View Full Version : How long would you wait?
No one seems to disagree with circumcision if it is due to medical reasons.
I understand that the vast majority of uncircumcised boys will not have a problem. But there are those few unfortunate boys that don't get it so easy.
According to JohnC, approximately 2% of uncircumcised boys will ultimately require a circumcision due to medical reasons.
If you happened to be the parent of one of these unfortunate boys, how long would you wait before you finally made the decision (with your doctor) for your boy to get him circumcised?
I will just make up a random scenario (some mothers that have gone through it may be able to help out here). Please forgive me if it seems too unrealistic.
Your boy is 18months old. He is getting infections despite your best attempts at (and teaching him) hygiene. Each time it lasts 3-4 days, during which period he has pain and discomfort, which you deem serious enough that you see the doctor.
This begins happening each month. How long would you wait? How long could you handle watching your boy in pain?
Personally. I think the first one I would let go, and get some good tips on preventative measures from the doctor. After the second time though - I would ask the question about circumcision. If the doctor agreed that it will stop the problem, I would get it done.
Fuchsia!
27-10-2009, 16:33
i would try everything possible, including alternitive options before even considering it.
Not sure how long i would wait, but it would probably be a long time to exhust all options.
i agree with jaxcoop, even though DS is circd, if i had a DS who wasn't i would exhaust all possible measures and research as much as possible before putting an 18 month old through a circ ... yes double standards I know
i would exhaust all possible measures and research as much as possible before putting an 18 month old through a circYes. I would expect that everyone would. But how long would your son being in pain be too long? How many visits to the doctor would be one too many?
maybe if the infections and doctors visits became a weekly thing?
i think any amount of time my son would be in pain is too long, but to consider surgery ... i don't know, i think i would have to be in the situation to make an appropriate judgement
RedPanda
27-10-2009, 17:50
I had tonsilitis six times a year as a child. It took the doctors about six years to agree to remove them (tonsillectomies are majorly frowned on these days - tonsils are seen to have a function and most surgeons are reluctant to remove them unless you've had years of issues). I'm wondering whether most doctors would be reluctant to operate on a child that young also?
I don't know what I'd do. I've got two boys and the only UTIs in this house have been mine. I'd seek lots of medical advice, but if there's a medical problem then a medical remedy is probably needed. I'd probably do it at two years of age (isn't that when GAs aren't considered as dangerous?).
As long as the foreskin is not forcibly retracted by misinformed parents or doctors, the likelihood of a medically required circumcision in a pre-school boy is exceedingly slight.
Much depends on prevailing medical practice guidelines. In Denmark the total lifetime risk of circumcision is < 2%, which is obviously much less than the estimates I gave based on current practice here.
It is indeed a bit like the tonsil question. The more parents and doctors recognise the intrinsic value of the foreskin, the more likely they are to opt for medical rather than surgical remedies. Prior to the introduction of RIC, circumcision was only considered for irretrievably diseased tissue resulting from trauma or obscure dermatological conditions.
sockstealingpoltergeist
27-10-2009, 18:15
This kind of scenario happened to my nephew (I have two nephews one circ'd at birth who is now 16, one who is 9, who is uncirc'd).
The Dr prescribed cream and salt baths, and they cleared up quickly. He has now outgrown in it and has an intact penis.:) Luckily my sister saw a Dr who thought there was to much unnecessary circing going on, and to many Dr's jumping the gun. I have to say I agree.
If my child was in the scenario you outlined, I would exhaust every opportunity, I would research as much as I could, I would consult numerous doctors and would not have any part of my child removed without at least three doctor's opinions all agreeing on the same treatment.
The Dr prescribed cream and salt baths, and they cleared up quickly. He has now outgrown in it
That's great. He obviously wasn't one of the 2% then and doesn't align with this scenario. You visit the doctor, but yet again, the problem comes back in a month.
How many days would you sit back watching your boy in pain (researching and getting third opinions) before you finally made the decision?
Would you let you boy suffer repeatedly for a year? 2 years? 3 years? How long would be enough for you?
Opinionated
27-10-2009, 20:05
At 18months, with a child getting repeat infections, I would be stopping all day care and any situations where they were out of my care to see if they were caused by something a lot more sinister than a foreskin.
