ඉස්ලාම්. ප්රශ්න-පිළිතුරු. 4. චර්මච්චේදනය.
මෙය පුහු තර්කයක්. ඒ අනුව අහන්න නම් ඕන තරම් තියනවා. ඇයි කොන්ඩේ, නියපොතු කපන්න ඕනේ, ඇයි බඩගිනි වෙන්නේ, ඇයි මලපහ-මුත්රා යන්නේ, ඇයි නින්ද යන්නේ, ඇයි මවපු දේ වසන්න ඇඳුම් අඳින්නේ, ඇයි නයි-පොලොඟුන් මැව්වේ ආදිය....
දෙවියන් කැමති දෙය කැමති විදිහට කරන්නෙකි. ඒ ගැන ප්රශ්න කරන්න කාටවත් බෑ. මෙලොව මැවීමට සහ මිනිසුන්ව මවා මෙලොවේ ටික කලක් ජිවත් වීමට අවස්ථාව දීමේ අරමුණ පරලොව ජිවිතයට සුදානම් වීමයි. ඔබේ මේ ප්රශ්න වලට හේතුව මෙලොව, මිනිසුන්ට ජිවත් වීමට ඇති ස්ථිර ස්ථානය යැයි සිතීමේ ඔබේ මුලාවයි. (ඒ මුලාව අනුව තමයි මේ ලෝකයේ දුකෙන් මිදෙන්න ඔබේ දහම වෙහෙසෙන්නේ. මෙලොව ජීවිතය දුකක් නොවේ. අවස්ථාවක් පමණයි!). ලෞකික ජිවිතයේ අලංකාරයේ මුලාව ගැන පාඩම් ඉගෙන ගැනීමට යම් දේවල් විවිධ ආකාරයෙන්, සුදුසු විදිහට මවා තිබෙනවා. කුරානයේ පවසනවා,
In the earth, there are signs for those who (seek truth to) believe, (20) And in your own selves! So, do you not perceive? (51:21)
එනිසා, මෙම මිනිස් ශරීරය අධ්යයනයෙන් පාඩම් ඉගෙනගත හැකි බව පවසනවා. එසේ ඒ ගැන හදාරන්න අනුබල දෙනවා.
මිනිසා මැවීම ගැන කුරානය මෙහෙම කියනවා.
Verily, We created man in the best stature (mould), (95:4)
මෙහි කියන්නේ නෑ perfect ලෙස මවනවා කියා. ඉතාමත්ම අලංකාර සහ සුදුසුම ලෙස මවා ඇති බව කියනවා. නවීන විද්යාවේ ඉගැන්වීම් සියල්ලෙන් සහ DNA තරම් වන දේවල් දක්වා කල සොයාගැනීම් වලින් එය මනාව පැහැදිලි වෙනවා. මැවීම් කිසිවක් perfect වන්නේ නෑ. හේතුව එය "මවනු ලද්දක්" වීමයි. එනම් තමන්ගේ පැවැත්මට වෙන කෙනෙකුහේ සහය අවශ්ය කෙනෙක් perfect විය නොහැකියි. Perfect වන්නේ මැවීමක් නොවන, කිසිම කෙනෙකුගේ අවශ්යතාවය සහ උපදෙස් අවශ්ය නොවන, සර්වබලධාරී එකම දෙවියන් පමණි.
ච්ර්මච්චේදනය යනු ආගමේ ඇති එක් උපදෙසක්. එයින් ප්රයෝජන ඇති බව කියනවා. එය හොඳ බව කියනවා. එසේ නොකිරීම පවක් නොවේ. එනිසා එය අනිවාර්ය දෙයක් නොවේ. ඔබ දන්නේ නැති වුනාට මෙලොවේ මුස්ලිම් නොවන විශාල පිරිසක් එය කරගන්නවා. ලංකාවේ සිංහල අය පවා එය කරගන්නවා. වෛද්ය විද්යාව අනුව අහි පැහැදිලි ප්රයෝජන තියනවා.
පිරිසිදුව සිටීම එහි ලොකු අරමුණක් නොවේ. එසේ නොකලද පිරිසිදුව සිටීම අපේ දහමේ ලොකු අංශයක්. මුත්රා කලාට පස්සේ ජලයෙන් සේදීම වැඩිහිටි සැමට අනිවාර්යයි. නැතිනම් නැමදුම පවා පිළිගැනෙන්නේ නැත. එසේ ජලය නැතිනම්, ජලය උරාගන්නා පිරිසිදු ගල්, පිරිසිදු පොඩි ගඩොල්/මැටි කෑලි ආදී පස් වලින් සැදුනු දේවලින් පිරිසිදු විය හැකියි. ඒ සිද්ධාන්තය අනුව මෙකල tissues භාවිතා කල හැකියි. මෙවැනි දේ කියා ඇත්තේ අපේම යහපත සඳහායි. ඔබලා ඉතින් කරන්නේ බල්ලෝ මුත්රා කරනවා වගේ දකින තැන කරලා ඔහේ යන එකනේ. පිරිසිදු කමේ නාමයක් නෑ.
