & Children’s Specialist Hospital (014-5185072) to provide the answers. Being one among a small pool of paediatric surgeons in Malaysia, Dr Syariz is often quoted in newspapers and medical websites regarding all manner of paediatric surgery including circumcision. 1. Motherhood: What foreskin problems would precipitate circumcision in a growing child ? Dr Syariz: During the first year of life, there is physiological phimosis (a congenital narrowing of the opening of the foreskin so that it cannot be retracted). Babies are naturally born with a tight foreskin that is adherent to the glans and the inability to retract the foreskin at this age is normal. As the child grows, the foreskin will separate from the glans and the opening will widen. For some, the foreskin opening will grow wide enough to allow it to slide over an erect penis. For others, the expansion of the foreskin never really catches up with the size of the glans and it remains adherent until adulthood. A tight foreskin secondary to physiological phimosis is usually not problematic – gentle stretching of the foreskin and sparing use of a steroid cream will usually allow the opening to widen. A pathological phimosis, on the other hand, is usually a consequence of some medical condition, or occurs following injury to the foreskin. For example, having a tight foreskin limits the ability to properly clean the child’s private part, hence, some residual urine may accumulate underneath the foreskin. This would predispose the child to infection of the glans penis, known as balanophosthitis. This problem can lead to a vicious cycle, because after each infection, the foreskin will heal by fibrosis (the thickening and scarring of connective tissue), which will further shrink the tight foreskin. This would be a medical indication for circumcision to alleviate the problem. If the preputial skin gets accidentally caught in the trousers’ zipper (a common presentation to the emergency room), it will usually end up with an unplanned circumcision. Another medical condition that warrants a circumcision is recurrent urinary tract infections (UTI). 2. Motherhood: How should parents prepare their child for circumcision? Dr Syariz: Before the procedure, it is very important that your child is mentally and physically prepared. Avoid saying that the procedure is not painful. Explore the fear that he has in his mind. It also helps if your child has had previous experience of a local anaesthetic injection. He can then gauge the level of discomfort that he will feel. The first challenge is to convince your child that the most painful part is the local anaesthetic injection, and not during the circumcision itself. Many children will perceive it differently. For the majority, the worst part is the “cutting”. Circumcision can be done with local anaesthetic alone, with the use of sedation, or under full general anaesthesia. The use of sedation or general anaesthesia avoids your child from having to undergo the pain of the local anaesthetic injection. They will first be given some sedation or anaesthetic gas before the local anaesthetic administration. In all cases, a local anaesthetic injection is administered at the base of the penile shaft. This injection is painful. Depending on the type of local anaesthetic used, the anaesthetic effect can last up to four hours. The utmost important factor for the circumcision procedure is the readiness of the child to undergo the procedure when done under local anaesthesia. In my setting, each child will undergo a counselling session in which a thorough explanation of the procedure is given to him. They will view a video of the procedure and will be encouraged to voice any doubts they have to ease their anxiety. Through this session, I will advise the parents whether their child is ready and suitable to undergo circumcision by local anaesthesia or general anaesthesia, a normal circumcision or a modified circumcision procedure. The ice breaking session really helps to bond me with the child and gain their trust. A child has his own right to know what procedure they will endure and once a bond is established, often times the procedure is a breeze. 3. Motherhood: What are the different techniques used for circumcision? Dr Syariz: There are several methods: Conventional method – The most common method used is the dorsal slit method. After the administration of the local anaesthetic, the foreskin is retracted and cleaned with antiseptic solution. The foreskin is held before being trimmed off with scissors or diathermy (a method that cuts tissue using heat).The inner and outer foreskin is then approximated with absorbable sutures, most importantly, at the underside of the glans. The sutured tissue is then covered with some topical antibiotic cream and dressing. This method will require daily dressings and may cause daily discomfort. The sutures will be fully absorbed by the second or third week. Clamp technique – There are many types of penile clamps, for example the Tara clamp and the Mogen clamp. A penile clamp is defined as a medical device used solely for the purpose of circumcision. After the administration of local anaesthetic and cleansing with antiseptic, an appropriate-sized clamp is chosen and applied. A basic clamp unit consists of two parts: the inner