domenica 31 marzo 2013
martedì 26 marzo 2013
Hands Off My Foreskin! Dr. Martin Winckler on the Care of Baby Boys
Hands Off My Foreskin! Dr. Martin Winckler on the Care of Baby Boys
By Martin Winckler, M.D. ©
2013
Lire en Français ici. Translated to English by Nicolas Maubert and Danelle Frisbie for DrMomma.org with Winckler's blessing. Dr. Martin Winckler is a general practitioner and author in France. Read more from him at his website, MartinWinckler.com
Many young mothers today are very worried because their mother, or their mother-in-law, or their doctor, told them they must 'clean' the glans (head) of the penis of their baby boy, and that to do so, you must retract (i.e. roll back) the foreskin like a turtleneck. In reality, however, this should not be done. The practice of retraction only causes problems and has no benefits.
What follows is an article interview printed in the L’Arbre à bébé Association's November 2005 issue. For this interview I answered some questions on the delicate topic of proper penile care and retraction that I am now sharing here with you.
Question One:
What is your position regarding foreskin retraction, as a physician and as a parent? Do you retract your own patients? Do you retract your own sons for 'cleaning?'
Answer:
I have never retracted the foreskin of a boy. Not any one of my patients, nor any of my five sons. (I believe if I asked them what they think of foreskin retraction they would look at me like something was wrong with me to have such strange ideas!)
Very early in my career, in the early 1980s, while reading the work of pediatrician Aldo Naouri, I had the notion that the practice of retraction was not only unnecessary, but aggressive for everyone -- starting with those most concerned (the boys), but also for their parents. The act itself is aggressive because once you touch a little boy’s penis, an erection is induced. Not all mothers [or fathers] are going to be comfortable with this, and we understand why. Boys will often smile or laugh that it tickles and very quickly we find that parents prefer to leave that area alone to care for itself.
Question Two:
What do you think of the arguments commonly used by proponents of retraction (that retraction will prevent adhesions, phimosis)?
Answer:
Phimosis is the condition in which the orifice of the foreskin is too tight to allow the glans to leave when the boy is erect. So it can not interfere with boys until the age at which they are likely to have intercourse. However, most studies that have been done on the subject show that any amount of retraction, 'just a little' or a lot, has no medical function, neither for hygienic purposes, nor to prevent phimosis, which is an uncommon condition to begin with. It used to be said that retraction was necessary to fight against adhesions and to 'clean up' anything under the prepuce. However, preputial secretions are as normal as vulvar secretions in the little girls. There is nothing wrong with them whatsoever. Never have we suggested that we 'clean' the vulva of our daughters with a cotton swab, yet I have seen mothers try to pass a cotton swab under the foreskin of their son because a doctor told them to do so!
Quite simply, the foreskin is self-cleaning. The orifice of the foreskin is tight at birth on purpose to prevent dirt (bacteria, viruses, etc.) from creeping into it. Retraction (a dilating force) is then entirely unnatural. And it hurts! Retraction causes tears and can cause paraphimosis (having the foreskin stuck in a retracted position behind a swollen glans) which itself is an emergency. This induced paraphimosis is actually much more common than true phimosis.
A common scenario: A mom wanted to retract a boy (usually in the bath). The manipulation resulted in a retraction after erection. Suddenly, the foreskin 'turtlenecks' (squeezes) the glans, which then swells and turns purple. The child yells. And in a warm bath, it gets worse. [Vasocongestion takes place, leading to more blood flow, a throbbing erection, and tighter constriction.] In short, parents call the doctor and then one of two things happen. Either the doctor panics and sends the child and his parents to the emergency room, or the doctor understands what has just happened solves it very simply:
Very quickly I started to pass along the message to young parents that they should not even touch the foreskin. Leave it alone. And with this advice, over the years, I began to see less and less paraphimosis among my patients. There were now more and more happy little boys who tugged on their own foreskin, laughing, without anxiety. And I saw more and more mothers delighted with the fact that they did not have to handle their son's penis - in fact, they did not have to do anything for its care. I have not had any little boys need surgery on their penis during my career as a general practitioner, and I saw very few boys ever in need of surgery during medical school, because in my district, no doctor was a fan of retraction.
Question Three:
At what age should I be worried and consider surgery for a boy whose foreskin does not retract?
Answer:
It's simple: you should never worry because there is no reason to worry. Foreskin retraction is a cultural practice [in a few nations], and does not take place at all in other countries. Still, there are no more cases of phimosis or 'problems' among those nations where foreskin retraction is unheard of. Retraction by someone other than a boy himself serves no purpose at any age. And yet, all parents of little boys can testify that fiddling and tugging on the foreskin are commonplace practices among infants and toddlers (up to eight to ten years old). This self-exploration causes no problems. Quite simply, the foreskin is not meant to be retracted by anyone other than the owner himself - it serves as a sheath to the glans in this way, a protector from outside invasion. As a child grows, the foreskin lengthens and softens over time. With puberty and masturbation, the foreskin opens on its own. It stretches along the penis little by little, allowing for erections to take place without cause for concern. By the time the hormones of puberty are in full swing, the vast majority of boys have already retracted their own foreskin and eased the preputial orifice open. Even if their prepuce was tightly closed in childhood, they do not have phimosis, and this is evident as young adults. So small is this concern that these boys do not even know the word 'phimosis!' In rare cases when there is a real issue, it is at puberty that this is discovered, not before. If a 'problem' arises before puberty, it is likely paraphimosis, because a boy is being retracted - see above.
Throughout my career as a general practitioner [~30 years in 2013] I have only had to circumcise one single man, aged 22 years, who had developed untreatable phimosis that was the result of brutal retraction as an infant and child that left tight foreskin scarring on his penis. This started to bother him at puberty - not before. And, in fact, it was the way he was treated as a baby and child that caused the inflammation that resulted in his phimosis - not the other way around. He had to be circumcised as a result of improper care by those who did not know any better. When we repeatedly tear the foreskin at an age of development, it does lead to scarring, and this in turn tightens the foreskin over time, causing the problems we then blame on foreskin (rather than improper care).
Question Four:
What is your advice to a mother who does not know what a pediatrician will do to her baby during a check-up? What should she do if a physician suggests that she retract? How should she handle guilt-trips pushing improper care?
Answer:
Retraction is a problem that exists merely because it is a matter of culture-based opinion and not a factual issue of prevention or health. Again, there is no evidence that retraction has even the slightest benefit, but its disadvantages are medically obvious.
Doctors do not exist to dictate their personal opinions onto parents, and there should be no guilting of mothers who consciously decide they will not 'mess with' the penises of their sons. In fact, I find these mothers to be the ones who are the most mentally stable and emotionally healthy. Would a mother okay the circumcision of her son just to please a physician who tells her it is 'cleaner?' Of course not. The same goes for retraction. If a doctor talks about such things, tell him that you will leave your child to figure things out for himself, and if a problem arises down the road, you will deal with it at that point. Above all, do not let a physician who is suggesting retraction use your child for their demonstration.
Just as there is zero justification in performing vaginal exams on infant and young girls, so also is there never justification to retract and examine the inside of a baby boy's or child's penis when there is nothing wrong. Doing so is not alright for girls, and it is not alright for boys. The only time a physician should be handling your child's genitals (gently!) is if the penis or vulva in question has a visible abnormality that requires examination. If this is not the case, then hands off!
- Martin Winckler, M.D.
Lire en Français ici. Translated to English by Nicolas Maubert and Danelle Frisbie for DrMomma.org with Winckler's blessing. Dr. Martin Winckler is a general practitioner and author in France. Read more from him at his website, MartinWinckler.com
Many young mothers today are very worried because their mother, or their mother-in-law, or their doctor, told them they must 'clean' the glans (head) of the penis of their baby boy, and that to do so, you must retract (i.e. roll back) the foreskin like a turtleneck. In reality, however, this should not be done. The practice of retraction only causes problems and has no benefits.
What follows is an article interview printed in the L’Arbre à bébé Association's November 2005 issue. For this interview I answered some questions on the delicate topic of proper penile care and retraction that I am now sharing here with you.
Question One:
What is your position regarding foreskin retraction, as a physician and as a parent? Do you retract your own patients? Do you retract your own sons for 'cleaning?'
Answer:
I have never retracted the foreskin of a boy. Not any one of my patients, nor any of my five sons. (I believe if I asked them what they think of foreskin retraction they would look at me like something was wrong with me to have such strange ideas!)
Very early in my career, in the early 1980s, while reading the work of pediatrician Aldo Naouri, I had the notion that the practice of retraction was not only unnecessary, but aggressive for everyone -- starting with those most concerned (the boys), but also for their parents. The act itself is aggressive because once you touch a little boy’s penis, an erection is induced. Not all mothers [or fathers] are going to be comfortable with this, and we understand why. Boys will often smile or laugh that it tickles and very quickly we find that parents prefer to leave that area alone to care for itself.
Question Two:
What do you think of the arguments commonly used by proponents of retraction (that retraction will prevent adhesions, phimosis)?
Answer:
Phimosis is the condition in which the orifice of the foreskin is too tight to allow the glans to leave when the boy is erect. So it can not interfere with boys until the age at which they are likely to have intercourse. However, most studies that have been done on the subject show that any amount of retraction, 'just a little' or a lot, has no medical function, neither for hygienic purposes, nor to prevent phimosis, which is an uncommon condition to begin with. It used to be said that retraction was necessary to fight against adhesions and to 'clean up' anything under the prepuce. However, preputial secretions are as normal as vulvar secretions in the little girls. There is nothing wrong with them whatsoever. Never have we suggested that we 'clean' the vulva of our daughters with a cotton swab, yet I have seen mothers try to pass a cotton swab under the foreskin of their son because a doctor told them to do so!
Quite simply, the foreskin is self-cleaning. The orifice of the foreskin is tight at birth on purpose to prevent dirt (bacteria, viruses, etc.) from creeping into it. Retraction (a dilating force) is then entirely unnatural. And it hurts! Retraction causes tears and can cause paraphimosis (having the foreskin stuck in a retracted position behind a swollen glans) which itself is an emergency. This induced paraphimosis is actually much more common than true phimosis.
A common scenario: A mom wanted to retract a boy (usually in the bath). The manipulation resulted in a retraction after erection. Suddenly, the foreskin 'turtlenecks' (squeezes) the glans, which then swells and turns purple. The child yells. And in a warm bath, it gets worse. [Vasocongestion takes place, leading to more blood flow, a throbbing erection, and tighter constriction.] In short, parents call the doctor and then one of two things happen. Either the doctor panics and sends the child and his parents to the emergency room, or the doctor understands what has just happened solves it very simply:
1) Do not pull the foreskin forward after retraction and paraphimosis (it does not work).
2) You must first empty the warm water bath. Then pour somewhat cooler water (but not iced/cold water) on the penis. The cooler water deflates the penile engorgement.
3) Then gently squeeze the swollen glans (head) of the penis. As the penis deflates, the foreskin will start to roll back down over the glans by itself.I saw dozens of situations like this one early in my career. It was always among boys whose mothers had a slight obsession of making sure their son was 'clean,' or among those whose parents had conscientiously felt pressure to retract following the advice of a relative or highly invasive physician. So much so that their little boy was retracted three times each week - so often that these little boys begin to develop anxiety when their mothers approached them to change or 'clean' them. The more mothers touched their boys' penises in this fashion, the more young children became angry, the more it hurt, the more retraction became torment, until they developed paraphimosis. And then parents call for help. In short, it is a vicious cycle.