චර්මච්චේදනයේ වෛද්ය විද්යාව අනුව ඇති ප්රයෝජන ගැන UpToDate 2012 release එකේ ඇත්තේ මෙහෙමයි. (UpToDate යනු වෛද්ය විද්යාවේ මුළු ලොවම පිළිගන්නා, මුලාශ්ර ගැඹුරින් අධ්යයනය කර සැකසුනු අටුවාවක්).
Circumcision
Author
Laurence S Baskin, MD, FAAP
Section Editors
Charles J Lockwood, MD
John G Bartlett, MD
Deputy Editor
Vanessa A Barss, MD
Disclosures
Last literature review version 19.3: Fri Sep 30 00:00:00 GMT 2011 | This topic last updated: Mon Sep 19 00:00:00 GMT 2011 (More)
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HISTORICAL BACKGROUND — The practice of male circumcision dates as far back as ancient Egypt, when circumcision was performed to improve male hygiene and for purification. Routine circumcision of male infants was also part of the Abrahamic covenants with Jehovah; all males of that tribe were circumcised as a sign of the covenant, a tradition that continues today as a religious symbol for followers of Judaism. Circumcision is also practiced by the followers of Islam and certain aboriginal tribes in Africa and Australia as a rite of passage into manhood [5].
Although Christians initially did not espouse the practice, circumcision became popular in western cultures in the mid-19th century to prevent masturbation [6]. Circumcision was also proposed as a means of preventing or treating a variety of medical problems, such as epilepsy, polio, and diarrhea.
PREVALENCE — The United States is the only country in the developed world where the majority of male infants are circumcised for nonreligious reasons. Circumcision rates in the United States vary according to geographic area, socioeconomic status, religious affiliation, insurance coverage, hospital type, and racial and ethnic group. Rates based on hospital coding data (circumcision prevalence 55 to 65 percent) probably underestimate the true prevalence of circumcised males (80 to 85 percent) due to miscoding and because some circumcisions are performed after hospital discharge or later in life for religious, medical or personal reasons [2-7].
The overall prevalence of circumcision in healthy newborn male infants appears to have decreased from the 1970s, but the decrease has not been linear: from 1988 to 2000 the rate of circumcision of newborn infants prior to hospital discharge increased by 6.8 percent per year [2,3], but then appeared to decrease by about 1 percent [8].
Circumcision rates in other nations tend to be lower, but vary from less than 20 percent to over 80 percent of males [9].
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BENEFITS — Circumcision has been associated with a number of medical benefits, including lower rates of urinary tract infection, penile cancer, penile inflammation, penile dermatoses, and sexually transmitted infections [16,17].
Reduction in urinary tract infection — Urinary tract infection (UTI) is uncommon in males at any age. The effect of circumcision on UTI has been studied primarily in infants because they have a higher prevalence of UTI than older males. UTIs in infants can result in pyelonephritis requiring hospitalization and, rarely, septicemia and death. In infants with congenital uropathy UTI can have serious sequelae, such as renal scaring and lifelong renal insufficiency.
Studies consistently report that circumcised male infants have significantly fewer UTIs than uncircumcised male infants [10,18-24]. A meta-analysis found that among febrile male infants less than 3 months of age, the prevalence of UTI in circumcised and uncircumcised infants was 2.4 and 20.1 percent, respectively [24]. The risk of developing a UTI is, on average, 3 to 12-fold lower in circumcised infants. However, since the absolute risk of UTI is small in male infants (0.4 to 1 percent), 100 to 200 circumcisions would need to be performed to prevent one UTI.
Uncircumcised male infants under six months of age have higher numbers of uropathogenic bacteria bound to the mucosal surface of the foreskin and at the urethral meatus than infants who have been circumcised [25]. This colonization probably plays a role in the pathogenesis of urinary infection. However, factors other than circumcision may affect the observed rate of UTI in these reports [10]. As an example, most hospitalized premature infants are not circumcised. Since premature infants have a higher rate of UTI than term infants, the inclusion of premature infants in a series may confound the data. Other factors that can affect UTI rates include the method of urine collection, type and timing of circumcision, and breastfeeding status (protective effect [26]).
Adult circumcised men have a lower rate of UTI than uncircumcised men [27]. The prevalence of UTIs in uncircumcised adult males increases with age and certain disease states, such as diabetes mellitus [27,28]. (See "Acute uncomplicated cystitis, pyelonephritis, and asymptomatic bacteriuria in men" and "Epidemiology and risk factors for urinary tract infections in children".)
Reduction of cancer — Compared to uncircumcised men, circumcised men appear to have a lower risk of penile cancer, and their sexual partners may have a lower risk of cervical cancer.
