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Why should I read this review?Circumcision is the commonest surgical procedure in males, because routine infant circumcision is practised in many countries for religious and cultural reasons. It originated over 15 000 years ago, being performed for religious, ritualistic, and cultural reasons, and it was not until the 19th century that the procedure was "medicalised." It is one of the most controversial surgical interventions: proponents claim benefits such as improved hygiene and reduced risks of infection (urinary and sexually transmitted) and of penile and cervical cancer, whereas opponents deny or minimise these benefits and cite substantial complication rates and reduced penile sensation. Many parents and patients have firmly held beliefs, placing medical workers under extreme pressure at times when dealing with requests for circumcision. It is vital for all medical staff to be aware of the various indications for circumcision and the operative techniques and their complications to cope with these consultations with an evidence base.This review concentrates solely on the medical indications for circumcision and does not address the issues of routine, religious, or ritual infant circumcision. It highlights clinical conditions frequently referred for circumcision but which are normal physiological variants and do not require surgery. It also lists the absolute medical indications for circumcision and the complications of the procedure. The various surgical techniques are listed in the table.What is the normal anatomy of the penis and foreskin? Preputial adhesions and physiological phimosis During development, the epithelium lining the prepuce and the glans are contiguous, such that preputial adhesions represent a normal feature of foreskin development. Epidemiological data from two seminal papers in the past century show that, at the age of 5 years, almost 75% of boys still have preputial adhesions and this figure drops steadily until puberty.1 2 Preputial adhesions, therefore, are not an indication for circumcision. In addition, it was noted that 8% of 7 year olds have a physiological phimosis which resolves spontaneously, leaving a 1% incidence at puberty. 2What are the relative indications for circumcision? Circumcision is performed for various conditions, but their natural course suggests that this is not always necessary. There are also many relative indications for circumcision, including the prevention of penile and cervical cancer, the prevention of sexually transmitted infection, particularly HIV, and the prevention of urinary tract infection. Many surgeons would also perform a circumcision during surgery for hypospadias. ParaphimosisParaphimosis occurs when the foreskin is not pulled back over the glans after retraction. A tight constricting band ensues, causing swelling of the distal penis and acute discomfort (see fig A on bmj.com). Reduction under local or general anaesthesia is nearly always possible with several minimally invasive methods; a literature review that included the Cochrane database...

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