Very quickly I started to pass along the message to young parents that they should not even touch the foreskin. Leave it alone. And with this advice, over the years, I began to see less and less paraphimosis among my patients. There were now more and more happy little boys who tugged on their own foreskin, laughing, without anxiety. And I saw more and more mothers delighted with the fact that they did not have to handle their son's penis - in fact, they did not have to do anything for its care. I have not had any little boys need surgery on their penis during my career as a general practitioner, and I saw very few boys ever in need of surgery during medical school, because in my district, no doctor was a fan of retraction.
Question Three:
At what age should I be worried and consider surgery for a boy whose foreskin does not retract?
Answer:
It's simple: you should never worry because there is no reason to worry. Foreskin retraction is a cultural practice [in a few nations], and does not take place at all in other countries. Still, there are no more cases of phimosis or 'problems' among those nations where foreskin retraction is unheard of. Retraction by someone other than a boy himself serves no purpose at any age. And yet, all parents of little boys can testify that fiddling and tugging on the foreskin are commonplace practices among infants and toddlers (up to eight to ten years old). This self-exploration causes no problems. Quite simply, the foreskin is not meant to be retracted by anyone other than the owner himself - it serves as a sheath to the glans in this way, a protector from outside invasion. As a child grows, the foreskin lengthens and softens over time. With puberty and masturbation, the foreskin opens on its own. It stretches along the penis little by little, allowing for erections to take place without cause for concern. By the time the hormones of puberty are in full swing, the vast majority of boys have already retracted their own foreskin and eased the preputial orifice open. Even if their prepuce was tightly closed in childhood, they do not have phimosis, and this is evident as young adults. So small is this concern that these boys do not even know the word 'phimosis!' In rare cases when there is a real issue, it is at puberty that this is discovered, not before. If a 'problem' arises before puberty, it is likely paraphimosis, because a boy is being retracted - see above.
Throughout my career as a general practitioner [~30 years in 2013] I have only had to circumcise one single man, aged 22 years, who had developed untreatable phimosis that was the result of brutal retraction as an infant and child that left tight foreskin scarring on his penis. This started to bother him at puberty - not before. And, in fact, it was the way he was treated as a baby and child that caused the inflammation that resulted in his phimosis - not the other way around. He had to be circumcised as a result of improper care by those who did not know any better. When we repeatedly tear the foreskin at an age of development, it does lead to scarring, and this in turn tightens the foreskin over time, causing the problems we then blame on foreskin (rather than improper care).
Question Four:
What is your advice to a mother who does not know what a pediatrician will do to her baby during a check-up? What should she do if a physician suggests that she retract? How should she handle guilt-trips pushing improper care?
Answer:
Retraction is a problem that exists merely because it is a matter of culture-based opinion and not a factual issue of prevention or health. Again, there is no evidence that retraction has even the slightest benefit, but its disadvantages are medically obvious.
Doctors do not exist to dictate their personal opinions onto parents, and there should be no guilting of mothers who consciously decide they will not 'mess with' the penises of their sons. In fact, I find these mothers to be the ones who are the most mentally stable and emotionally healthy. Would a mother okay the circumcision of her son just to please a physician who tells her it is 'cleaner?' Of course not. The same goes for retraction. If a doctor talks about such things, tell him that you will leave your child to figure things out for himself, and if a problem arises down the road, you will deal with it at that point. Above all, do not let a physician who is suggesting retraction use your child for their demonstration.
Just as there is zero justification in performing vaginal exams on infant and young girls, so also is there never justification to retract and examine the inside of a baby boy's or child's penis when there is nothing wrong. Doing so is not alright for girls, and it is not alright for boys. The only time a physician should be handling your child's genitals (gently!) is if the penis or vulva in question has a visible abnormality that requires examination. If this is not the case, then hands off!
- Martin Winckler, M.D.
sabato 23 marzo 2013
Vaccino HPV quadrivalente, efficacia oltre la prevenzione del cancro alla cervice
Vaccino HPV quadrivalente, efficacia oltre la prevenzione del cancro alla cervice
Un’analisi combinata di 3 studi clinici di fase II/III, che ha coinvolto più di 18 mila giovani donne, ha confermato che il vaccino quadrivalente (6, 11, 61 e 18) contro il cancro del collo dell’utero (Gardasil, SanofiPasteur MSD) ha dimostrato un’efficacia del 96% contro le lesioni iniziali al collo dell’utero, del 99% contro i condilomi genitali e del 100% verso le lesioni iniziali e precancerose alla vulva e alla vagina causate dai tipi di virus direttamente colpiti dal vaccino. Questi nuovi dati sono stati presentati in occasione del 20esimo Congresso Europeo di Ginecologia e Ostetricia (EBCOG) svoltosi nei gironi scorsi a Lisbona. Alla luce dell’alta efficacia del vaccino quadrivalente, l’Independent Data and Safety Monitoring Board (DSMB) dei due ampi studi di fase III sulle giovani donne (FUTURE I & II) ha raccomandato che questi studi fossero conclusi nel più breve tempo possibile affinché anche le donne inserite nel gruppo placebo potessero beneficiare dei benefici della vaccinazione con Gardasil. In Europa, circa il 25% delle lesioni iniziali al collo dell’utero sono causate dai tipi di HPV 16 e 18 (~200 mila casi ogni anno) e più del 10% sono provocate dai tipi 6 e 11 (~80 mila casi). Sebbene quelle legate ai tipi 6 e 11 di solito non evolvano in cancro, lo screening non è in grado di distinguerle da quelle provocate dai tipi 16 e 18 che invece possono trasformarsi in tumore. Richiedono, infatti, lo stesso follow-up medico, e possono generare stati di ansia nelle donne. I tipi di virus 6 e 11 sono anche la causa del 90% dei casi di condilomi genitali (circa 225 mila casi). I condilomi genitali possono causare stress e impattare nella vita di coppia. Anche se efficaci nel breve termine, le terapie ablative sono dolorose, e i tassi di ricorrenza possono essere alti. Infatti, anche nel caso in cui la lesione esterna sia stata eliminata, l’infezione persiste.
Responsabile Nazionale FIMP Ricerca e Sperimentazione sui Farmaci Membro Gruppo Multidisciplinare AIFA “ Farmaci e Bambini”
Responsabile Nazionale FIMP Ricerca e Sperimentazione sui Farmaci Membro Gruppo Multidisciplinare AIFA “ Farmaci e Bambini”
venerdì 22 marzo 2013
Educazione sessuale
Sai come sei?
La vulva, cioè gli organi genitali femminili esterni, comprende il monte di Venere, un cuscinetto al di sopra
 del pube, ricoperto di peli dopo la pubertà, le grandi labbra pieghe della pelle ricoperte di peli, e le piccole labbra, più interne; nella parte superiore c'è il clitoride, un piccolo organo molto sensibile, che influisce sulla risposta sessuale femminile. Nelle ragazze che non hanno avuto rapporti sessuali completi, la vulva è in parte chiusa da una membrana chiamata imene.
- La vagina è il condotto che unisce la vulva all'utero, è costituita di mucosa. L'utero è l'organo
che accoglie l'ovulo fecondato. E' costituito da tre strati: il perimetrio, una membrana che ne copre la superficie esterna; il miometrio, una forte muscolatura che ne forma le pareti; l'endometrio, una mucosa che ne riveste l'interno.
- Le tube o trombe di Falloppio o salpingi, sono due condotti, lunghi 12-13 cm., che collegano l'utero con le ovaie. Attraverso le tube l'ovocita, cioè la cellula femminile della riproduzione, scende verso l'utero e può essere fecondato.
- Le ovaie, sono due ghiandole a forma di mandorla, poste ai lati dell'utero.
Nelle ovaie, nel corso di ogni ciclo mestruale, matura un follicolo, cioè l'organo che contiene l'ovocita. Le ovaie producono anche gli ormoni sessuali femminili: estrogeni e progesterone. Nelle ragazze, il primo segno dello sviluppo è la crescita della mammella, i capezzoli diventano più sporgenti e si allarga l'areola che li circonda; subito dopo compaiono i primi peli pubici (quelli ascellari compaiono più tardi). Il passo successivo è la modifica degli organi genitali: le grandi labbra si allargano e si separano dalle piccole labbra, il clitoride acquista la capacità di erezione e il corpo comincia a modellarsi. Infine, tra i 9 e i 15 anni compare il menarca, cioè la prima mestruazione. Da questo momento è possibile una gravidanza. |
- Il pene, cioè l'organo genitale maschile, è ricoperto di pelle molto elastica, con una parte mobile,
 il prepuzio, che riveste il glande cioè la parte finale del pene, dove ha sbocco l'uretra; il prepuzio è fissato al glande con un filamento, chiamato frenulo.Il pene è composto da due corpi cavernosi, due cavità spugnose che si riempiono di sangue durante l'erezione  - I testicoli sono due ghiandole contenute nello scroto: un sacchetto di pelle alla base del pene. Questa posizione esterna al corpo è importante: all'interno dei testicoli si formano gli spermatozoi, cioè le cellule maschili della riproduzione; perché questo avvenga la temperatura dei testicoli deve essere più bassa di quella del corpo. Gli spermatozoi sono piccole cellule costituite da una parte più grossa, "la testa", nella quale sono contenuti 23 cromosomi, il contributo paterno di patrimonio genetico per il figlio, e da una coda. La coda serve agli spermatozoi per muoversi con rapidità e poter risalire dalla vagina nelle tube, dove possono incontrare una cellula uovo da fecondare. I testicoli producono anche gli ormoni che attivano le funzioni sessuali maschili.
- I testicoli contengono una rete di tubicini, i tubuli seminiferi. Di qui gli spermatozoi passano nell'epididimo, un condotto nel quale acquisiscono la capacità di muoversi autonomamente. L'epididimo prosegue nel dotto deferente che conduce alle vescicole seminali, dove si produce il liquido seminale, che serve a mantenere vivi e mobili gli spermatozoi. La stessa funzione viene svolta dalla prostata. I dotti deferenti sfociano nei canali eiaculatori, i quali attraversano la prostata e sbucano nell'uretra.
Nei ragazzi, il corpo comincia a modificarsi con circa un anno di ritardo rispetto alle ragazze. I primi segnali dello sviluppo sono l'aumento di volume del pene, dei testicoli e dello scroto, più la comparsa dei peli pubici. Subito dopo aumentano la statura e la massa muscolare, si modifica il tono della voce e compare il pomo d'Adamo. I peli ascellari e la barba compaiono circa due anni dopo. Lo spermarca, cioè la prima emissione di liquido seminale, avviene intorno ai 13-14 anni, di solito per "polluzione notturna" (significa che succede durante il sonno). |
giovedì 21 marzo 2013
Infezioni alle vie urinarie nei bambini
Infezioni alle vie urinarie nei bambini
Le infezioni alle vie urinarie nei bambini: come riconoscerle e curarle. Generalmente non si tratta di disturbi gravi ma è importante riconoscerli e curarli tempestivamente perchè, se trascurati, possono danneggiare i reni
Le infezioni delle vie urinarie (IVU) sono molto frequenti in età pediatrica tanto che la loro incidenza è stimata nel 7,5% tra i bambini che si presentano al pronto soccorso con febbre che supera i 38°C. Generalmente non si tratta di disturbi gravi ma è importante riconoscerli e curarli tempestivamente perchè, se trascurati, possono danneggiare i reni. Nei neonati (sotto il 1 anno di vita) il rischio di contrarre un'infezione alle vie urinarie (anche se alcuni studi più recenti smentirebbero questo) è maggiore nei maschietti rispetto alle femminucce, con una percentuale rispettivamente del 7% e del 3,2%. Questo perchè c'è una maggiore frequenza di malformazioni delle vie urinarie nei neonati maschi.