Penile cancer — Squamous cell cancer of the penis is a rare disease. The age-adjusted incidence in the United States is less than 1 per 100,000 males, comparable to that in other developed countries [29]. It has been estimated that the risk is increased three to six-fold in uncircumcised men. Much of the protective benefit of circumcision is lost if circumcision is not performed in early infancy. The data supporting these conclusions are presented separately. (See "Carcinoma of the penis: Epidemiology, risk factors, and clinical presentation", section on 'Circumcision'.)
Cervical cancer in partners — Cervical cancer is less common in the sexual partners of circumcised men. In one study, sex with either uncircumcised men or men circumcised after infancy increased a woman's risk of cervical cancer four-fold [30]. In another, monogamous women whose circumcised male partners had ≥ 6 sexual partners had a lower risk of cervical cancer than women whose partners were uncircumcised (OR 0.42, 95% CI 0.23-0.79) [31].
HPV infection is a necessary, but not sufficient, factor in development of virtually all cervical cancer. A partial explanation for the link between cervical cancer and lack of male circumcision is that uncircumcised men are more likely to acquire and transmit HPV to their partners [32] (see 'Sexually transmitted infections (not including HIV)' below and "Cervical intraepithelial neoplasia: Definition, incidence, and pathogenesis", section on 'Overview of HPV infection')
Other — Case-control studies have reported that circumcised men have a lower rate of prostate cancer than uncircumcised men [33,34]. This could be related to multiple confounders; further investigation is required.
Reduction in penile inflammation and retractile disorders — Penile inflammatory disorders, such as meatitis and balanitis (ie, inflammation of the glans), are extremely uncommon in circumcised men, but can develop whether or not circumcision has been performed. Balanoposthitis, a suppurative inflammation of the glans and foreskin, usually requires surgical intervention [28]. Uncircumcised males who retract the foreskin while bathing are less likely to experience problems with inflammation [35]. (See "Balanoposthitis in children: Clinical manifestations, diagnosis, and treatment".)
Most studies suggest penile problems occur more often in uncircumcised men [36-38]:
• A longitudinal study of 500 New Zealand boys followed from birth to age 8 reported that circumcised infants had a higher rate of meatitis in infancy, but a lower rate of penile problems after infancy due to absence of foreskin-associated disorders (eg, balanitis and inflammation) [36]. By age 8, the rate of penile problems in circumcised and uncircumcised boys was 11.1 and 18.8 problems per 100 children, respectively. Most of these problems were minor and could be treated medically, but some required surgical intervention for phimosis or balanoposthitis.
• A retrospective survey of 272 uncircumcised boys and 273 controls who were circumcised at birth found that the total frequency of medical visits for penile problems (eg, balanitis, irritation, phimosis) was significantly lower in the circumcised group (5 versus 10 percent, respectively) [37]. Most of the problems were minor.
Chronic inflammation or repeated forceful retraction of a congenital phimosis may cause scarring and secondary phimosis, which sometimes requires surgical intervention [14,15,39]. Frequent catheterization without replacement of the foreskin, poor hygiene, and chronic balanoposthitis can also lead to phimosis and eventual paraphimosis (ie, entrapment of a retracted foreskin behind the coronal sulcus). Urinary obstruction, hematuria, pain, and edema and necrosis of the glans may occur in severe cases. (See "Paraphimosis: Definition, pathophysiology, and clinical features".)
Acute and recurrent problems of the foreskin can sometimes be managed medically with hyaluronidase or topical betamethasone cream [40-42], but mechanical or surgical intervention may be required.
Reduction in sexually transmitted infections — If only biological factors are considered, uncircumcised men may be at greater risk of acquiring sexually transmitted infections because the warm, moist environment provided by the prepuce may provide more favorable conditions for infection than the circumcised glans.
A significant reduction in risk of acquiring sexually transmitted infections would be an important medical benefit of circumcision. However, behavioral factors, such as having a low number of sexual partners and consistent correct use of condoms, are probably more important than circumcision status for protection against sexually transmissible diseases. Unfortunately, there is no evidence that any public health or educational program has had an effect on the hygienic practices of adolescent or adult males, other than the increased use of condoms in a few HIV high risk populations in the western world [43-45]. (See "Prevention of sexually transmitted diseases".)
There is high quality evidence that circumcision protects against acquisition of HIV, HPV, and HSV-2, but not gonorrhea or syphilis (see below). It appears to protect against trichomonas infection as well.
HIV infection — Randomized trials in South Africa, Kenya, and Uganda have shown that circumcision protects against the acquisition of HIV [46-49]. As an example, a randomized trial in South Africa demonstrated that the risk of acquiring human immunodeficiency virus (HIV) infection was 50 to 60 percent lower in adult men who were offered circumcision at trial entry compared to those who were not offered circumcision [47]. It is presumed that neonatal circumcision would offer a similar benefit. (See "The stages and natural history of HIV infection", section on 'Lack of circumcision'.)