Most foreskins don't retract at this age anyway so repreated infection would likely be caused by forced retraction, or some sort of abuse.
My niece had recurrent infections at 3 (about 8 in 6 months). Her parents fully investigated the cause and found it was because they only have a shower at their house and she wasn't washing inside the folds well enough. They treated the infections, added a couple of supplements into her diet, and put a little washbasin for her to sit in inside their shower. They haven't had any further trouble. Not once was it suggested that circumcision would be a good remedy, that would be ridiculous. Surgical amputation of a body part is a pretty extreme treatment for infection.
There would have to be no other option for me to submit a child to have a part of their genitals removed. It would have to be extreme. I don't think your example is. I think it could be managed with a host of interventions, some of which many people would consider after they consider circumcision. Me, I would consider them first.
Mrs Nietzsche
27-10-2009, 20:12
I would be wondering what I was doing wrong re environment, health and hygiene that my child was getting such recurrent infections. To me, such a pattern would indicate a need for an environmental, and not a bodily, modification.
In the event there was some kind of deformity or malformation that was causing this scenario, then I would be guided by informed medical advice (re surgical options)
At 18months, with a child getting repeat infections, I would be stopping all day care and any situations where they were out of my care to see if they were caused by something a lot more sinister than a foreskin.
Most foreskins don't retract at this age anyway so repreated infection would likely be caused by forced retraction, or some sort of abuse.
My niece had recurrent infections at 3 (about 8 in 6 months). Her parents fully investigated the cause and found it was because they only have a shower at their house and she wasn't washing inside the folds well enough. They treated the infections, added a couple of supplements into her diet, and put a little washbasin for her to sit in inside their shower. They haven't had any further trouble. Not once was it suggested that circumcision would be a good remedy, that would be ridiculous. Surgical amputation of a body part is a pretty extreme treatment for infection.
There would have to be no other option for me to submit a child to have a part of their genitals removed. It would have to be extreme. I don't think your example is. I think it could be managed with a host of interventions, some of which many people would consider after they consider circumcision. Me, I would consider them first.
I'm just going to be lazy and say :iagree:
It would have to be extreme. I don't think your example is.
Ok Opinionated. Can you please tell me what problem would be extreme enough for it to warrant you to make the circumcision decision?
Or do you think there is never a medical justification for a circumcision?
That's great. He obviously wasn't one of the 2% then ...
Wrong. It is likely that many of boys with recurrent balanitis who are currently circumcised could in fact be dealt with by appropriate medical treatment.
However, your main question should perhaps be answered in more detail.
There are two scenarios, often conflated under the heading of "infections".
Recurrent UTI. In this case a referral should be sought to a paediatric urologist. Such cases are almost always the result of some congenital abnormality, most often vesico-ureteric reflux, which needs to be determined. Most cases resolve spontaneously, but some may require surgery. They are not foreskin related but some doctors may recommend circumcision nonetheless.
Recurrent balanoposthitis. There seems to be a variety of practices by primary care providers, some of which are not helpful, to say the least. Should a boy suffer regular bouts for no apparent reason then I would recommend a culture (or biopsy) to determine the infective organism. Treatment for fungal infection will likely worsen a bacterial infection, and vice versa. Again, a paediatric urologist is one's best port of call, since it may be that the underlying cause could be something like diabetes or one of the more obscure conditions that GP will know little or nothing about. Again, some doctors will be more inclined to recommend circumcision than others.
There is no single answer, and like recurrent tonsil or appendix inflammation (both of which are generally much more painful for the child), the best a parent can do is try to get the best advice possible and from multiple practitioners if that seems necessary.
It is likely that many of boys with recurrent balanitis who are currently circumcised could in fact be dealt with by appropriate medical treatment.
Do you agree John that there are cases that cannot be treated any other way? I don't care about the numbers here, are there cases where circumcision is the only cure?
Opinionated
27-10-2009, 20:33
Ok Opinionated. Can you please tell me what problem would be extreme enough for it to warrant you to make the circumcision decision?
Or do you think there is never a medical justification for a circumcision?