Nei bambini al di sotto degli 11 anni la situazione si capovolge, ossia il rischio risulta maggiore nelle femmine rispetto ai maschi per via della vicinanza del retto all'uretra. La causa principale dell'insorgenza delle infezioni alle vie urinarie è la presenza di batteri, mentre più raramente l'infezione può essere originata da virus o funghi. Le forme più frequenti di infezioni delle vie urinarie si dividono in tre categorie:
Batteriuri asintomatica: è una patologia di lieve entità che non presenta sintomi ed è provocata da batteri a bassa virulenza. Si individua in genere attraverso esami delle urine o urinocolture occasionali e non richiede una terapia, tranne che per i pazienti immunodepressi (portatori di trapianto renale, diabetici, etc.).
Infezione urinaria bassa sintomatica o cistite acuta: può essere favorita da fattori locali, quali infezioni vaginali e del glande, fimosi (restringimenti), sinechie (aderenze) delle piccole labbra etc. Tra i sintomi prevalgono i disturbi nella minzione con febbre che generalmente non supera i 38° C. Nel lattante i sintomi possono essere aspecifici. Alle volte può comparire sangue nelle urine alla fine della minzione, anche con coaguli. Dall'esame ecografico si può individuare un aumento dello spessore della parete vescicale. Questa tipologia di infezione riguarda principalmente le bambine in età prescolare
Infezioni urinarie basse ricorrenti: sono molto frequenti nelle femmine in età scolare e sono spesso associate a disfunzioni vescicali e dello sfintere uretrale esterno
Nel 30 - 40% dei casi si associano a reflusso vescico-uretrale, di solito di lieve entità. È frequente la concomitanza con vulvo-vaginiti, sinechie delle piccole labbra e stipsi. La terapia può comprendere, oltre ad un trattamento specifico antibatterico, anche una rieducazione minzionale e l'utilizzo di farmaci che regolano la muscolatura vescicale
Infezione urinaria alta o pielonefrite acuta (PNA): è caratterizzata generalmente da febbre elevata accompagnata da brividi e dolori lombari o addominali. Questo tipo di infezione non è sempre facile da diagnosticare ed spesso associata ad una malformazione delle vie urinarie (nel 40% dei casi a reflusso vescico-uretrale) e/o a disfunzioni.
Per riconoscere un'infezione delle vie urinarie è molto importante individuare i sintomi che, come abbiamo visto, non sempre sono specifici o eclatanti. Ad esempio nei lattanti e nei neonati il sospetto di un'infezione di questo tipo deve nascere anche in presenza di sintomi aspecifici come febbre, irritabilità, scarso aumento di peso, pianto durante la minzione, disturbi gastroenterici, urina maleodorante, arrossamento all'interno delle cosce e ittero. Nei bambini più grandi invece occorre fare attenzione alla presenza di disturbi minzionali, cioè se il piccolo avverte dolore nella zona lombare o bruciore mentre fa pipì e se si verificano episodi di incontinenza.
In presenza di tali sintomi è necessario rivolgersi subito al medico. La diagnosi sulla presenza o meno di infezioni alle vie urinarie è possibile attraverso due esami specifici: l'esame completo delle urine e l'urinocoltura. Questi esami devono essere effettuati prima d'iniziare l'eventuale terapia con gli antibiotici perchè anche una sola dose di antibiotico può rendere sterili le urine impedendo quindi di identificare il germe responsabile dell'infezione. Altri esami che vengono effettuati una volta che l'infezione è passata sono l'ecografia renale e la cistografia.
Soprattutto nel caso di infezioni alte può essere eseguita anche una scintigrafia renale statica al fine di valutare gli eventuali esiti dopo un certo periodo di tempo. Nel caso delle infezioni delle basse vie urinarie si interviene in genere con un ciclo di 3-5 giorni di terapia antibatterica per via orale. Con cicli di questa durata è possibile prevenire gli effetti collaterali degli antibiotici e le alterazioni della flora batterica intestinale.
Se si è in presenza di una infezione alle alte vie urinarie il ciclo di terapia deve avere una durata maggiore (almeno 10 giorni). Una volta diagnosticata un'infezione del genere, come nel caso della pielonefrite acuta, la terapia va iniziata prima possibile. Infatti se si interviene tempestivamente, entro 48-72 ore dall'esordio dell'infezione, è possibile prevenire i possibili danni ai reni. A seconda dei sintomi e dell'età del bambino la terapia può essere effettuata a casa oppure in ospedale. Il ricovero viene in genere consigliato per i bambini più piccoli in presenza di febbre elevata, vomito o segni di disidratazione
Nei bambini al di sotto degli 11 anni la situazione si capovolge, ossia il rischio risulta maggiore nelle femmine rispetto ai maschi per via della vicinanza del retto all'uretra. La causa principale dell'insorgenza delle infezioni alle vie urinarie è la presenza di batteri, mentre più raramente l'infezione può essere originata da virus o funghi. Le forme più frequenti di infezioni delle vie urinarie si dividono in tre categorie:
Batteriuri asintomatica: è una patologia di lieve entità che non presenta sintomi ed è provocata da batteri a bassa virulenza. Si individua in genere attraverso esami delle urine o urinocolture occasionali e non richiede una terapia, tranne che per i pazienti immunodepressi (portatori di trapianto renale, diabetici, etc.).
Infezione urinaria bassa sintomatica o cistite acuta: può essere favorita da fattori locali, quali infezioni vaginali e del glande, fimosi (restringimenti), sinechie (aderenze) delle piccole labbra etc. Tra i sintomi prevalgono i disturbi nella minzione con febbre che generalmente non supera i 38° C. Nel lattante i sintomi possono essere aspecifici. Alle volte può comparire sangue nelle urine alla fine della minzione, anche con coaguli. Dall'esame ecografico si può individuare un aumento dello spessore della parete vescicale. Questa tipologia di infezione riguarda principalmente le bambine in età prescolare
Infezioni urinarie basse ricorrenti: sono molto frequenti nelle femmine in età scolare e sono spesso associate a disfunzioni vescicali e dello sfintere uretrale esterno
Nel 30 - 40% dei casi si associano a reflusso vescico-uretrale, di solito di lieve entità. È frequente la concomitanza con vulvo-vaginiti, sinechie delle piccole labbra e stipsi. La terapia può comprendere, oltre ad un trattamento specifico antibatterico, anche una rieducazione minzionale e l'utilizzo di farmaci che regolano la muscolatura vescicale
Infezione urinaria alta o pielonefrite acuta (PNA): è caratterizzata generalmente da febbre elevata accompagnata da brividi e dolori lombari o addominali. Questo tipo di infezione non è sempre facile da diagnosticare ed spesso associata ad una malformazione delle vie urinarie (nel 40% dei casi a reflusso vescico-uretrale) e/o a disfunzioni.
Per riconoscere un'infezione delle vie urinarie è molto importante individuare i sintomi che, come abbiamo visto, non sempre sono specifici o eclatanti. Ad esempio nei lattanti e nei neonati il sospetto di un'infezione di questo tipo deve nascere anche in presenza di sintomi aspecifici come febbre, irritabilità, scarso aumento di peso, pianto durante la minzione, disturbi gastroenterici, urina maleodorante, arrossamento all'interno delle cosce e ittero. Nei bambini più grandi invece occorre fare attenzione alla presenza di disturbi minzionali, cioè se il piccolo avverte dolore nella zona lombare o bruciore mentre fa pipì e se si verificano episodi di incontinenza.
In presenza di tali sintomi è necessario rivolgersi subito al medico. La diagnosi sulla presenza o meno di infezioni alle vie urinarie è possibile attraverso due esami specifici: l'esame completo delle urine e l'urinocoltura. Questi esami devono essere effettuati prima d'iniziare l'eventuale terapia con gli antibiotici perchè anche una sola dose di antibiotico può rendere sterili le urine impedendo quindi di identificare il germe responsabile dell'infezione. Altri esami che vengono effettuati una volta che l'infezione è passata sono l'ecografia renale e la cistografia.
Soprattutto nel caso di infezioni alte può essere eseguita anche una scintigrafia renale statica al fine di valutare gli eventuali esiti dopo un certo periodo di tempo. Nel caso delle infezioni delle basse vie urinarie si interviene in genere con un ciclo di 3-5 giorni di terapia antibatterica per via orale. Con cicli di questa durata è possibile prevenire gli effetti collaterali degli antibiotici e le alterazioni della flora batterica intestinale.
Se si è in presenza di una infezione alle alte vie urinarie il ciclo di terapia deve avere una durata maggiore (almeno 10 giorni). Una volta diagnosticata un'infezione del genere, come nel caso della pielonefrite acuta, la terapia va iniziata prima possibile. Infatti se si interviene tempestivamente, entro 48-72 ore dall'esordio dell'infezione, è possibile prevenire i possibili danni ai reni. A seconda dei sintomi e dell'età del bambino la terapia può essere effettuata a casa oppure in ospedale. Il ricovero viene in genere consigliato per i bambini più piccoli in presenza di febbre elevata, vomito o segni di disidratazione
domenica 17 marzo 2013
Sinechie o aderenze labiali nella bambina
Sinechie o aderenze labiali nella bambina
Le aderenze labiali, in termini medici sinechie o conglutinazione labiale o vulvite labiali, sono favorite da diversi fattori caratteristici di questa età: la mancanza di estrogeni; la possibilità di infezioni ripetute dell’uretra, dell’entrata vaginale, della vulva (i genitali esterni) o dell’intestino; un’igiene scarsa o non appropriata, che favorisca l’accumulo di sebo tra le piccole e le grandi labbra; e inoltre fattori individuali, tra cui dermatopatie [dermatiti da contatto, psoriasi, eczemi, ma anche il lichen scleroatrofico) e/o sequele di traumi (accidentali ma anche abusi)].
L’ipotesi più accreditata è che le aderenze labiali siano conseguenti a uno stimolo irritante che altera l’epitelio sottile e delicato della mucosa delle piccole labbra e che inneschi un processo di riepitelizzazione formando una connessione priva di vasi tra le due labbra. La fusione quando è completa può fare pensare a una assenza congenita della vagina o ad alterazioni anatomiche. I sintomi più comuni sono irritazione vulvovaginale e infezioni del tratto urinario. La bambina in genere non ritiene la pipì ma si osserva spesso uno sgocciolamento.
Diagnosi e terapia in caso di sinechieLa diagnosi e la terapia vanno fatte e seguite dal pediatra curante o da un ginecologo esperto in ginecologia dell’infanzia e dell’adolescenza. In alcuni casi le aderenze si risolvono spontaneamente senza terapia quando comincia la produzione di ormoni estrogeni con la pubertà. Quando la fusione è semplice, spesso lo specialista consiglia una crema agli estrogeni da applicare localmente con un dito o un cotton fioc sulla linea di fusione tra le piccole labbra per alcune settimane in base alla singola situazione. Considerato che la fusione delle labbra tende a ripetersi viene spesso consigliata anche l’applicazione di una crema emolliente per esempio a base di olio di germe di grano. Se all’adesione si associa anche un lichen sclerosus, come spesso avviene, allora la terapia locale richiede l’associazione di una pomata cortisonica. E’ importante seguire rigorosamente le indicazioni del medico sia come durata che come quantità dei medicinali da utilizzare. In passato veniva utilizzata anche la dilatazione forzata delle aderenze labiali, pratica che oggi si tende a sconsigliare per diversi motivi: è ritenuta inutilmente aggressiva (perché il trauma meccanico facilita la rifusione delle due labbra) e può lasciare conseguenze durature sulla sessualità futura della bambina.