In Africa, the lack of circumcision appears to be one of several facilitating factors in HIV seroconversion. The World Health Organization has recommended that circumcision be considered as part of a comprehensive HIV prevention package that includes provision of voluntary HIV testing and counseling services, treatment for sexually transmitted infections, promotion of safer sex practices (delayed initiation of sexual activity, reduced numbers of sexual partners, avoidance of penetrative sex), and provision of male and female condoms and promotion of their correct and consistent use [50]. Additional research is required to develop male circumcision programs in resource poor settings, but there is increasing support for circumcision as a part of the preventative public health care plan for the prevention of HIV spread in Africa [51].
It is important to remember that circumcision only reduces the risk of acquisition of HIV infection by about half and that there is no strong evidence that circumcised HIV-infected men are less likely to transmit the infection to their female or male partners [50]. Consistent correct use of condoms are highly effective for both preventing acquisition of and transmitting HIV.
Circumcision may significantly reduce HIV infection because the inner aspect of the foreskin appears to be richer in cells with HIV-1 receptors than the glans [52-54]. Thus, removal of these target cells may reduce, but not eliminate, the risk of acquiring infection when the man is exposed to HIV.
Sexually transmitted infections (not including HIV) — An embedded study within the randomized South African trial discussed above [47] assessed the effect of circumcision on acquisition of high oncogenic risk HPV (HR-HPV), Neisseria gonorrhoeae, and Trichomonas vaginalis infections [55,56]. Urethral swabs and urine samples were analyzed using PCR.
• Male circumcision had a protective effect on HR-HPV prevalence (intention-to-treat analysis, HR-HPV prevalence in the circumcision group 14.8 percent (94/637) versus 22.3 percent (140/627) in the control group; RR 0.66, 95%CI 0.51-0.86) [56].
• Male circumcision had a borderline effect on prevalence of trichomonas infection (intention to treat analysis OR 0.54, 95% CI 0.29-1.03), but the reduction became statistically significant in the 'as treated' analysis (OR 0.49, 95% CI 0.25-0.93) [55].
• There was no evidence of a protective effect against Neisseria gonorrhoeae infection [55].
This study is the best evidence to date that circumcision reduces the risk of HR-HPV and trichomonas infections among heterosexual men and explains why women with circumcised partners are at a lower risk of cervical cancer than other women.
The Ugandan randomized trials of adult male circumcision confirmed and extended these findings [57]:
• Male circumcision had a protective effect on HR-HPV prevalence (HR-HPV prevalence in the circumcision group 18 percent versus 27.9 percent in the control group; RR 0.65, 95% CI 0.46-0.90).
• Male circumcision had a protective effect on HSV-2 seroconversion (HSV-2 seroconversion in the circumcision group 7.8 versus 10.3 percent in the control group, RR 0.72, 95% CI 0.56-0.92).
• There was no evidence of a protective effect against syphilis infection.
Females can benefit from male circumcision, as well. An analysis of the spouses of men enrolled in the Ugandan randomized trial of adult male circumcision for HIV prevention [49] found partners of circumcised men had lower rates of genital ulceration (adjusted prevalence risk ratio [aPRR] 0.78, 95% CI 0.61-0.99), trichomonas infection (aPRR 0.55, 95%CI 0.34-0.89), and bacterial vaginosis (aPRR 0.82, 95% CI 0.74-0.91) than partners of uncircumcised men [58]. Possible explanations for these findings are that circumcised men may be less susceptible to infection/colonization with these organisms or the circumcised penis may be less likely to transmit these organisms than the uncircumcised penis.
Easier hygiene — Genital hygiene is easier in the absence of a foreskin. Good hygiene may prevent many problems associated with the foreskin [35], but can be difficult to maintain in uncircumcised boys, even in developed countries. Studies of middle class British and Scandinavian schoolboys concluded that penile hygiene is usually not well-maintained [11,59].
සමහරු මෙවැනි ප්රයෝජන නැති බව පෙන්වන්න පුහු තර්ක වල යෙදෙති. එහෙත් වෛද්ය විද්යාව එය හොඳ දෙයක් ලෙස පිළිගෙන ඇති බව කාටත් වසන් කල නොහැකි කරුණකි. මෙය routine procedure එකක් ලෙස recommend කරනවාද යන ප්රශ්නය දක්වා එය ඇවිත්. එය balanced තත්වයක තියන බව කියනවා. එසේ recommend කරන්න තවත් evidence අවශ්ය බව කියනවා. එසේ STD වලින් ආරක්ෂා වීමේ අලුත් evidence තියන නිසා මේ තත්වය පසුව review කරන්න සිදු විය හැකි බවත් කියනවා.
The American Academy of Pediatrics (AAP) established a task force to evaluate the medical research, ethics, and other issues related to circumcision of the male infant and concluded that "existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these the data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision" [10]. They also noted that cultural, religious, and ethnic traditions could be considered in addition to medical factors, and that pain control should be provided. Although this statement was reaffirmed in 2005, the AAP is reviewing this position, given recent evidence of the protective effect of circumcision against HIV and other sexually transmitted infections.
ඉස්ලාමය කියන්නෙත් මෙයමයි. මෙය හොඳයි. කැමතිනම් කරගන්න, නැතිනම් නිකන් ඉන්න කියලයි.