Extreme to me would mean that I had consulted a pediatrician, a urologist and had a multitude of pathology tests done. My child would never be out of my care so I could guarantee it was not caused by abuse. I would stop using detergents on bedding and clothing that touched the area, stopped the use of any soaps/shampoos/toilet tissue/ wipes/ creams and any other product that could aggravate the area. I would consult a natropath and look into dietry changes including adding in more good bacteria (eg inner health plus) into the diet as well as things that support the urinary tract like cranberry. After bathtime, I would sit my child in a basin of salt water for a few minutes, dry the area and perhaps apply an antibacterial/antifungal/steroid cream as directed by my doctor.
If after doing all of that, if we were still having repeated problems 9-12 months later I would consider circumcision. Even then, I would be looking into circumcision a lot more in depth than getting a referral from someone on here. I personally don't think the plastibell method is the way to go, and would be looking for one that was less radical.
Happy Father? I do actually know about circ you know. Why don't you go crazy and actually post in a thread about another topic. Doesn't your interest in parenting go any further than circumcision? Every one of your posts is in this part of the forum. Is your name actually Terry Russell?
Do you agree John that there are cases that cannot be treated any other way? I don't care about the numbers here, are there cases where circumcision is the only cure?
The only absolute indication is lichen sclerosis atrophica (also known as BXO). Some people will argue for conservative therapy there as well, but my view is that in confirmed cases circumcision is the preferred treatment, if only to avoid urethral involvement.
Best estimate is this will affect 0.5% of boys up to age of puberty, after which incidence seems to drop. Treatment modalities are probably more flexible in adults. The condition is substantially more common in females.
WorkingClassMum
27-10-2009, 20:45
If my 18 month old had one UTI - I'd treat it as per advised by the GP.
If he had one 6 months later - then I'd also just treat it as per the GP.
If he had one every 6 weeks or 6 days, I'd want it investigated closer.
If after investigation, swabs/tests, a 2nd opinion and all other lifestyle changes didn't fix it with in a reasonable period (say a couple of months) then I would get DS circ's if that's what the professional opinion was.
Even then, I would be looking into circumcision a lot more in depth than getting a referral from someone on here. I personally don't think the plastibell method is the way to go, and would be looking for one that was less radical.
I don't believe any surgeon in Australia would perform a medically required circumcision with a Plastibell.
The device is only used for routine (ie cosmetic) circumcisions on children, and in the vast majority of cases by doctors who are not surgically qualified (such as Terry Russell) , and in the absence of a suitably trained anaesthetist.
sockstealingpoltergeist
27-10-2009, 21:30
That's great. He obviously wasn't one of the 2% then and doesn't align with this scenario. You visit the doctor, but yet again, the problem comes back in a month.
How many days would you sit back watching your boy in pain (researching and getting third opinions) before you finally made the decision?
Would you let you boy suffer repeatedly for a year? 2 years? 3 years? How long would be enough for you?
He could very well have been in the 2%. I believe to many circs are performed due to improper care and advice and because lots of Dr's recommend foreskin retraction when there is no need.
Why would that have to be the scenario, it isn't very realistic and I know of no child who has had that type of pain or problem.
MummaBear03
27-10-2009, 21:46
I'd rather be the parent of one of the 2% of children who *may* need surgery, if no other method worked, than to be a parent who subjected their child to surgery without any medical reason.
Why would that have to be the scenario, it isn't very relistic and I know of no child who has had that type of pain or problem.
Doesn't have to be realistic. If I read Father's position correctly, it's that any possibility of a future foreskin problem -- however remote -- justifies surgical removal as soon as possible after birth.
The problem with that position is that if we applied this consistently there would nothing left of our newborns after the surgeons finished removing all the potential problem parts.
Pippi Longstocking
28-10-2009, 06:53
I would address the problem holistically rather than immediately leap to the most radical position of surgery.
As others have said, first I would want to know why my 18 month old child was suffering from repeat infections. I understand that the majority of 'medically indicated' circumcisions are due to human error rather than inherent biologically deficiencies. I would want to make sure no one was attempting to retract his foreskin, in any way at all.