L’igiene appropriata è la migliore prevenzioneMolti esperti sono concordi nel suggerire alcune norme igieniche quale migliore soluzione preventiva alla formazione di aderenze delle piccole labbra nella bambina in età pre-pubere:
- rimuovere tutti i fattori potenzialmente irritanti sulla mucosa vulvo-vaginale (bagnoschiuma, saponi, abbigliamento occlusivo o di tessuto sintetico etc);
- insegnare alla bambina sin da piccola la cura e l’igiene intima personali, per evitare l’a ccumulo di sebo e secrezioni tra le labbra stesse, che possono essere irritanti, utilizzando detergenti ultra-delicati;
- dopo la detersione, idratare i genitali con gel alla vitamina E o olio di germe di grano;
- in caso di prurito, verificare con il pediatra o il ginecologo che non vi siano associati infezioni intestinali da ossiuri e/o un lichen sclerosus in fase iniziale;
- se il lichen è presente, probabilmente lo specialista consiglierà sempre una crema alla vitamina E da associare al cortisone in modo da ridurre il prurito e la lesione. Più è precoce la diagnosi e più la terapia verrà effettuata correttamente migliori saranno i risultati.
Il lichen sclerosus
Il lichen sclerosus o lichen scleroatrofico è una patologia cutanea dei genitali che si presenta in circa il 10-15% delle bambine in età prepuberale, mediamente verso i 6-7 anni ma anche sin dalla primissima infanzia. Si tratta di una patologia cutanea a carattere autoimmune. E’ stato documentato che il lichen sclerosus si associa spesso e favorisce le aderenze delle piccole labbra e altre malattie autoimmuni come: vitiligine, alopecia areata, malattie della tiroide e altre. La causa è sconosciuta ma si pensa che il fattore ormonale abbia un ruolo importante considerato che il lichen sclerosus compare nelle bambine e nelle donne dopo la menopausa ovvero in due situazioni di carenza di estrogeni.
Segni e sintomi caratteristici del lichenLa mucosa vulvare in questi casi si presenta molto sottile, atrofica e pallida, quasi biancastra. Spesso la malattia è asintomatica, ma alcune bambine si grattano e si graffiano continuamente provocandosi in tal modo escoriazioni dolorose che possono causare difficoltà anche ad urinare (disuria). Le lesioni tipiche sono piccole papule biancastre che tendono a confluire formando vere e proprie placche in cui la cute assume un aspetto caratteristico di carta pergamena. Le lesioni che si localizzano alla vulva, al perineo o nella zona perianale, possono avere questa caratteristica a placche oppure assumere la forma di una sorta di “otto” biancastro traslucido. Con il tempo se il lichen sclerosus viene trascurato si sviluppa un’atrofia cicatriziale che può portare alla scomparsa delle labbra vulvari e del clitoride. Il grattamento causa eritema, bruciore, erosioni ed escoriazioni che possono essere talvolta confuse con segni di abuso sessuale.
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martedì 12 marzo 2013
Sacramento: un'altro bambino muore a causa della circoncisione
SACRAMENTO: Another circumcision death
March 8, 2013
Brayden Tyler Frazier, an 11-day-old infant, died tonight at UC Davis Children's Hospital in Sacramento, California.
He had been diagnosed with hemophilia following his circumcision which resulted in seizures and later a coma.
Details have been coming to light as a result of the Facebook posts of various family and friends.
It has all happened before.
And, until the non-therapeautic circumcision of infants is banned, it will all happen again.
But this time, it happened in Sacramento, California.
Within the last hour, Brayden Tyler Frazier died after circumcision put him in critical condition.
He started bleeding uncontrollably after he was circumcised Wednesday at UC Davis Medical Center in Sacramento.
They tried to use coagulants, platelets, plasma etc. to try and save his life, but to no avail.
His body started having seizures because of it, which lead to his liver and kidneys starting to shows signs of failure.
He was 9 days old when he was circumcised, and he died at 11 days of age.
He was alive and well for 9 days until the day he was circumcised, and it was found that he had hemophilia.
His parents are now grieving at the Lodi Memorial Hospital.
As a Californian who was born and raised in this area, this is very, very close to home for me.
What will happen now?
Here's what will happen.
Just like all circumcision deaths, this one will be swept neatly underneath the rug.
The cause of death will be recorded as "hemorrhaging to death."
Hemophilia will be blamed.
The baby will have died of "organ failure."
No mention is going to be made of his circumcision.
Ever.
Nobody is going to ask why doctors didn't test the child for hemophilia prior.
Everyone will demand nobody bother the parents because they are grieving.
They will not press charges.
They will be complicit in covering up this circumcision, and protecting the doctor that did it.
They may have yet another child, and go on to circumcise him too.
People will keep quiet, and demand others do too.
And so it will continue.
One conservative estimate says that 117 deaths a year happen in the US as a result of circumcision.
Although, a recent study in Brasil suggests that rate is closer to 156 deaths a year.
Because circumcision is performed in healthy, non-consenting children without any medical or clinical indication whatsoever, how is anything above 0 conscionable?
Death is a risk of circumcision.
Were these parents not made aware of this risk?
Do the benefits truly "outweigh" it, as the AAP repeats over and over?
Or was this child's death not important "because he was going to die anyway?"
I hate having to write these.
When will it end?
And, until the non-therapeautic circumcision of infants is banned, it will all happen again.
But this time, it happened in Sacramento, California.
Within the last hour, Brayden Tyler Frazier died after circumcision put him in critical condition.
He started bleeding uncontrollably after he was circumcised Wednesday at UC Davis Medical Center in Sacramento.
They tried to use coagulants, platelets, plasma etc. to try and save his life, but to no avail.
His body started having seizures because of it, which lead to his liver and kidneys starting to shows signs of failure.
He was 9 days old when he was circumcised, and he died at 11 days of age.
He was alive and well for 9 days until the day he was circumcised, and it was found that he had hemophilia.
His parents are now grieving at the Lodi Memorial Hospital.
As a Californian who was born and raised in this area, this is very, very close to home for me.
What will happen now?
Here's what will happen.
Just like all circumcision deaths, this one will be swept neatly underneath the rug.
The cause of death will be recorded as "hemorrhaging to death."
Hemophilia will be blamed.
The baby will have died of "organ failure."
No mention is going to be made of his circumcision.
Ever.
Nobody is going to ask why doctors didn't test the child for hemophilia prior.
Everyone will demand nobody bother the parents because they are grieving.
They will not press charges.
They will be complicit in covering up this circumcision, and protecting the doctor that did it.
They may have yet another child, and go on to circumcise him too.
People will keep quiet, and demand others do too.
And so it will continue.
One conservative estimate says that 117 deaths a year happen in the US as a result of circumcision.
Although, a recent study in Brasil suggests that rate is closer to 156 deaths a year.
Because circumcision is performed in healthy, non-consenting children without any medical or clinical indication whatsoever, how is anything above 0 conscionable?
Death is a risk of circumcision.
Were these parents not made aware of this risk?
Do the benefits truly "outweigh" it, as the AAP repeats over and over?
Or was this child's death not important "because he was going to die anyway?"
I hate having to write these.
When will it end?
FONTE: http://joseph4gi.blogspot.it/2013/03/circu...ther-one-i.html
sabato 9 marzo 2013
Preputial Plasty
Preputial Plasty:
A Good Alternative to Circumcision
By Peter M. Cuckow, Gerald Rix, and Pierre D.E. Mouriquand
Cambridge, England
Cambridge, England
Since 1991, boys needing surgery for tight nonretractile foreskin have been offered a choice of preputial plasty or circumcision, providing that there is no clinical evidence of preputial scarring. We compared two similar groups of 50 boys that underwent each procedure, through our routine audit and questionnaires sent to their parents. Of the boys with circumcisions, 20% required an overnight stay after the operation; 14% had anesthetic complications, and 6% required reoperation because of bleeding. Only 8% of patients with preputial plasty had an overnight stay, and no bleeding was observed. Parental assessment of both operations showed that morbidity was significantly less and of shorter duration for the preputial plasty group. Two patients in the preputial plasty group (4%) had recurrent narrowing of the foreskin caused by scarring and contraction of the incision. Parents were pleased with the long-term results of both procedures. This simple alternative to circumcision is easy to perform and allows full mobilization of the foreskin, preserving its function and providing an excellent cosmetic result.
Copyright © 1994 by W.B. Saunders Company
INDEX WORDS: Circumcision, alternative.
Treatment for the complications of a tight nonretractile foreskin in British boys is almost exclusively circumcision. With this radical approach, some patients experience postoperative complications and have poor cosmetic results. Moreover, the normal protective and sexual functions of the foreskin are lost, and irreversible changes occur in the epithelium of the glans. Less radical approaches have failed to gain general acceptance because of their often complex and specialized nature or allegedly poor cosmetic results. A small number of our patients, in whom scarring of the prepuce has occurred because of recurrent infection or, rarely, from balanitis xerotica et obliterans, are always treated by circumcision. The parents of the remainder have been given a choice between circumcision and a conservative technique - preputial plasty. This policy has enabled the study and comparison of two similar groups of patients.