මෙය පුහු තර්කයක්. ඒ අනුව අහන්න නම් ඕන තරම් තියනවා. ඇයි කොන්ඩේ, නියපොතු කපන්න ඕනේ, ඇයි බඩගිනි වෙන්නේ, ඇයි මලපහ-මුත්රා යන්නේ, ඇයි නින්ද යන්නේ, ඇයි මවපු දේ වසන්න ඇඳුම් අඳින්නේ, ඇයි නයි-පොලොඟුන් මැව්වේ ආදිය....
දෙවියන් කැමති දෙය කැමති විදිහට කරන්නෙකි. ඒ ගැන ප්රශ්න කරන්න කාටවත් බෑ. මෙලොව මැවීමට සහ මිනිසුන්ව මවා මෙලොවේ ටික කලක් ජිවත් වීමට අවස්ථාව දීමේ අරමුණ පරලොව ජිවිතයට සුදානම් වීමයි. ඔබේ මේ ප්රශ්න වලට හේතුව මෙලොව, මිනිසුන්ට ජිවත් වීමට ඇති ස්ථිර ස්ථානය යැයි සිතීමේ ඔබේ මුලාවයි. (ඒ මුලාව අනුව තමයි මේ ලෝකයේ දුකෙන් මිදෙන්න ඔබේ දහම වෙහෙසෙන්නේ. මෙලොව ජීවිතය දුකක් නොවේ. අවස්ථාවක් පමණයි!). ලෞකික ජිවිතයේ අලංකාරයේ මුලාව ගැන පාඩම් ඉගෙන ගැනීමට යම් දේවල් විවිධ ආකාරයෙන්, සුදුසු විදිහට මවා තිබෙනවා. කුරානයේ පවසනවා,
In the earth, there are signs for those who (seek truth to) believe, (20) And in your own selves! So, do you not perceive? (51:21)
එනිසා, මෙම මිනිස් ශරීරය අධ්යයනයෙන් පාඩම් ඉගෙනගත හැකි බව පවසනවා. එසේ ඒ ගැන හදාරන්න අනුබල දෙනවා.
මිනිසා මැවීම ගැන කුරානය මෙහෙම කියනවා.
Verily, We created man in the best stature (mould), (95:4)
මෙහි කියන්නේ නෑ perfect ලෙස මවනවා කියා. ඉතාමත්ම අලංකාර සහ සුදුසුම ලෙස මවා ඇති බව කියනවා. නවීන විද්යාවේ ඉගැන්වීම් සියල්ලෙන් සහ DNA තරම් වන දේවල් දක්වා කල සොයාගැනීම් වලින් එය මනාව පැහැදිලි වෙනවා. මැවීම් කිසිවක් perfect වන්නේ නෑ. හේතුව එය "මවනු ලද්දක්" වීමයි. එනම් තමන්ගේ පැවැත්මට වෙන කෙනෙකුහේ සහය අවශ්ය කෙනෙක් perfect විය නොහැකියි. Perfect වන්නේ මැවීමක් නොවන, කිසිම කෙනෙකුගේ අවශ්යතාවය සහ උපදෙස් අවශ්ය නොවන, සර්වබලධාරී එකම දෙවියන් පමණි.
ච්ර්මච්චේදනය යනු ආගමේ ඇති එක් උපදෙසක්. එයින් ප්රයෝජන ඇති බව කියනවා. එය හොඳ බව කියනවා. එසේ නොකිරීම පවක් නොවේ. එනිසා එය අනිවාර්ය දෙයක් නොවේ. ඔබ දන්නේ නැති වුනාට මෙලොවේ මුස්ලිම් නොවන විශාල පිරිසක් එය කරගන්නවා. ලංකාවේ සිංහල අය පවා එය කරගන්නවා. වෛද්ය විද්යාව අනුව අහි පැහැදිලි ප්රයෝජන තියනවා.
පිරිසිදුව සිටීම එහි ලොකු අරමුණක් නොවේ. එසේ නොකලද පිරිසිදුව සිටීම අපේ දහමේ ලොකු අංශයක්. මුත්රා කලාට පස්සේ ජලයෙන් සේදීම වැඩිහිටි සැමට අනිවාර්යයි. නැතිනම් නැමදුම පවා පිළිගැනෙන්නේ නැත. එසේ ජලය නැතිනම්, ජලය උරාගන්නා පිරිසිදු ගල්, පිරිසිදු පොඩි ගඩොල්/මැටි කෑලි ආදී පස් වලින් සැදුනු දේවලින් පිරිසිදු විය හැකියි. ඒ සිද්ධාන්තය අනුව මෙකල tissues භාවිතා කල හැකියි. මෙවැනි දේ කියා ඇත්තේ අපේම යහපත සඳහායි. ඔබලා ඉතින් කරන්නේ බල්ලෝ මුත්රා කරනවා වගේ දකින තැන කරලා ඔහේ යන එකනේ. පිරිසිදු කමේ නාමයක් නෑ.
