Health: A campaign to save the foreskin: As some doctors attack the 'rape' of the penis, surgeons are offering an alternative to circumcision with fewer side-effects. Denise Winn reports

'NO OTHER part of the body has aroused so much passion and misconception . . . Americans want to get rid of it for hygienic reasons . . . Latins love to play with it, like to keep it and are taught to mobilise it often; the British would like to ignore it, not to touch it, and eventually get rid of it when it causes too much trouble.'

So began a recent letter to the British Medical Journal, on the much maligned subject of the foreskin - or prepuce, as it is properly known.

It is more than 40 years since circumcision, the surgical removal of the foreskin, was carried out in any way routinely in Britain, on the largely discredited grounds that doing so improved hygiene. Yet circumcision is still one of the most common operations carried out on boys under 15, with 6 to 7 per cent undergoing surgery.

Not counting circumcision carried out on newborn babies for religious reasons, and those done privately, around 21,000 operations are performed every year in England and Wales on boys in this age group.

Some specialists estimate that two-thirds of these operations are unnecessary. The foreskin is often removed when it has failed to retract from the glans, or tip of the penis, or where the area beneath becomes infected. Mr David Frank, consultant paediatric urologist at the Bristol Hospital for Sick Children, says that neither of these conditions makes circumcision inevitable.

'An awful lot of people don't realise that the foreskin doesn't necessarily retract in young boys,' he argues. 'Or that a few episodes of infection won't lead to problems.' Only 1 per cent of boys will need circumcision for a foreskin that permanently fails to retract; an additional 1 per cent, at the most, will require the cut because of recurrent infections.

A less drastic operation has now been developed by doctors at Addenbrooke's Hospital, Cambridge. The new procedure is a method of retracting the foreskin that doctors believe could reduce the number of unnecessary circumcisions.

Not a great deal is known about the normal foreskin by your average GP, not least because little has been written about it; but there do exist two important pieces of research. In 1949 Dr Douglas Gairdner, a paediatrician at Addenbrooke's Hospital, pointed out that by the age of three, only 10 per cent of boys had retractable foreskins. In 1968 a Danish doctor who followed up 2,000 five-year-old uncircumcised boys reported that only one did not have a retractable foreskin by the age of 17.

Specialists now accept that while the majority of boys can retract by the age of five, there is nothing abnormal about not being able to do so until their teens. In most boys retraction occurs naturally, without need of aid from owner, parent or paediatrician. Only 1 per cent of boys under 15 will need circumcision for a foreskin that permanently fails to retract from the glans; an additional 1 per cent, at the most, will require the cut because of recurrent infections.

Yet a great many GPs still refer boys to urologists for possible circumcision inappropriately. A recent survey of 120 GP referrals to the Bristol Hospital for Sick Children revealed that only a quarter of the boys genuinely required surgery. Apart from non-retraction, the GPs referred for infections under the foreskin that cause soreness on urinating; and for 'ballooning', a condition in which urine under the foreskin makes it swell up. Both are often thought to be caused by a too tight foreskin.

Mr Frank, however, points out that small children often experience episodes of infection but that this does not make circumcision necessary. 'Usually it happens in children aged one to three and they might have two or three attacks over a couple of years. Then the problems stop. It is not uncommon to get infections but still have a normal foreskin.'

Specialists now believe that the only medical reason for performing circumcision is a 'true' phimosis. Phimosis, literally, means 'muzzling' and is often used by doctors to describe any foreskin that cannot be retracted to reveal the glans of the penis. A true phimosis, however, is a condition in which the tip of the foreskin becomes so scarred that it permanently loses the capacity to retract. A common cause is an inflammatory disease, balanitis xerotica obliterans (BXO). What causes BXO is unknown.

A true phimosis is so rare in boys under five that one large children's hospital offers surgeons a pounds 10 prize for each one diagnosed - the prize has been collected only twice in 10 years. Yet about half of all circumcisions are described as being carried out for phimosis.

After being referred by a GP, most boys will see a relatively junior doctor when they attend the out-patients' clinic. Most circumcisions are not performed by very experienced doctors: the operation is one of the first to be carried out by junior surgeons, often without supervision.

Unfortunately, although the operation is minor, complications are not negligible. A study from Southampton of 99 boys who were circumcised revealed that 46 per cent vomited afterwards, 36 per cent bled slightly and 26 had to avoid wearing pants for seven days. Healing took on average 10 days, but more than 14 days in nearly a quarter of cases. Four children had to be readmitted for complications. As the authors of the study published in European Urology pointed out: 'All the operations were performed by an experienced surgeon, either the consultant, senior registrar or post-fellowship registrar. One might expect the morbidity to be higher in more junior hands.'

Other possible but not unknown complications include accidental amputation of the glans; damage to the urethra so that urine emerges from the side of the penis, not the tip; and disastrous cosmetic results. Up to 6 per cent of boys suffer bleeding from the artery that runs underneath the penis.

Because complications are frequent, even if not severe, and because repeated infections are unpleasant, urologists at Addenbrooke's Hospital now recommend an alternative to circumcision, in cases where there is no true phimosis. The procedure, preputial plasty, can be carried out safely even by inexperienced surgeons.

'We can widen a foreskin that is tight by pushing the glans through it, under general anaesthetic, then cutting the tight band longitudinally at the tip to widen the foreskin. It takes five minutes. Because the foreskin can be mobilised afterwards, hygiene can be better,' explains Mr Peter Cuckow, research registrar in urology and paediatric surgery.

For 50 boys aged three to 12 who underwent preputial plasty at Addenbrooke's, early post-operative complications were negligible, whereas three of a comparison 50 who were circumcised needed another operation for haemorrhage. Only three of the first group felt any discomfort afterwards, compared with just under half of the circumcised boys. Most of the parents thought their son's penis looked normal after preputial plasty and did not notice the slight scarring caused by the surgery.

'Some urologists would say that unless you need to operate, you shouldn't,' says Mr Cuckow. 'But we feel that, as a lot of circumcisions are carried out because of recurrent infections, parental pressure or misunderstandings about what is a normal foreskin, a more minor procedure is preferable and, in the case of bothersome recurrent infections, definitely helpful. It certainly enables many more foreskins to be saved.'

Mr Frank is one doctor who will not opt for this compromise. His preference is to see doctors educated to recognise a true phimosis and to avoid any kind of surgery unless this is present. 'Perhaps if this is achieved, the 'rape' of the phallus will be increasingly recognised as an unnecessary and traumatic procedure for the majority of boys,' he says.