Materials and Methods
The technique of preputial plasty is illustrated in Fig 1. The foreskin is mobilized, dividing glanular adhesions, and retracted to show the tight constricting band. This is incised longitudinally, along the dorsum of the penis. The underlying tissue is spread with artery forceps to expose Bucks' fascia, and the incision is closed transversely with absorbable sutures. This widens the tube of the prepuce and allows its free movement. Apart from lignocaine gel applied to the glans and suture line, no other local anesthetic is used. Parents are advised to mobilize the foreskin regularly, once the initial discomfort has subsided. A standard technique is used for circumcision, and these patients are given either a caudal or penile local anesthetic block. All operations were performed or directly supervised by a senior surgeon, and all patients had follow-up in the outpatient department, between 4 and 6 weeks after surgery.![[Fig 1]](http://www.cirp.org/library/treatment/phimosis/cuckow/fig1.gif)
Results
The reported surgical complications are listed in Table 1. Our normal practice is to discharge patients the evening after their surgery. Twenty percent of those who underwent circumcision required an overnight stay because of bleeding or anesthetic complications (nausea, vomiting, drowsiness) compared with 8% in the preputial plasty group. Interestingly, there were no overnight admissions from the day surgical unit during the study period, and no patient required catheterization for urinary retention. Infection or inflammation of the penis seen in outpatients, and presenting as gross preputial edema in one patient after preputial plasty, was treated by bathing in aqueous chlorhexidine solution. Recurrent adhesions were divided in the clinic, using topical lignocaine. Two patients who did not attempt foreskin mobilization after preputial plasty (4%) had recurrent narrowing of the foreskin, which resulted from scarring and contraction of the incision. Both were offered circumcision. Poor cosmetic results were due to an excess of mucosa (two circumcisions) or scarring (one preputial plasty).| Complication | Preputial Plasty | Circumcision |
|---|---|---|
| Bleeding requiring reoperation Retention of urine Overnight stay due to anesthetic Infected/inflamed penis Huge edema Recurrent adhesions Nonretractile foreskin Poor cosmetic result | - - 8% (4) 10% (5) 2% (1) 2% (1) 4% (2) 2% (1) | 6% (3) - 14% (7) 12% (6) - 2% (1) - 6% (3) |
| Severity | ||||||
|---|---|---|---|---|---|---|
| Question | Procedure | None | Negligible | Moderate | Poor | Severe |
| Any postoperative distress? | Preputial plasty Circumcision | 45% (18) 5.5% (2) | 27.5% (11) 13% (5) | 27.5% (11) 39.5% (15) | - 29% (11) | - 13% (5) |
| Any postoperative bleeding? | Preputial plasty Circumcision | 37.5% (15) 21% (8) | 45% (18) 45% (17) | 17.5% (7) 21% (8) | - 5% (2) | - 8% (3) |
| Any problems passing urine? | Preputial plasty Circumcision | 32.5% (13) 45% (17) | 30% (12) 18.5% (7) | 27.5% (11) 23.5% (9) | 10% (4) 8% (3) | - 5% (2) |
| Time From Surgery | ||||||
|---|---|---|---|---|---|---|
| Question | Procedure | < 2 d | 2 to 7 d | 1 to 2 wk | > 2 wk | |
| When could normal underwear be worn with comfort? | Preputial Plasty Circumcision | 37.5% (15) 5% (2) | 55% (22) 37% (14) | 5% (2) 42% (16) | 2.5% (1) 16% (6) | |
Discussion
Circumcision is associated with considerable morbidity. It is often performed by unsupervised junior surgeons in district hospitals, and the actual complication rate may be much higher than that reported from specialized pediatric centers [1], [2]. There is no doubt that far too many patients are referred for circumcision because of a lack of understanding of normal preputial development [3-5]. However, even when strict criteria are adopted, many tight unscarred prepuces are still subjected to circumcision on medical grounds or because of parental pressure [6]. Although the clinically scarred prepuce, because of recurrent infection or balanitis xerotica et obliterans [7], represents an absolute indication for circumcision, the remainder are suitable for more conservative treatment.Several alternatives to circumcision have been proposed, all aimed at widening the prepuce to allow its easy retraction and better hygiene, while retaining the normal cosmetic appearance of the penis. These range from local resection of the phimotic ring [8] to more complex V-Y and Z plasties of the prepuce [9-11] and helicoid plasty [12]. Unfortunately, there is little objective data to support the claims of excellent results with these procedures, and no complication rates are reported. The complicated nature of many of these procedures has almost certainly limited their acceptance to enthusiasts and specialists in plastic surgery. Most recently, a technique of triple incision plasty was reported, together with the results of 63 cases [13], one of which bled and four (6.3%) required reoperation.
Preputial plasty by a single dorsal incision of the prepuce has already been described [14], and is used widely throughout Europe [15]. Its simplicity and, in particular, the avoidance of the frenular area of the penis make it a quick, easy, and safe operation, with few complications even in inexperienced hands. In our study, its success is evident by the absence of serious bleeding problems, the improvement in post-operative morbidity, and the high level of patient satisfaction. The poor cosmetic results used to justify more complex procedures [13] are not borne out by our patients or by the long-term results observed in our clinic.
Attention is now being given to the physiological role of the foreskin by groups in the United States that oppose circumcision [16]. It certainly protects the sensitive skin of the glans, provides additional lubrication, and allows greater freedom of movement during sexual intercourse. Although meatal stenosis has not developed in any patient in the circumcision group, six patients have returned for meatoplasty in the past 2 years. Preputial plasty is a quick and safe method of preserving preputial function in patients needing surgical relief of a tight but unscarred foreskin. Compared with circumcision, preputial plasty has few complications, and functional and cosmetic results are good, providing the prepuce is mobilized regularly after surgery.
References
- Griffiths DM, Atwell JD, Freeman NV: A prospective study of the indications and morbidity of circumcision in children. Eur Urol 11:184-187, 1985
- Stenram A, Malmfors G, Okmian L: Circumcision for phimosis: A follow up study. Scand J Urol Nephrol 20:89-92, 1986
- Rickwood AMK, Walker J: Is phimosis overdiagnosed and are too many circumcisions performed in consequence? Ann Coll Surg Eng 71:275-277, 1989
- Gordon A, Collin J: Save the normal foreskin. Br Med J 306:1-2,1993
- Griffiths D, Frank JD: Inappropriate circumcision referrals by GPs. J R Soc Med 85:324-325, 1992
- Williams N, Chell J, Kapila L: Why are children referred for circumcision? Br Med J 306:28, 1993
- Rickwood AMK, Hemalatha V, Batcup G, et al: Phimosis in boys. Br J Urol 52:147-50, 1980
- Parkash S, Rao BR: Preputial stenosis - Its site and correction. Plast Reconstr Surg 66:281-282, 1980
- Emmett AJ: Four V flap repair of preputial stenosis (phimosis). Plast Reconstr Surg 55:687-689, 1975
- Emmett AJ: Z-plasty reconstruction for preputial stenosis - A surgical alternative to circumcision. Aust Paediatr J 18:219-220, 1982
- Hoffman S, Metz P, Ebbehoj J: A new technique for phimosis: Prepuce saving technique with multiple V-Y plasties. Br J Urol 56:319-321.1984
- Codega G, Guizzardi D, Di Guiseppe P, et al: Helicoid plasty in the treatment of phimosis. Minerva Chir 38:1903-1907, 1983
- Wahlin N: Triple incision plasty. A convenient procedure for preputial relief. Scand J Urol Nephrol 26:107-110, 1992
- Holmlund DE: Dorsal incision of the prepuce and skin closure with Dexon in patients with phimosis. Scand J Urol Nephrol 7:97-99, 1973
- Mollard P: Malformations de la verge et du scrotum, in Précis d'Urologie de l'Enfant. Paris, France, Masson, 1984, pp 331-333
- Purvis K: The forgotten foreskin. Nocirc Newsletter 6:1, 1992
From the Department of Paediatric Surgery, Addenbrooke's Hospital, Cambridge, England.
Date accepted: April 8, 1993.
Address reprint requests to:
Peter M. Cuckow, MB, BS, FRCS, Department of Paediatric Surgery, Addenbrooke's Hospital, Hills Rd, Cambridge CB2 2QQ, England.
Some American Jews Think That Child Circumcision Should Be Against the Law
A growing number of Jews are in favor of banning child circumcision. These Jews recognize a minor's right to their own body, a right that supersedes the rights of a parent to harm the body of a child in the name of religion.
The past century has been marked by the declaration and protection of universal human rights, as well as a marked increase in the quality of life, both in the United States and worldwide. With these improvements, higher expectations regarding a child’s right to bodily autonomy have become socially accepted and legally mandated. Many argue that since female children in the U.S. are protected by a 1996 law banning female circumcision, this law should be expanded to include the protection of male children as well.
There are a growing number of Jews who are becoming increasingly vocal in questioning both the ethics and the legality of circumcision. Jews in the Reform Judaism movement have already been advocating for an end to ritual circumcision during the past 180 years. Some forward-thinking Rabbis have created symbolic ceremonies to replace circumcision surgery. The Humanistic Jewish movement only does peaceful welcoming covenants. Already, more than 100 Rabbis from a wide range of Jewish denominations perform symbolic covenant rituals. More and more Jewish and Israeli parents, Rabbis, scholars, and thinkers have come to oppose circumcision.
What follows is a collection of statements from Jews who question the ethics and legality of forced under-age circumcision.
Jewish Americans Support Outlawing Child Circumcision
"I am a Jewish mother against circumcision and in support of passing Bill 1777. For years I was a certified childbirth educator and now a journalist and filmmaker. I continue to educate people that childbirth is a natural event rather than one filled with unnecessary drugs and other medical intervention, and circumcision is an unnatural event. These are two clear-cut examples of interfering with nature."
- Katherine Mora, Jewish Mother , Testimony before the Massachusetts Joint Committee on the Judiciary
“In Massachusetts, two Jewish mothers testified in favor of a law making circumcision illegal. Moreover, several Jews and Jewish organizations throughout the country are backing a proposed national law against circumcision. Jewish groups such as Jews Against Circumcision and the Israeli Association Against Genital Mutilation have endorsed the proposed American MGM bill, which would rewrite the U.S. Female Genital Mutilation Act of 1996 so that boys are also protected from genital mutilation.”
- Questioning circumcision, by Shani McManus and Sergio Carmona, Florida Jewish Journal, June 06, 2011
“Jewish baby boys are human and have rights too, and those rights are violently trampled by his (and my) religion, in the case of brit milah. We must all learn to take the blinders off and somehow stop this heinous practice -- yes, by a law, if necessary.
- Tina Kimmel, PhD, MSW, MPH, Director of NoCirc, East Bay Area
Letter to the Bay Citizen
“I’d heard how my uncle had fainted during my bris and what a horrible event it was. This was the thing everyone would talk about at the Passover seder… The ban on circumcision that’s on the ballot in San Francisco is a triumph for intactivists… I'm totally for it. San Francisco has often lead the country in elevating our consciousness. It has already helped spread awareness of this human rights crime to other states and hopefully will lead people everywhere to be more compassionate, thoughtful and rational not only towards their own fragile newborn children but to other fellow men and women as well.”
- Jason Paige, Jewish SingerBlood, Sweat & Tears Lead Singer Protests Infant Circumcision, by Rebecca Wald, J.D., BeyondTheBris.com, July 1, 2011
“The human right to body integrity would, in this instance, override their religious right.…non-fundamentalist Jews, who constitute a very large number of Reform, Conservative, and even some Orthodox Jews, believe that human ethics are an essential element in the Jewish tradition. …there is a Jewish tradition practiced by virtually all Jewish parents today that is morally wrong. This should give pause to any non-fundamentalist religious Jew, and it is a black eye for the liberal movements that they have not taken this issue more seriously. Perhaps a law prohibiting circumcision is just what these Jews need to start a serious discussion about the problem of brit milah.”
- Eli Ungar-Sargon, Outlawing Circumcision: Good for the Jews?, Forward, the Jewish Daily, May 20, 2011
“I happen to agree with you that foreskin removal should be illegal. It is a mutilation… I agree with you that men should not be circumcised. . . I don’t know where this circumcision came from, some people feel it’s a religious thing, it’s about health, it’s about cutting off the foreskin makes your penis less likely to get cancer. There’s been all kinds of myths. I think it’s nonsense. That if you’re born that way, it seems to me it’s a mutilation to cut it off. The same way in Africa they sometimes cut off a woman’s clitoris and they think that’s justified. I think our foreskins were cut off in order to desensitize us, and I think it was a bunch of religious nudnicks who decided they didn’t want us going around fornicating so they cut off some of our penis skin.”
- Howard Stern, Talk Radio HostHoward Stern, Jewish Intactivist by Rebecca Wald, J.D., BeyondTheBris.com, March 31, 2011
"Laurie Evans, the Jewish director of New York's National Organization of Circumcision Information Resource Centers (NOCIRC), told the Committee that under Jewish law, the son of a Jewish mother is Jewish, whether circumcised or not, and that despite great pressure she had kept her son intact. She said that many Jewish mothers confide to having been horrified by their boy's circumcision ceremony. She said that initially the ceremony involved removing only a small amount of foreskin, not all of it, and that several Jewish organizations recommend a peaceful birth ceremony instead. She urged the panel to watch a circumcision and raised the issue of botched circumcisions. The second Jewish mother to speak, Kathryn Mora, testified she had been devastated that her son was taken from her in the hospital and circumcised without her consent."