චර්මච්චේදනයේ වෛද්ය විද්යාව අනුව ඇති ප්රයෝජන ගැන UpToDate 2012 release එකේ ඇත්තේ මෙහෙමයි. (UpToDate යනු වෛද්ය විද්යාවේ මුළු ලොවම පිළිගන්නා, මුලාශ්ර ගැඹුරින් අධ්යයනය කර සැකසුනු අටුවාවක්).
Circumcision
Author
Laurence S Baskin, MD, FAAP
Section Editors
Charles J Lockwood, MD
John G Bartlett, MD
Deputy Editor
Vanessa A Barss, MD
Disclosures
Last literature review version 19.3: Fri Sep 30 00:00:00 GMT 2011 | This topic last updated: Mon Sep 19 00:00:00 GMT 2011 (More)
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HISTORICAL BACKGROUND — The practice of male circumcision dates as far back as ancient Egypt, when circumcision was performed to improve male hygiene and for purification. Routine circumcision of male infants was also part of the Abrahamic covenants with Jehovah; all males of that tribe were circumcised as a sign of the covenant, a tradition that continues today as a religious symbol for followers of Judaism. Circumcision is also practiced by the followers of Islam and certain aboriginal tribes in Africa and Australia as a rite of passage into manhood [5].
Although Christians initially did not espouse the practice, circumcision became popular in western cultures in the mid-19th century to prevent masturbation [6]. Circumcision was also proposed as a means of preventing or treating a variety of medical problems, such as epilepsy, polio, and diarrhea.
PREVALENCE — The United States is the only country in the developed world where the majority of male infants are circumcised for nonreligious reasons. Circumcision rates in the United States vary according to geographic area, socioeconomic status, religious affiliation, insurance coverage, hospital type, and racial and ethnic group. Rates based on hospital coding data (circumcision prevalence 55 to 65 percent) probably underestimate the true prevalence of circumcised males (80 to 85 percent) due to miscoding and because some circumcisions are performed after hospital discharge or later in life for religious, medical or personal reasons [2-7].
The overall prevalence of circumcision in healthy newborn male infants appears to have decreased from the 1970s, but the decrease has not been linear: from 1988 to 2000 the rate of circumcision of newborn infants prior to hospital discharge increased by 6.8 percent per year [2,3], but then appeared to decrease by about 1 percent [8].
Circumcision rates in other nations tend to be lower, but vary from less than 20 percent to over 80 percent of males [9].
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BENEFITS — Circumcision has been associated with a number of medical benefits, including lower rates of urinary tract infection, penile cancer, penile inflammation, penile dermatoses, and sexually transmitted infections [16,17].
Reduction in urinary tract infection — Urinary tract infection (UTI) is uncommon in males at any age. The effect of circumcision on UTI has been studied primarily in infants because they have a higher prevalence of UTI than older males. UTIs in infants can result in pyelonephritis requiring hospitalization and, rarely, septicemia and death. In infants with congenital uropathy UTI can have serious sequelae, such as renal scaring and lifelong renal insufficiency.
Studies consistently report that circumcised male infants have significantly fewer UTIs than uncircumcised male infants [10,18-24]. A meta-analysis found that among febrile male infants less than 3 months of age, the prevalence of UTI in circumcised and uncircumcised infants was 2.4 and 20.1 percent, respectively [24]. The risk of developing a UTI is, on average, 3 to 12-fold lower in circumcised infants. However, since the absolute risk of UTI is small in male infants (0.4 to 1 percent), 100 to 200 circumcisions would need to be performed to prevent one UTI.
Uncircumcised male infants under six months of age have higher numbers of uropathogenic bacteria bound to the mucosal surface of the foreskin and at the urethral meatus than infants who have been circumcised [25]. This colonization probably plays a role in the pathogenesis of urinary infection. However, factors other than circumcision may affect the observed rate of UTI in these reports [10]. As an example, most hospitalized premature infants are not circumcised. Since premature infants have a higher rate of UTI than term infants, the inclusion of premature infants in a series may confound the data. Other factors that can affect UTI rates include the method of urine collection, type and timing of circumcision, and breastfeeding status (protective effect [26]).
Adult circumcised men have a lower rate of UTI than uncircumcised men [27]. The prevalence of UTIs in uncircumcised adult males increases with age and certain disease states, such as diabetes mellitus [27,28]. (See "Acute uncomplicated cystitis, pyelonephritis, and asymptomatic bacteriuria in men" and "Epidemiology and risk factors for urinary tract infections in children".)
Reduction of cancer — Compared to uncircumcised men, circumcised men appear to have a lower risk of penile cancer, and their sexual partners may have a lower risk of cervical cancer.
Penile cancer — Squamous cell cancer of the penis is a rare disease. The age-adjusted incidence in the United States is less than 1 per 100,000 males, comparable to that in other developed countries [29]. It has been estimated that the risk is increased three to six-fold in uncircumcised men. Much of the protective benefit of circumcision is lost if circumcision is not performed in early infancy. The data supporting these conclusions are presented separately. (See "Carcinoma of the penis: Epidemiology, risk factors, and clinical presentation", section on 'Circumcision'.)