and outer parts. These two parts will clamp the inner and outer foreskin together, effectively cutting off blood supply to the distal part of the foreskin. The skin is usually excised during the procedure, leaving the clamp intact. Sutureless circumcision – The sutureless circumcision technique using tissue glue was first introduced in Malaysia in 2008. The technique omits the use of a suture or a clamp, and relies heavily on tissue glue for tissue approximation. After the administration of LA and excision of the distal foreskin, best done using diathermy, the tissues are approximated with tissue glue. The glue also has antimicrobial properties and gives better protection to the wound. There is no foreign body (like a penile clamp) attached to the surgical wound, hence, it reduces the risk of infection. 4. Motherhood: What is the method you most prefer? Dr Syariz: I'm a big fan of the sutureless circumcision technique as it promises a bloodless procedure, minimal pain and ease of care to the child. They can shower normally on the very same day and the technique does not need daily dressing of the penile part unlike the stitch or the clamp technique. 5. Motherhood: When is the best time to circumcise a child? Dr Syariz: In Malaysia, Muslims traditionally circumcise their children at school-going age. However, a neonate up until two months of age is the best candidate for circumcision. During this period, all their body systems are still developing and this includes their sensory. The pain is short lived and will not be as intense as when they are older. On top of that, their immobility at this age allows easy handling. Their rapid growth period hastens recovery. 6. Motherhood: Can you say a few things about mass circumcision? Dr Syariz: I have been involved before in such events and have stopped doing so. The experience is not only traumatic for the child, but also for myself. The children are paraded around, and have to wait their turn to be circumcised, either by a medical doctor or a medical assistant. The venue (not in a clinic or hospital setting) is usually suboptimal and non-conducive. Inavailability of proper sterilising equipment may increase the risk of infection, despite taking all the necessary antiseptic precautions. Although circumcision is compulsory for every Muslim, the child should experience it in the best way possible, and not be traumatised by the experience. I believe each child has their right to receive true information about the procedure and must be willing to undergo the procedure. In mass circumcision, these aspects are often missed and neglected. Mass circumcisions are usually held either at the mosque or hall, sometimes without individual partition to protect the modesty of the child. We need to respect the child as an individual, after all we only have one chance to make it right. 7. Motherhood: How long does it take for the wound to heal in general? Should the child wear a sarong after circumcision? Dr Syariz: In general the wound healing takes seven to 10 days. A child does not typically wear a sarong, hence it is not an ideal attire for him to wear. Loose pants would be adequate. 8. Motherhood: How would you advise parents to take care of the wound? Dr Syariz: If they choose the clamp or stitch technique, they must perform a good daily dressing on the penile wound to avoid infection. There may be slight variations of advice given between different centres. The sutureless circumcision technique allows the child to have daily showers without the need for daily dressing. 9. Motherhood: Is there anything the child should or shouldn’t eat or do to hasten healing? Dr Syariz: During this recovery period, your child needs a good source of protein such as eggs, chicken, fish or meat along with Vitamin C to hasten their recovery. Avoid sports during this period but leisurely activities such as walking; going shopping is not a problem. 10. Motherhood: With so many options available to parents for circumcising their child, what advice would you give them to help them choose the right clinic, doctor or method? Also, what would be the cost? Dr Syariz: Choose a clinic which can give your child the best explanation before the procedure and can repair a complication after the procedure should the need arise. A simple complication such as bleeding is normal and should be accepted. In general, circumcision is divided into three basic techniques ─ using a stitch, a clamp or a sutureless technique. Each of these techniques needs different post procedural care. Choose a technique to your liking. As circumcision is the most common procedure done in Malaysia, a local Tok Mudim, a trained medical assistant, a general practitioner in a clinic, or a doctor or consultant can perform the procedure. The price will vary according to the technique used, facilities offered and expertise of the doctor. In GP settings, the price usually starts from RM150 onwards while in a private hospital where a consultant performs the procedure, the price usually starts from RM2,500. Circumcision is a once in a lifetime experience for a child. Choose your doctor properly and get it done correctly. For more informative stories including controversial topics, always turn to Motherhood.com.my.

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