- Peter W. Adler, A Bird's Eye View of the Hearing On the Massachusetts Bill to Outlaw Genital MutilationAttorneys for the Rights of the Child Newsletter, Summer 2010
International Jews Also Favor Outlawing Child Circumcision
From Israel to the U.K., some Jews feel that circumcision surgery is an outdated tradition, and recognize that it violates many international laws.
“What about religious freedom? Certainly, the ability to freely practise one's religion remains a vital component of any liberal democracy. But should this trump an individual's right to their bodily integrity? And shouldn't such a principle be extended to all those who, by virtue of their age, are too young to decide on which body parts they would or would not like to keep?...
"Article 3 of the European Convention on Human Rights outlaws the kind of "harm" that circumcision can cause; article 14 forbids the discrimination that prevents baby boys from enjoying the same protection of their genitalia as baby girls. In the 21st century, it is time to remember that men, too, can be victims of unjust hegemonic systems tolerated in the name of tradition, culture or religion. If we oppose female genital mutilation, has the time not come for us also to oppose male genital mutiliation?"
- Neil Howard and Rebecca Steinfeld, Time to ban male circumcision?, Guardian UK, June 14, 2011Rebecca Steinfeld, is a PhD. candidate at Oxford University and has served as an under-35 director and as an associate of the Board of Deputies for New West End Synagogue.
"In Europe today, human rights groups have mounted a grass roots campaign opposing circumcision, comparing it to the brutal mutilation of African women. The Netherlands Institute of Human Rights wants to outlaw Bris Milah. And an article published in the prestigious British Medical Journal (April 2000), written by obstetricians, gynecologists, and midwives from hospitals in France, claimed:
“The [African] women we interviewed considered their daughters’ mutilation and their sons’ circumcision to be similar. Male circumcision is also a form of genital mutilation because it involves removing a healthy part of an organ. How can we convince mothers that they should not mutilate their daughters while they continue to have their sons circumcised?”
A group of Israelis petitioned the Israeli Supreme Court to outlaw circumcision on the grounds that it is criminal assault. Shockingly, this campaign even has adherents in Israel. In February 1998, a group of Israelis petitioned the Israeli Supreme Court to outlaw circumcision on the grounds that it is criminal assault. A joke? No. Case number 5780/98 is a real case, and the court has already held hearings.
Avshalom Zoossmann-Diskin, Executive Director of the Israeli Association Against Genital Mutilation in Tel Aviv, says that a campaign is urgently needed to end Bris Milah. “Why are they discriminating against me as victim of Jewish male genital mutilation?” he decries. “Are my human rights, bodily integrity and suffering less important than those of African girls?!”
- Circumcision: Beautiful or Barbaric? by Rabbi Shraga Simmons.
"As a liberal Jewish woman, I agree 100 per cent with the German court’s decision [to ban circumcision].
Maimonides knew, centuries ago, that circumcision impacted men’s sex drive, making sex and masturbation more difficult and less pleasurable, in addition to leaving penises weaker. According to him, circumcision’s job is to cause pain to boys’ members in order to accomplish the objectives stated above; it’s not about any covenantal accord referred to in scripture at all.
It’s also interesting to note that the first people to be circumcised in the Torah are teens and adults capable of making the decision on their own terms, something that makes sense given a comment in the Talmud that somebody ready for circumcision is akin to a groom.
On first glance, they’re not similar at all, since eight-day-old infants are vulnerable and deserve to be protected from anything unnecessary that can hurt them and grooms are older, capable of independent decision-making.
However, if we return to the Scripture and think about everything in a marriage context, perhaps the similarity is this: if someone ready for circumcision is akin to a groom, he has to be capable of rational decision-making and ready to live with the consequences of his actions. Circumcision will always be a hotly debated topic but in the long run, it, like any genital surgery, deserves to be chosen by the people who have to live with its effect."
- Amy Soule, Hamilton, Circumcision of boys amounts to bodily harm, German court rules (June 27) The Spec.
Amy Soule is a volunteer cantor and a Bris Shalom celebrant in the Reform Judaism movement. She also wrote the essay Parshat Lech L'cha: Why Infant Circumcision in Judaism Isn't Kosher on the website Beyondthebris.com.
“It seems to me that for liberal Jews the choice comes down to this. Do we want to in some way circumscribe the sexual possibilities of our sons by performing a body modification when they are infants so as to bear witness to the covenant? Are there not other ways to bear witness? Are there not other ways to maintain our distinctiveness from the society around us? Despite having circumcised my two sons, the more I think about the issue, the more likely – were I a resident of San Francisco – I would support the referendum.”
- Sandford Borins, Ph.D., The Circumcision Referendum: A Liberal Jewish Perspective
Sandford Borins, Ph.D., is a professor of Management at the University of Toronto.
Jewish Intactivist Media.BeyondtheBris.com
* Jewish Intactivist Articles & Opinions.
Cut: Slicing Through the Myths of Circumcision
* A Movie by Orthodox Intactivist, Eliyahu Ungar-Sargon
Questioning Circumcision: A Jewish Perspective by Ronald Goldman, Ph.D. *
Rabbis and other leaders who lead covenant without cutting ceremonies. *
Jewish Intactivist Groups.
Jews Against Circumcision * Jews For the Rights of the Child * Questioning Circumcision: A Jewish Perspective by Ron Goldman, PhD. *Gonnen * Kahal * Af-Mila: An Israeli Jewish Intactivist Journal *
The Israeli Association Against Genital Mutilation *
Judaism, the Foreskin and Human Rights Law.
Jewish Questioning of Traditional Circumcision * Part 1.
Jewish Questioning of Traditional Circumcision * Part 2.
Jewish Questioning of Traditional Circumcision * Part 3.
The Moral Problems of Circumcision & the Search for Jewish Alternatives.
Jewish Rationales for Abolishing Circumcision
* by Jews Against Circumcision.
Eli Ungar-Sargon & Rabbi Shmuley Boteach on the Ethical Problems of Circumcision
* At the Manhattan Jewish Experience.
Eli Ungar-Sargon: Outlawing Circumcision: Good for the Jews?
* Published in the Jewish Daily Forward.
Hebrew Scholar Vadim Cherny: How Judaic is circumcision?
* It’s not at all, he finds.
Circumcision Questions (letter from an intact Jew).
* Published in the Northern California Jewish Bulletin.
Miriam Pollack: Circumcision: Identity, Gender, and Power
* Originally published in Tikkun magazine.
Miriam Pollack: Circumcision : A Jewish Feminist Perspective
* Published in Jewish Women Speak Out.
The Measure of His Grief by Lisa Braver Moss
* A new book exploring Jewish intactivism.
Lisa Braver Moss: The Jewish Roots of Anti-Circumcision Arguments *
Jenny Goodman, MD: An Alternative Perspective
* A Jewish doctor in the UK urges us to keep our sons intact.
A Progressive Case for Bris without Milah. *
Moshe Rothenberg: Being Rational About Circumcision and Jewish Observance *
Brit Milah: Inconsistent with Jewish Ethics?
* Written by a Jewish parent.
Leaders in the Jewish Movement to Abolish Circumcision.
Intact America: Profile of Orthodox Intactivist Eliyahu Ungar-Sargon *
Intact America: Profile of Jewish Intactivist Miriam Pollack *
Intact America: Profile of Jewish Scholar and Intactivist Leonard Glick, MD, PhD.
* A Jewish history of circumcision.
The Intactivist Movement Within Judaism.
* Published on Saving Sons.
Jewish mom: Circumcision spiritually wounds
* From a lecture by Miriam Pollack.
Today’s Jews Reject Circumcision and Choose Peaceful Welcoming Covenants *
An Intactivist Midwife.
Regretting Circumcision: Women’s Perspectives
* Published on Dr. Ron Goldman’s site.
Progressive, Moral Jews speak out in Favor of Banning Circumcision on Minors.
* Intactivism and Human Rights.
The History of Circumcision: Leonard Glick , MD, PhD. explains how he came to write Marked In Your Flesh. *
American Jews Speak Out in Favor of Banning Circumcision on Minors *
International Jews Also Favor Outlawing Circumcision of Minors *
Judaism, Human Rights and the History of Circumcision *
Peaceful Covenant Texts for Jewish Parents.
Worldwide list of Rabbis who lead covenant without cutting ceremonies *
Song for an Intact Jewish Boy’s Welcoming Ceremony *
Brit B'lee Milah Ceremony *
A Brit Shalom Ceremony *
Norm Cohen: A Brit B’lee Milah Ceremony *
Jewish Parents' Experiences Keeping their Sons Intact.
Dear Elijah: A Conservative Jewish Father's Letter to His Intact Son
* Published on Peaceful Parenting.
Moshe Rothenberg: Ending Circumcision in the Jewish Community?
* Envisioning an Intactivist Judaism.
Laura Shanley: A Jewish Woman Denounces Circumcision
* A Childbirth educator chooses intact.
Michael Kimmel: The Kindest Un-Cut: Feminism, Judaism, and My Son's Foreskin
* Published in Tikkun.
The Naming
* Published on Very, Very Fine.
Stacey Greenberg: My Son: The Little Jew with a Foreskin
* Published in Mothering Magazine.
Intact & Jewish
* Published on the Natural Parents Network
The past century has been marked by the declaration and protection of universal human rights, as well as a marked increase in the quality of life, both in the United States and worldwide. With these improvements, higher expectations regarding a child’s right to bodily autonomy have become socially accepted and legally mandated. Many argue that since female children in the U.S. are protected by a 1996 law banning female circumcision, this law should be expanded to include the protection of male children as well.
There are a growing number of Jews who are becoming increasingly vocal in questioning both the ethics and the legality of circumcision. Jews in the Reform Judaism movement have already been advocating for an end to ritual circumcision during the past 180 years. Some forward-thinking Rabbis have created symbolic ceremonies to replace circumcision surgery. The Humanistic Jewish movement only does peaceful welcoming covenants. Already, more than 100 Rabbis from a wide range of Jewish denominations perform symbolic covenant rituals. More and more Jewish and Israeli parents, Rabbis, scholars, and thinkers have come to oppose circumcision.
What follows is a collection of statements from Jews who question the ethics and legality of forced under-age circumcision.
Jewish Americans Support Outlawing Child Circumcision
"I am a Jewish mother against circumcision and in support of passing Bill 1777. For years I was a certified childbirth educator and now a journalist and filmmaker. I continue to educate people that childbirth is a natural event rather than one filled with unnecessary drugs and other medical intervention, and circumcision is an unnatural event. These are two clear-cut examples of interfering with nature."
- Katherine Mora, Jewish Mother , Testimony before the Massachusetts Joint Committee on the Judiciary
“In Massachusetts, two Jewish mothers testified in favor of a law making circumcision illegal. Moreover, several Jews and Jewish organizations throughout the country are backing a proposed national law against circumcision. Jewish groups such as Jews Against Circumcision and the Israeli Association Against Genital Mutilation have endorsed the proposed American MGM bill, which would rewrite the U.S. Female Genital Mutilation Act of 1996 so that boys are also protected from genital mutilation.”
- Questioning circumcision, by Shani McManus and Sergio Carmona, Florida Jewish Journal, June 06, 2011
“Jewish baby boys are human and have rights too, and those rights are violently trampled by his (and my) religion, in the case of brit milah. We must all learn to take the blinders off and somehow stop this heinous practice -- yes, by a law, if necessary.