Cervical cancer in partners — Cervical cancer is less common in the sexual partners of circumcised men. In one study, sex with either uncircumcised men or men circumcised after infancy increased a woman's risk of cervical cancer four-fold [30]. In another, monogamous women whose circumcised male partners had ≥ 6 sexual partners had a lower risk of cervical cancer than women whose partners were uncircumcised (OR 0.42, 95% CI 0.23-0.79) [31].
HPV infection is a necessary, but not sufficient, factor in development of virtually all cervical cancer. A partial explanation for the link between cervical cancer and lack of male circumcision is that uncircumcised men are more likely to acquire and transmit HPV to their partners [32] (see 'Sexually transmitted infections (not including HIV)' below and "Cervical intraepithelial neoplasia: Definition, incidence, and pathogenesis", section on 'Overview of HPV infection')
Other — Case-control studies have reported that circumcised men have a lower rate of prostate cancer than uncircumcised men [33,34]. This could be related to multiple confounders; further investigation is required.
Reduction in penile inflammation and retractile disorders — Penile inflammatory disorders, such as meatitis and balanitis (ie, inflammation of the glans), are extremely uncommon in circumcised men, but can develop whether or not circumcision has been performed. Balanoposthitis, a suppurative inflammation of the glans and foreskin, usually requires surgical intervention [28]. Uncircumcised males who retract the foreskin while bathing are less likely to experience problems with inflammation [35]. (See "Balanoposthitis in children: Clinical manifestations, diagnosis, and treatment".)
Most studies suggest penile problems occur more often in uncircumcised men [36-38]:
• A longitudinal study of 500 New Zealand boys followed from birth to age 8 reported that circumcised infants had a higher rate of meatitis in infancy, but a lower rate of penile problems after infancy due to absence of foreskin-associated disorders (eg, balanitis and inflammation) [36]. By age 8, the rate of penile problems in circumcised and uncircumcised boys was 11.1 and 18.8 problems per 100 children, respectively. Most of these problems were minor and could be treated medically, but some required surgical intervention for phimosis or balanoposthitis.
• A retrospective survey of 272 uncircumcised boys and 273 controls who were circumcised at birth found that the total frequency of medical visits for penile problems (eg, balanitis, irritation, phimosis) was significantly lower in the circumcised group (5 versus 10 percent, respectively) [37]. Most of the problems were minor.
Chronic inflammation or repeated forceful retraction of a congenital phimosis may cause scarring and secondary phimosis, which sometimes requires surgical intervention [14,15,39]. Frequent catheterization without replacement of the foreskin, poor hygiene, and chronic balanoposthitis can also lead to phimosis and eventual paraphimosis (ie, entrapment of a retracted foreskin behind the coronal sulcus). Urinary obstruction, hematuria, pain, and edema and necrosis of the glans may occur in severe cases. (See "Paraphimosis: Definition, pathophysiology, and clinical features".)
Acute and recurrent problems of the foreskin can sometimes be managed medically with hyaluronidase or topical betamethasone cream [40-42], but mechanical or surgical intervention may be required.
Reduction in sexually transmitted infections — If only biological factors are considered, uncircumcised men may be at greater risk of acquiring sexually transmitted infections because the warm, moist environment provided by the prepuce may provide more favorable conditions for infection than the circumcised glans.
A significant reduction in risk of acquiring sexually transmitted infections would be an important medical benefit of circumcision. However, behavioral factors, such as having a low number of sexual partners and consistent correct use of condoms, are probably more important than circumcision status for protection against sexually transmissible diseases. Unfortunately, there is no evidence that any public health or educational program has had an effect on the hygienic practices of adolescent or adult males, other than the increased use of condoms in a few HIV high risk populations in the western world [43-45]. (See "Prevention of sexually transmitted diseases".)
There is high quality evidence that circumcision protects against acquisition of HIV, HPV, and HSV-2, but not gonorrhea or syphilis (see below). It appears to protect against trichomonas infection as well.
HIV infection — Randomized trials in South Africa, Kenya, and Uganda have shown that circumcision protects against the acquisition of HIV [46-49]. As an example, a randomized trial in South Africa demonstrated that the risk of acquiring human immunodeficiency virus (HIV) infection was 50 to 60 percent lower in adult men who were offered circumcision at trial entry compared to those who were not offered circumcision [47]. It is presumed that neonatal circumcision would offer a similar benefit. (See "The stages and natural history of HIV infection", section on 'Lack of circumcision'.)
In Africa, the lack of circumcision appears to be one of several facilitating factors in HIV seroconversion. The World Health Organization has recommended that circumcision be considered as part of a comprehensive HIV prevention package that includes provision of voluntary HIV testing and counseling services, treatment for sexually transmitted infections, promotion of safer sex practices (delayed initiation of sexual activity, reduced numbers of sexual partners, avoidance of penetrative sex), and provision of male and female condoms and promotion of their correct and consistent use [50]. Additional research is required to develop male circumcision programs in resource poor settings, but there is increasing support for circumcision as a part of the preventative public health care plan for the prevention of HIV spread in Africa [51].
