Circumcision—The Debates Goes On

To the Editor.
The AAP circumcision policy in the March issue ofPediatrics still leaves me with the following questions concerning foreskin and penile hygiene.
What active interventions are recommended to ensure eventual retraction of the foreskin, if indeed such retraction is necessary for intercourse and reproduction? I understand that the production of smegma dissects free the foreskin's adhered epithelial layers over time. Does this process require the help of a caretaker's increasingly vigorous attempts to roll back the foreskin or does the genital play of the infant or masturbation of the older child assist the process? Does the 7-year-old with a long, adhered foreskin and no symptoms require surgical release of these adhesions? I've heard it rumored that “popping” the glans free of the adhered foreskin is a father-son “ritual” in some cultures. It used to be a pediatrician-patient ritual in ours. Finally, even after circumcision, the cut foreskin often readheres to the corona of the glans. One can see pearls of smegma accumulated under the adhesions. Should this rim of adhesions be manually lysed followed by application of antibiotic ointment or perhaps premarin cream, as pediatricians who lyse female labia minora adhesions have done for years (another questionable practice). Does this cause or prevent senechial adhesions between foreskin and glans?
What is meant by penile hygiene? Does this imply rolling back the easily retractable foreskin for a soap and water wash to remove smegma and bacteria, then replacing it to physiologic position? Should the washwater be dried from the glans? Is it possible, teleologically, that smegma by pH or bacteriostatic function has a protective function and normal sterile urine cleanses the redundant foreskin? We recommend against vaginal douching and know the pH of cerumen seems to prevent otitis externa. The AAP statement does not support smegma as carcinogenic, …
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