- Tina Kimmel, PhD, MSW, MPH, Director of NoCirc, East Bay Area
Letter to the Bay Citizen
“I’d heard how my uncle had fainted during my bris and what a horrible event it was. This was the thing everyone would talk about at the Passover seder… The ban on circumcision that’s on the ballot in San Francisco is a triumph for intactivists… I'm totally for it. San Francisco has often lead the country in elevating our consciousness. It has already helped spread awareness of this human rights crime to other states and hopefully will lead people everywhere to be more compassionate, thoughtful and rational not only towards their own fragile newborn children but to other fellow men and women as well.”
- Jason Paige, Jewish SingerBlood, Sweat & Tears Lead Singer Protests Infant Circumcision, by Rebecca Wald, J.D., BeyondTheBris.com, July 1, 2011
“The human right to body integrity would, in this instance, override their religious right.…non-fundamentalist Jews, who constitute a very large number of Reform, Conservative, and even some Orthodox Jews, believe that human ethics are an essential element in the Jewish tradition. …there is a Jewish tradition practiced by virtually all Jewish parents today that is morally wrong. This should give pause to any non-fundamentalist religious Jew, and it is a black eye for the liberal movements that they have not taken this issue more seriously. Perhaps a law prohibiting circumcision is just what these Jews need to start a serious discussion about the problem of brit milah.”
- Eli Ungar-Sargon, Outlawing Circumcision: Good for the Jews?, Forward, the Jewish Daily, May 20, 2011
“I happen to agree with you that foreskin removal should be illegal. It is a mutilation… I agree with you that men should not be circumcised. . . I don’t know where this circumcision came from, some people feel it’s a religious thing, it’s about health, it’s about cutting off the foreskin makes your penis less likely to get cancer. There’s been all kinds of myths. I think it’s nonsense. That if you’re born that way, it seems to me it’s a mutilation to cut it off. The same way in Africa they sometimes cut off a woman’s clitoris and they think that’s justified. I think our foreskins were cut off in order to desensitize us, and I think it was a bunch of religious nudnicks who decided they didn’t want us going around fornicating so they cut off some of our penis skin.”
- Howard Stern, Talk Radio HostHoward Stern, Jewish Intactivist by Rebecca Wald, J.D., BeyondTheBris.com, March 31, 2011
"Laurie Evans, the Jewish director of New York's National Organization of Circumcision Information Resource Centers (NOCIRC), told the Committee that under Jewish law, the son of a Jewish mother is Jewish, whether circumcised or not, and that despite great pressure she had kept her son intact. She said that many Jewish mothers confide to having been horrified by their boy's circumcision ceremony. She said that initially the ceremony involved removing only a small amount of foreskin, not all of it, and that several Jewish organizations recommend a peaceful birth ceremony instead. She urged the panel to watch a circumcision and raised the issue of botched circumcisions. The second Jewish mother to speak, Kathryn Mora, testified she had been devastated that her son was taken from her in the hospital and circumcised without her consent."
- Peter W. Adler, A Bird's Eye View of the Hearing On the Massachusetts Bill to Outlaw Genital MutilationAttorneys for the Rights of the Child Newsletter, Summer 2010
International Jews Also Favor Outlawing Child Circumcision
From Israel to the U.K., some Jews feel that circumcision surgery is an outdated tradition, and recognize that it violates many international laws.
“What about religious freedom? Certainly, the ability to freely practise one's religion remains a vital component of any liberal democracy. But should this trump an individual's right to their bodily integrity? And shouldn't such a principle be extended to all those who, by virtue of their age, are too young to decide on which body parts they would or would not like to keep?...
"Article 3 of the European Convention on Human Rights outlaws the kind of "harm" that circumcision can cause; article 14 forbids the discrimination that prevents baby boys from enjoying the same protection of their genitalia as baby girls. In the 21st century, it is time to remember that men, too, can be victims of unjust hegemonic systems tolerated in the name of tradition, culture or religion. If we oppose female genital mutilation, has the time not come for us also to oppose male genital mutiliation?"
- Neil Howard and Rebecca Steinfeld, Time to ban male circumcision?, Guardian UK, June 14, 2011Rebecca Steinfeld, is a PhD. candidate at Oxford University and has served as an under-35 director and as an associate of the Board of Deputies for New West End Synagogue.
"In Europe today, human rights groups have mounted a grass roots campaign opposing circumcision, comparing it to the brutal mutilation of African women. The Netherlands Institute of Human Rights wants to outlaw Bris Milah. And an article published in the prestigious British Medical Journal (April 2000), written by obstetricians, gynecologists, and midwives from hospitals in France, claimed:
“The [African] women we interviewed considered their daughters’ mutilation and their sons’ circumcision to be similar. Male circumcision is also a form of genital mutilation because it involves removing a healthy part of an organ. How can we convince mothers that they should not mutilate their daughters while they continue to have their sons circumcised?”
A group of Israelis petitioned the Israeli Supreme Court to outlaw circumcision on the grounds that it is criminal assault. Shockingly, this campaign even has adherents in Israel. In February 1998, a group of Israelis petitioned the Israeli Supreme Court to outlaw circumcision on the grounds that it is criminal assault. A joke? No. Case number 5780/98 is a real case, and the court has already held hearings.
Avshalom Zoossmann-Diskin, Executive Director of the Israeli Association Against Genital Mutilation in Tel Aviv, says that a campaign is urgently needed to end Bris Milah. “Why are they discriminating against me as victim of Jewish male genital mutilation?” he decries. “Are my human rights, bodily integrity and suffering less important than those of African girls?!”
- Circumcision: Beautiful or Barbaric? by Rabbi Shraga Simmons.
"As a liberal Jewish woman, I agree 100 per cent with the German court’s decision [to ban circumcision].
Maimonides knew, centuries ago, that circumcision impacted men’s sex drive, making sex and masturbation more difficult and less pleasurable, in addition to leaving penises weaker. According to him, circumcision’s job is to cause pain to boys’ members in order to accomplish the objectives stated above; it’s not about any covenantal accord referred to in scripture at all.
It’s also interesting to note that the first people to be circumcised in the Torah are teens and adults capable of making the decision on their own terms, something that makes sense given a comment in the Talmud that somebody ready for circumcision is akin to a groom.
On first glance, they’re not similar at all, since eight-day-old infants are vulnerable and deserve to be protected from anything unnecessary that can hurt them and grooms are older, capable of independent decision-making.
However, if we return to the Scripture and think about everything in a marriage context, perhaps the similarity is this: if someone ready for circumcision is akin to a groom, he has to be capable of rational decision-making and ready to live with the consequences of his actions. Circumcision will always be a hotly debated topic but in the long run, it, like any genital surgery, deserves to be chosen by the people who have to live with its effect."
- Amy Soule, Hamilton, Circumcision of boys amounts to bodily harm, German court rules (June 27) The Spec.
Amy Soule is a volunteer cantor and a Bris Shalom celebrant in the Reform Judaism movement. She also wrote the essay Parshat Lech L'cha: Why Infant Circumcision in Judaism Isn't Kosher on the website Beyondthebris.com.
“It seems to me that for liberal Jews the choice comes down to this. Do we want to in some way circumscribe the sexual possibilities of our sons by performing a body modification when they are infants so as to bear witness to the covenant? Are there not other ways to bear witness? Are there not other ways to maintain our distinctiveness from the society around us? Despite having circumcised my two sons, the more I think about the issue, the more likely – were I a resident of San Francisco – I would support the referendum.”
- Sandford Borins, Ph.D., The Circumcision Referendum: A Liberal Jewish Perspective
Sandford Borins, Ph.D., is a professor of Management at the University of Toronto.
Jewish Intactivist Media.BeyondtheBris.com
* Jewish Intactivist Articles & Opinions.
Cut: Slicing Through the Myths of Circumcision
* A Movie by Orthodox Intactivist, Eliyahu Ungar-Sargon
Questioning Circumcision: A Jewish Perspective by Ronald Goldman, Ph.D. *
Rabbis and other leaders who lead covenant without cutting ceremonies. *
Jewish Intactivist Groups.
Jews Against Circumcision * Jews For the Rights of the Child * Questioning Circumcision: A Jewish Perspective by Ron Goldman, PhD. *Gonnen * Kahal * Af-Mila: An Israeli Jewish Intactivist Journal *
The Israeli Association Against Genital Mutilation *
Judaism, the Foreskin and Human Rights Law.
Jewish Questioning of Traditional Circumcision * Part 1.
Jewish Questioning of Traditional Circumcision * Part 2.
Jewish Questioning of Traditional Circumcision * Part 3.
The Moral Problems of Circumcision & the Search for Jewish Alternatives.
Jewish Rationales for Abolishing Circumcision
* by Jews Against Circumcision.
Eli Ungar-Sargon & Rabbi Shmuley Boteach on the Ethical Problems of Circumcision
* At the Manhattan Jewish Experience.
Eli Ungar-Sargon: Outlawing Circumcision: Good for the Jews?
* Published in the Jewish Daily Forward.
Hebrew Scholar Vadim Cherny: How Judaic is circumcision?
* It’s not at all, he finds.
Circumcision Questions (letter from an intact Jew).
* Published in the Northern California Jewish Bulletin.
Miriam Pollack: Circumcision: Identity, Gender, and Power
* Originally published in Tikkun magazine.
Miriam Pollack: Circumcision : A Jewish Feminist Perspective
* Published in Jewish Women Speak Out.
The Measure of His Grief by Lisa Braver Moss
* A new book exploring Jewish intactivism.
Lisa Braver Moss: The Jewish Roots of Anti-Circumcision Arguments *
Jenny Goodman, MD: An Alternative Perspective
* A Jewish doctor in the UK urges us to keep our sons intact.
A Progressive Case for Bris without Milah. *
Moshe Rothenberg: Being Rational About Circumcision and Jewish Observance *
Brit Milah: Inconsistent with Jewish Ethics?
* Written by a Jewish parent.
Leaders in the Jewish Movement to Abolish Circumcision.
Intact America: Profile of Orthodox Intactivist Eliyahu Ungar-Sargon *
Intact America: Profile of Jewish Intactivist Miriam Pollack *
Intact America: Profile of Jewish Scholar and Intactivist Leonard Glick, MD, PhD.
* A Jewish history of circumcision.
The Intactivist Movement Within Judaism.
* Published on Saving Sons.
Jewish mom: Circumcision spiritually wounds
* From a lecture by Miriam Pollack.
Today’s Jews Reject Circumcision and Choose Peaceful Welcoming Covenants *
An Intactivist Midwife.
Regretting Circumcision: Women’s Perspectives
* Published on Dr. Ron Goldman’s site.
Progressive, Moral Jews speak out in Favor of Banning Circumcision on Minors.
* Intactivism and Human Rights.
The History of Circumcision: Leonard Glick , MD, PhD. explains how he came to write Marked In Your Flesh. *
American Jews Speak Out in Favor of Banning Circumcision on Minors *
International Jews Also Favor Outlawing Circumcision of Minors *
Judaism, Human Rights and the History of Circumcision *
Peaceful Covenant Texts for Jewish Parents.
Worldwide list of Rabbis who lead covenant without cutting ceremonies *
Song for an Intact Jewish Boy’s Welcoming Ceremony *
Brit B'lee Milah Ceremony *
A Brit Shalom Ceremony *
Norm Cohen: A Brit B’lee Milah Ceremony *
Jewish Parents' Experiences Keeping their Sons Intact.