It is important to remember that circumcision only reduces the risk of acquisition of HIV infection by about half and that there is no strong evidence that circumcised HIV-infected men are less likely to transmit the infection to their female or male partners [50]. Consistent correct use of condoms are highly effective for both preventing acquisition of and transmitting HIV.
Circumcision may significantly reduce HIV infection because the inner aspect of the foreskin appears to be richer in cells with HIV-1 receptors than the glans [52-54]. Thus, removal of these target cells may reduce, but not eliminate, the risk of acquiring infection when the man is exposed to HIV.
Sexually transmitted infections (not including HIV) — An embedded study within the randomized South African trial discussed above [47] assessed the effect of circumcision on acquisition of high oncogenic risk HPV (HR-HPV), Neisseria gonorrhoeae, and Trichomonas vaginalis infections [55,56]. Urethral swabs and urine samples were analyzed using PCR.
• Male circumcision had a protective effect on HR-HPV prevalence (intention-to-treat analysis, HR-HPV prevalence in the circumcision group 14.8 percent (94/637) versus 22.3 percent (140/627) in the control group; RR 0.66, 95%CI 0.51-0.86) [56].
• Male circumcision had a borderline effect on prevalence of trichomonas infection (intention to treat analysis OR 0.54, 95% CI 0.29-1.03), but the reduction became statistically significant in the 'as treated' analysis (OR 0.49, 95% CI 0.25-0.93) [55].
• There was no evidence of a protective effect against Neisseria gonorrhoeae infection [55].
This study is the best evidence to date that circumcision reduces the risk of HR-HPV and trichomonas infections among heterosexual men and explains why women with circumcised partners are at a lower risk of cervical cancer than other women.
The Ugandan randomized trials of adult male circumcision confirmed and extended these findings [57]:
• Male circumcision had a protective effect on HR-HPV prevalence (HR-HPV prevalence in the circumcision group 18 percent versus 27.9 percent in the control group; RR 0.65, 95% CI 0.46-0.90).
• Male circumcision had a protective effect on HSV-2 seroconversion (HSV-2 seroconversion in the circumcision group 7.8 versus 10.3 percent in the control group, RR 0.72, 95% CI 0.56-0.92).
• There was no evidence of a protective effect against syphilis infection.
Females can benefit from male circumcision, as well. An analysis of the spouses of men enrolled in the Ugandan randomized trial of adult male circumcision for HIV prevention [49] found partners of circumcised men had lower rates of genital ulceration (adjusted prevalence risk ratio [aPRR] 0.78, 95% CI 0.61-0.99), trichomonas infection (aPRR 0.55, 95%CI 0.34-0.89), and bacterial vaginosis (aPRR 0.82, 95% CI 0.74-0.91) than partners of uncircumcised men [58]. Possible explanations for these findings are that circumcised men may be less susceptible to infection/colonization with these organisms or the circumcised penis may be less likely to transmit these organisms than the uncircumcised penis.
Easier hygiene — Genital hygiene is easier in the absence of a foreskin. Good hygiene may prevent many problems associated with the foreskin [35], but can be difficult to maintain in uncircumcised boys, even in developed countries. Studies of middle class British and Scandinavian schoolboys concluded that penile hygiene is usually not well-maintained [11,59].
සමහරු මෙවැනි ප්රයෝජන නැති බව පෙන්වන්න පුහු තර්ක වල යෙදෙති. එහෙත් වෛද්ය විද්යාව එය හොඳ දෙයක් ලෙස පිළිගෙන ඇති බව කාටත් වසන් කල නොහැකි කරුණකි. මෙය routine procedure එකක් ලෙස recommend කරනවාද යන ප්රශ්නය දක්වා එය ඇවිත්. එය balanced තත්වයක තියන බව කියනවා. එසේ recommend කරන්න තවත් evidence අවශ්ය බව කියනවා. එසේ STD වලින් ආරක්ෂා වීමේ අලුත් evidence තියන නිසා මේ තත්වය පසුව review කරන්න සිදු විය හැකි බවත් කියනවා.
The American Academy of Pediatrics (AAP) established a task force to evaluate the medical research, ethics, and other issues related to circumcision of the male infant and concluded that "existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these the data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision" [10]. They also noted that cultural, religious, and ethnic traditions could be considered in addition to medical factors, and that pain control should be provided. Although this statement was reaffirmed in 2005, the AAP is reviewing this position, given recent evidence of the protective effect of circumcision against HIV and other sexually transmitted infections.
ඉස්ලාමය කියන්නෙත් මෙයමයි. මෙය හොඳයි. කැමතිනම් කරගන්න, නැතිනම් නිකන් ඉන්න කියලයි.
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.....Thopita mona sanwara wachanada kalakanni hambayo..!