A few others used the tonsils analogy, and I will too because it is the most apt. My daughter suffered from extensive ENT problems. Recurrent ear infections, endless bouts of tonsillitis, chest infections and pneumonia resulting in a collapsed lung. This all began when she was 4 months old. She had her first surgery at 4 years, after we had exhausted all other options. This surgery was to insert grommets and remove adenoids - her adenoids were not healthy, they were hugely enlarged and causing an obstruction. Her second surgery was to reinsert grommets and....remove her freaky re-growing adenoids again (I wish little guys could regrow their foreskins like that!). Only after both these procedures did we even consider removing her tonsils and this wasn't done until she was 6 years old. We recognised that her tonsils were an important and useful part of her anatomy, and therefore worth doing everything we possibly could to protect them. I would do the same for a foreskin, leaving surgery as a last resort.
This scenario alludes to why I think your scenario is somewhat flawed. If all parents took this holistic approach and endeavoured to do all they could before resorting to circumcision, your figure of 2% would be far far smaller.
serendipity22
28-10-2009, 22:35
In the USA where most doctors are circumcised and doctors are taught little about the foreskin, circumcision tends to be suggested at the first sign of any problem (even if its imaginary, frequently normal development has been mistaken for pathology.)
In countries such as Australia where circ was recently widespread circ is suggested less but more than the UK where circ went out of fashion in the late 1940s.
Nonetheless UK doctors can still be gung-ho about circing for medical reasons compared to say Scandanavia where circ never took off.
Circumcision is really a very unimaginative approach (and mentally lazy). Another way of looking at it, the greater the skill of the doctor the less likely they are to advocate circ.
I see the tonsillectomy analogy has been raised again. There is definately a connection with that in regard to the scenario that I mentioned as it deals with recurring problems.
Forgive me for my lack of knowledge on the tonsils. I have just done a small amount of reading, so feel free to correct me if I'm wrong at any stage. (I am not a doctor ie. Dr Russell:))
From Pippi:
We recognised that her tonsils were an important and useful part of her anatomy
From http://www.pedisurg.com/PtEducENT/tonsils.htm
Since we generally consider antibody production to be a good thing, many studies have been performed to try to clarify the importance of the tonsils. There seems to be no adverse effect on the immune status or health of patients who have had them removed. Any noticable effect has generally been positive.
Sorry for the source, but it was one of the first pages I read.
This was backed up by an Australian ENT surgeon.
http://www.australiandoctor.com.au/news/62/0c017d62.asp
What is also interesting from that site is that there is also a definition of 'recurrent acute tonsillitis'.
Tonsillectomy is also indicated for recurrent acute tonsillitis, defined by the American Academy of Otolaryngology as:
Seven episodes in one year.
Five episodes a year for two consecutive years.
Three episodes a year for three consecutive years.
It does also appear to be more risky.
Adenotonsillectomy has a 10% risk of complications and between 1:16,000 and 1:20,000 risk of death.
Another random link.
http://www.wisegeek.com/why-do-we-have-tonsils.htm
I would like to read something more 'official' about the tonsillectomy argument, if anyone has any more information.
Would 7 episodes of Recurrent balanoposthitis be enough to make the decision?
Or 3 episodes a year for 3 years?
It seems that it is enough for a decision to be made about the tonsils - even though the procedure is alot more risky.
Any thoughts?
I would weigh up the risks both ways before making any dicision. I would give it the same consideration as I hve with every surgery my DD has had after all it is stil an operation and with operation comes risk. I wouldnt have my child go through a tonsilectomy for a few bouts of tonsilitus so I also wouldnt get my child circed for a couple of UTI that may or may not be caused by not being circed. If we are talkign topical infection on the skin they would be treated with topical oitments be is bactroban or clorsig depedning on the bug. I would also but some antibacterial wash ( obstetrics wash) in the bath just like I do for DD becuase of her stoma infections.
I certainly wouldnt jump at surgery with out treating the same consideration that has gone into DDs 10 or so surgerys. If there was no other way then I would consent to surgery.
sockstealingpoltergeist
28-10-2009, 23:42
I see the tonsillectomy analogy has been raised again. There is definately a connection with that in regard to the scenario that I mentioned as it deals with recurring problems.