Dear Elijah: A Conservative Jewish Father's Letter to His Intact Son
* Published on Peaceful Parenting.
Moshe Rothenberg: Ending Circumcision in the Jewish Community?
* Envisioning an Intactivist Judaism.
Laura Shanley: A Jewish Woman Denounces Circumcision
* A Childbirth educator chooses intact.
Michael Kimmel: The Kindest Un-Cut: Feminism, Judaism, and My Son's Foreskin
* Published in Tikkun.
The Naming
* Published on Very, Very Fine.
Stacey Greenberg: My Son: The Little Jew with a Foreskin
* Published in Mothering Magazine.
Intact & Jewish
* Published on the Natural Parents Network
lunedì 4 marzo 2013
The Prepuce
Previous Chapter Contents Page
Chapter Two: The Prepuce
One must understand the nature and function of the structure that is amputated by circumcision in order to properly evaluate the effects of male circumcision. This chapter provides that information.
General Description
The prepuce traditionally has been described as a simple fold of skin,1 for which the purpose and function are unknown. This is inaccurate. In reality, the prepuce is a complex structure with multiple anatomical and physiological functions.2
The prepuce is a portion of the entire covering of the penis. It is specialized tissue, composed of skin, mucosa, nerves, blood vessels, and muscle fibers.2 It is anchored by the abdominal wall at the proximal end of the penis and at the proximal end of the glans penis. It is not attached to the shaft of the penis, so, after puberty, it is free to slide back and forth, everting and inverting as it does.3 The sliding/rolling back and forth is called the gliding action.3,4
A frenulum is found on the ventral side of the penis. The frenulum serves to tether a movable structure to a non-movable structure. The penile frenulum returns the foreskin to its normal protective forward position.2 Most men report that the frenulum is highly erogenous tissue.
Peripenic Muscle
In the skin of the penis, there is a sheath of dartos fascia muscle fibers — the peripenic muscle.2,3,5 The muscle fibers keep the prepuce snug against the glans penis.3 The fibers of the peripenic muscle sheath form a whorl at the tip of the prepuce, which act as a sphincter,3 especially in infants and children. The sphincter also serves to prevent inadvertent retraction of the prepuce. The peripenic muscle gives the prepuce great elasticity, allows it to stretch, and helps to return the prepuce to its forward, protective position after retraction.2 The elasticity of the prepuce plays an important role in the erogenous and sexual functions of the prepuce.
Immunology
The prepuce covers and protects the glans penis and urinary meatus. In most males, the prepuce protects the sterile urinary tract environment in infancy and maintains the moistness — beneficial to good health — of the mucosal surface of the glans penis throughout life.6 Fleiss et al. (1998) have identified immunological functions that help to protect the body from pathogens:7
- sphincter action of the preputial orifice functions like a one-way valve, allowing urine to flow out but preventing the entry of infectious contaminants;
- apocrine glands of the inner prepuce, which secrete lysozyme, an enzyme that breaks down cell walls of pathogens (and also acts against HIV8);
- sub-preputial moisture that lubricates and protects the mucosa of the glans penis; and
- high vascularity to bring phagocytes to fight infection.
The epidermis of the prepuce contains Langerhans cells that secrete cytokines,2 hormone-like low-molecular-weight proteins, which regulate the intensity and duration of immune responses.9 de Witte and colleagues (2007) report that the Langerhans cells produce langerin, a substance that provides a barrier to HIV infection.10
Innervation
The prepuce of the newborn male has extensive innervation. Winkelmann (1956) reported, “[t]he principal form of innervation of human newborn prepuce consists of a deep and superficial network of nerve fibres in the dermis.”11 Moldwin & Valderrama (1989) reported an extensive neuronal network in the prepuce.12
The prepuce of adult males is even more extensively innervated. Winkelmann (1959) described the prepuce as a specific erogenous zone with nerves arranged near the surface in rete ridges.13 Taylor et al. (1996) also found nerves near the surface in rete ridges and further described a concentration of nerve endings in a ring of ridged tissue just inside the tip of the prepuce near the mucocutaneous boundary, which he named the ridged band.14 The nerve endings in the ridged band are Meissner's corpuscles and Krause's end-bulbs.
The nerves of the penis, including the preputial nerves, supply sensory input to both the somatosensory and autonomic nervous systems by different routes.2 The sensory input to the somatosensory nervous system is supplied through the dorsal nerve of the penis, and the autonomic nervous system is supplied through the parasympathetic nerves, which run adjacent to and through the wall of the membranous urethra.
The prepuce is provided with an extensive vascular network to bring oxygen to support the heavy innervation.2,7,14
Several writers have commented on the sensitivity of the prepuce. Winkelmann (1956) wrote, “…it is a region of great sensitivity and possessed of an abundant nerve supply,”11 and later (1959) identified the prepuce as a specific erogenous zone.13 Falliers (1970) noted the “sensory pleasure associated with tactile stimulation of the foreskin.”15 A landmark study by Sorrells et al. (2007) of the fine-touch sensitivity of the penis finds that the areas most sensitive to fine touch are on the foreskin.16 Circumcision, therefore, amputates the most sensitive areas of the penis.
Sexual Function
The prepuce is primary, erogenous tissue necessary for normal sexual function.2 In adult life, the gliding action facilitates introitus4 and reduces friction and chafing during coitus.5 The movement and stretching of the prepuce during coitus stimulate the nerve endings in the prepuce, produce erogenous sensation, and eventually ejaculation.18,19 The presence of the prepuce tends to protect the corona of the glans penis from direct stimulation, helps to prevent premature ejaculation20,21 and contributes to female satisfaction.22 (See Chapter Six for a discussion of the sexual harm of prepuce excision.)
Natural Development
The great majority of newborn infant boys are born with the inner surface of the prepuce fused with the glans.2 In addition, the tip of the prepuce at birth usually is too narrow to allow retraction. The duration of these conditions vary with the individual but can last until the completion of puberty or longer. For these two reasons, the non-retractile foreskin is normal in childhood and adolescence and cannot be considered a disease requiring treatment.
The first data on development of the retractile prepuce was provided in 1949 by British pediatrician Douglas Gairdner.22 Gairdner said 80 percent of boys have a retractable foreskin by the age of two years, and 90 percent of boys have a retractable prepuce by the age three. His erroneous information23 has been incorporated into medical textbooks and medical school curricula for decades, and it still is repeated in medical literature today.24
Gairdner’s data are inaccurate23-25 and, unfortunately, most healthcare providers have been taught this inaccurate information,24,25 which contributes to improper diagnosis of “pathological phimosis” in the healthy, normal, non-retractile foreskin. Retractability usually occurs much later than previously believed.2,24,25 About 44 percent of boys have a fully retractable prepuce by age 10-112,27,28,29 and about 95 percent have a fully retractable prepuce by age 18.2,27 Non-retractile foreskin is the more common condition until 10-11 years of age. Thorvaldsen & Meyhoff (2005) report that the mean age of first foreskin retraction is 10.4 years.29 Non-retractile foreskin in childhood and adolescence is not a disease and does not require treatment.
Ballooning of the prepuce in childhood during urination is harmless and self-limiting. Babu et al. (2004) have shown that ballooning does not cause obstructed voiding.30 Ballooning disappears with increasing maturity. No treatment is required.31
References
- Williams PL, Warwick R, Dyson M et al. (eds): Gray's Anatomy, 37th ed, Churchill Livingstone, New York, 1989: 1432
- Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83 Suppl. 1:34–44. [Full Text]
- Lakshmanan S., Prakash S. Human prepuce: some aspects of structure and function. Indian J Surg 1980;44:134–7. [Full Text]
- Warren J, Bigelow J. The case against circumcision. Br J Sex Med 1994;21:6–8. [Full Text]
- Jefferson G. The peripenic muscle; some observations on the anatomy of phimosis. Surg Gynecol Obstet (Chicago) 1916;23(2):177–81. [Full Text]
- Parkash S, Raghuram R, Venkatesan, et al. Sub-preputial wetness - Its nature. Ann Nat Med Sci (India) 1982;18(3):109–12. [Full Text]
- Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Inf 1998;74(5):364–7. [Full Text]
- Lee-Huang S, Huang PL, Sun Y, et al. Lysozyme and RNases as anti-HIV components in beta-core preparations of human chorionic gonadotropin. Proc Natl Acad Sci U S A 1999;96(6):2678–81. [Full Text]
- Stedman’s Medical Dictionary, 26th edition, q.v. "cytokine."
- de Witte L, Nabatov A, Pion M, et al. Langerin is a natural barrier to HIV-1 transmission by Langerhans cells. Nat Med 2007;13:367–371. [Abstract]
- Winkelmann RK. The cutaneous innervation of human newborn prepuce. J Invest Dermatol 1956 26(1):53–67. [Full Text]
- Moldwin RM, Valderrama E. Immunochemical analysis of nerve distribution patterns within prepucial tissue. J Urol 1989;141(4) Part 2:499A. [Abstract]
- Winkelmann RK. The erogenous zones: their nerve supply and significance. Mayo Clin Proc 1959;34(2):39–47. [Full Text]
- Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291–5. [Full Text]
- Falliers CJ. Circumcision (letter). JAMA 1970;214(12):2194. [Full Text]
- Sorrells ML, Snyder JL, Reiss MD, et al. Fine-touch pressure thresholds in the adult penis. BJU Int 2007;99:864–9. [Full Text]
- Taves D. The intromission function of the foreskin. Med Hypotheses 2002;59(2):180.
- Taylor JR. Letter. Can Fam Physician 2003;49:1592. [Full Text]
- Taylor JR. Fine touch pressure thresholds in the adult penis (letter). BJU Int 2007;100(1):218. [Full Text]
- Zwang G. Functional and erotic consequences of sexual mutilations. In: Denniston GC and Milos MF, eds. Sexual Mutilations: A Human Tragedy New York and London: Plenum Press, 1997.
- O'Hara K, O'Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int 1999;83 Suppl 1:79–84.
- Gairdner D. The fate of the foreskin: a study of circumcision. Br Med J 1949;2:1433–7. [Full Text]
- Wright JE. Further to the "Further Fate of the Foreskin." Med J Aust 1994; 160: 134–5. [Full Text]
- Hill G. Circumcision for phimosis and other medical indications in Western Australian boys. Med J Aust 2003;178(11):587. [Full Text]
- Hill G. Triple incision plasty to treat phimosis: an alternative to circumcision BJU Int 2004;93:636. [Full Text]
- Øster J. Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child 1968;43:200–3. [Full Text]
- Kayaba H, Tamura H, Kitajima S, et al. Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol 1996;156(5):1813–5. [Full Text]
- Morales Concepción JC, Cordies Jackson E, Guerra Rodriguez M, et al. ¿Debe realizarse circuncisión en la infancia? Arch Esp Urol 2002;55(7):807–11. [Abstract]
- Thorvaldsen MA, Meyhoff H. Patologisk eller fysiologisk fimose? Ugeskr Læger 2005;167(17):1858–62. [Abstract]
- Babu R, Harrison SK, Hutton KA. Ballooning of the foreskin and physiological phimosis: is there any objective evidence of obstructed voiding? BJU Int 2004;94(3):384–7. [Full Text]
- Simpson ET, Barraclough P. The management of the paediatric foreskin. Aust Fam Physician 1998;27(5):381–3. [Full Text]