Forgive me for my lack of knowledge on the tonsils. I have just done a small amount of reading, so feel free to correct me if I'm wrong at any stage. (I am not a doctor ie. Dr Russell:))
From Pippi:
From http://www.pedisurg.com/PtEducENT/tonsils.htm
Sorry for the source, but it was one of the first pages I read.
This was backed up by an Australian ENT surgeon.
http://www.australiandoctor.com.au/news/62/0c017d62.asp
What is also interesting from that site is that there is also a definition of 'recurrent acute tonsillitis'.
It does also appear to be more risky.
Another random link.
http://www.wisegeek.com/why-do-we-have-tonsils.htm
I would like to read something more 'official' about the tonsillectomy argument, if anyone has any more information.
Would 7 episodes of Recurrent balanoposthitis be enough to make the decision?
Or 3 episodes a year for 3 years?
It seems that it is enough for a decision to be made about the tonsils - even though the procedure is alot more risky.
Any thoughts?
I had my tonsils out, only after having tonsilitus 13 times in one year. (As an adult). They seem to like to wait and see if things will turn around for you before taking out the tonsils. I had been getting tonsilitus since I was a child.
More on the tonsils thing.
The RACP seems to think we are not doing enough adenotonsillectomys:
Australian and New Zealand Experience: Present data suggests that only 0.3 - 0.7 per cent of children aged 0-9 years currently undergo adenotonsillectomy. Even if one accepts that the present epidemiology data may be over-estimating the incidence of
OSA in children, the incidence of adenotonsillectomy in Australia and New Zealand for this indication alone is significantly below that expected. The above analysis suggests that only 1 in 7-10 children who could benefit from adenotonsillectomy is
being treated.
In Australia this difference is particularly marked within the public health system. The
present overall adenotonsillectomy rate is approximately 3 - 7 per thousand, but
within the public health systems of both countries it is less than 4 per thousand. The
best epidemiological data suggests that the figure should be closer to 20 - 30 per
thousand.
http://www.racp.edu.au/download.cfm?DownloadFile=9593A506-C9B1-B386-B8A70A8697244B9F
sockstealingpoltergeist
29-10-2009, 00:00
More on the tonsils thing.
The RACP seems to think we are not doing enough adenotonsillectomys:
http://www.racp.edu.au/download.cfm?DownloadFile=9593A506-C9B1-B386-B8A70A8697244B9F
Well they would know what they are talking about, and if they recommend more adenotonsillectomys, and no RIC, then I'd be inclined to believe them.:)
More on the tonsils thing.
The RACP seems to think we are not doing enough adenotonsillectomys:
http://www.racp.edu.au/download.cfm?DownloadFile=9593A506-C9B1-B386-B8A70A8697244B9F
Yes and some people are just scalpol happy, Before having ANY surgery done on a child there needs to be proof that it needs to be done, Now if a child need there T and As out any dr worth there weight would do the proper investigations first includeinga postnasal scope, and a sleep study to determine the levels of o2 sats in teh blood while they are sleeping ( as sleep is the time that the levels ar mostly affected) if there are little or no desats in teh o2 levels then they may not need to be removed. If the tonsils getting infected poses a resp risk due to swelling to obsctuting the tracea then of course surgery would likely be needed, however if it is the case of a sore throat and needing some oral ABs then unless that is a regular occurance the risks of a tonsilectomy may wel and truely out weigh the risks of needing oral Abs once in a blue moon.
Each case with ANY surgery needs to be assesed on its own merits I am no more anti med needed circ then I am anti Gastrostomy, or anti tonsilectomy or what ever surgery you wish to compare it too, but I beleive that every single surgery needs to be looked at at every angle before the child goes into the OR and on a vent and cut open.
I dont see what the obsesion with circumsition is on this site lately i really dont its an operation there should be no for and against its crazy.
Opinionated
29-10-2009, 00:21
Well they would know what they are talking about, and if they recommend more adenotonsillectomys, and no RIC, then I'd be inclined to believe them.:)
Father, surely you saw that coming quoting the RACP:)
Pippi Longstocking
29-10-2009, 07:53
Would 7 episodes of Recurrent balanoposthitis be enough to make the decision?
Or 3 episodes a year for 3 years?
Father, I think you kinda missed the point...
It seems that it is enough for a decision to be made about the tonsils - even though the procedure is alot more risky.
Any thoughts? It's not a matter of simply counting the number of infections and then going in to operate. To have missed all of what I said in my post and come to that conclusion is indicative of your unwillingness to actually hear what I'm saying.
Once again, I would be more concerned with the causes of the infections rather than simply counting them. I would attempt to discover and address those causes. I would exhaust all possible avenues before resorting to permanent, body-altering surgery. I would never, ever ever go straight to surgery, especially not prior to healthy body parts 'just in case!' That goes for tonsils, foreskins, breast-buds, teeth, fingers....
Also, only one of my children has had their tonsils removed. Should I have had the others done too so they wouldn't be different? ;)
MummaBear03
29-10-2009, 09:06
Father, I think you kinda missed the point...
It's not a matter of simply counting the number of infections and then going in to operate. To have missed all of what I said in my post and come to that conclusion is indicative of your unwillingness to actually hear what I'm saying.
Once again, I would be more concerned with the causes of the infections rather than simply counting them. I would attempt to discover and address those causes. I would exhaust all possible avenues before resorting to permanent, body-altering surgery. I would never, ever ever go straight to surgery, especially not prior to healthy body parts 'just in case!' That goes for tonsils, foreskins, breast-buds, teeth, fingers....
Also, only one of my children has had their tonsils removed. Should I have had the others done too so they wouldn't be different? ;)
Out of all 3 of us (between me and my brothers) only 1 has had his tonsils out. I get tonsilitis often, it knocks me around for a day or so but does not need medication very often to fix it, it often just runs its course and is done with. My older brother did not get it very much, maybe once every 3 to 4 years, but when he got it, it would take at least 3 courses of anti-biotics to clear it up. It was investigated further and decided (when he was 25) that it's best for the tonsils to come out. My younger brother and myself still have ours.
My older brother was also prone to ear infections, but there was never any discussion of amputation ;)
Pippi Longstocking
29-10-2009, 09:16
It sucks eh? I used to get tonsillitis too. I once had it so bad I developed quinsy (http://en.wikipedia.org/wiki/Peritonsillar_abscess) resulting in hospitalisation, lots of morphine and a horrendously large needle shoved down my gob to drain it. Poor me. :crying: It was horrid.
I still have my tonsils. :cool: Using my aforementioned holistic approach, I wanted to know what was causing the problem to begin with. Turned out it was actually related to dental issues. I haven't had tonsillitis for about three years now - ever since I went to the dentist.
Infection and inflammation is usually caused by -something-, rather than the organ/body part being inherently flawed. I think it's a good idea to discover the cause and treat that, rather than simply lopping off the offending body part - particularly so if we do not own said body part. We have a responsibility to our children to do all we can to keep them intact so that they can choose which bits they wanna keep and which they're happy to have removed.
Infection and inflammation is usually caused by -something-, rather than the organ/body part being inherently flawed. I think it's a good idea to discover the cause and treat that ...
I think that hits the nail on the head :yelclap:
It's called differential diagnosis and, to quote Wikipedia, "is the process whereby a given condition or circumstance, called the presenting problem or chief complaint, is examined in terms of underlying causal factors and concurrent phenomena ..." (bolding added)
This is why Father's framing of question is flawed -- it's ignorant of how correct medical practice should work. There is no magic number of infections, for either tonsils or foreskins, at which point one pulls the surgery trigger.
An anecdote, hopefully illustrative.
A few years ago I was PMed by a member here about her 3yo who had persistent irritation. They had been to the doctor several times who had prescibed a steroid-antibiotic cream and suggested full retraction be attempted over time. :eek:
I messaged back a series of simple questions to determine what the boy does and what he is exposed to. What stood out in the reply was his spending several hours a day in the backyard sandpit.
I suggested that next time he goes to urinate, the foreskin be lightly and briefly pinched until it balloons and then released. Repeat for a couple of days.
Problem solved within three days, never to return, apparently. Cream in trash can.
This did not require Einsteinian insight. But both myself and my boys happen to be happy owners of foreskins and certain things are just common sense if they are part of your everyday life. Familiarity breeds content ;)
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