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Rabu, 16 Maret 2011
Female Circumcision: Indications and a New Technique
Circumcision of the female is not a new subject. Early writings testify that this problem was known and discussed by physicians of the Roman Empire. Bryk in 1935 compiled a comprehensive book on the history and practice of male and female circumcision. The 265 references abstracted in his text cover the circumcision of the female from the ancient Egyptian era (approximately 1500 B.C.) to the present day.The value of this procedure in improving function has been accepted by various cultures for the past 3,500 years.Although this subject is not new, there are indications for its use that are being overlooked by some modern physicians.
Indications for Circumcision
In general terms, the main indications for circumcision are: (1) functional need - lack of ability to have a climax or ability to have one only with considerable difficulty, (2) an anatomic or mechanical factor that needs correction.
When does this problem present itself and become our concern and responsibility as physicians? It is advisable to investigate sexual compatibility if unexplained symptoms of a psychosomatic type are elicited or if the problem of divorce is present. If there is no shyness or embarrassment on the doctor's part and his attitude is correct, the patient is seldom embarrassed. Often a patient appreciates being questioned on this subject because she had thought this might be her problem. If a patient is not sure that she has ever experienced a climax, it is probable that she has not.
Patients with psychosomatic illness and marital problems make up a good portion of all types of medical practice. If these problems are based on abnormal anatomy, and it is corrected, these patients are often permanently cured. This cure is explained by the common origin of the primitive urges and of the subconscious, from which psychosomatic illnesses develop.
Failure to elicit proper history and to examine patients carefully is illustrated by the following case. Mrs. B. G., age 34, had five divorces before coming to my office as a patient. She was found to have a rather severe redundancy and phimosis, and had never experienced a climax. After being circumcised, she remarried the last man she had divorced and has had no further sexual problem. She stated that she "wasted four perfectly good husbands." While having the five marriages and divorces, she had a great number of psychosomatic symptoms and illnesses. During this time she had been examined and treated by a number of physicians. None of them had told her of the severe phimosis and redundancy or suggested its correction. She has had no recurrence of psychosomatic illness since the circumcision five years ago. No tranquilizers, injections or other treatments were used.
A difficult phase of the problem is presented when the wife of a recurrent ulcer patient states, "What difference does it make that I do not enjoy sex life if I do not refuse my husband"?
In the earlier years of married life this form of prostitution is possibly not too harmful. A number of problems will probably develop in time however, because this practice is contrary to our instincts. If a man is legally married to a woman but not "mated" with her, one of four complications will probably develop: (1) a divorce, (2) another woman, (3) excessive use of alcohol or (4) suppression of normal urges with psychosomatic illness.
Two Common Abnormalities
The two common problems that make the highly sensitive area of the clitoris unable to be stimulated arephimosis and redundancy.Sebaceous glands about the clitoris attempt to prevent adhesions of the prepuce to it. This sometimes fails and the clitoris is tightly adherent to the prepuce. This defect is recorded as 1 plus or 25 per cent of the normal surface adherent, to 4 plus or complete coverage. A prepuce for the protection of the clitoris is normal and useful, butif it is excessive and extends past the eminence of clitoris it can prevent contact and is harmful.This excess is also classified from 1 to 4 plus. The greatest amount of redundant prepuce I have observed extended approximately one inch past the clitoris so that it is classified 4 plus. Thus, a 1 plus would represent approximately one-fourth inch of redundant tissue. Figure 5 represents a 3 plus redundancy.
In general, the greater the degree of phimosis or redundancy, the greater the probability of satisfactory result by its correction. A 3 or 4 plus phimosis or 3 or 4 plus redundancy could be the anatomic indication. A combination of a 2 plus redundancy and 2 plus phimosis, could be an indication as well. Two rather unusual conditions which could be indications are the hard fibrotic prepuce and the type in which the prepuce is stretched tightly across the glans. Routine circumcision because of a functional problem alone, without the proper anatomic indications, will probably be of no benefit and might be harmful.
The following situations would indicate the need for circumcision although less phimosis or redundancy is present.
1. If the patient is quite adipose, a circumcision could be indicated although she has less anatomic defect. Obstruction by the adjacent tissues adds to her problem. This operation may help cure her adiposity by relieving psychosomatic factors.
2. If the husband is unusually awkward or difficult to educate, one should at times make the clitoris easier to find.
3. If the clitoris is quite small and is difficult to contact, a circumcision might help by making it more accessible.
On the other hand, there are relative contraindications that make one more cautious and more selective in deciding to operate, for example:
1. Frigidity from psychologic causes, such as fear of pregnancy, early adverse training and experiences.
2. Incorrect attitude of patient or husband concerning desire to be helped, factors of abnormal jealousy, excessive psychoneurosis.
Percentage of Favorable Results
What percentage of favorable results can be expected when the previous indications are followed? To determine this percentage, a questionnaire (Figure 1) was sent to women whom I had circumcised within the past 15 years. One hundred twelve questionnaires were completed and returned. (Figure 2) gives the results obtained. A greater proportion of poor results occurred in early cases, giving evidence that my indications have improved. If cases are carefully selected, one should expect 85 to 90 per cent to show satisfactory improvement. This percentage could not be expected without adequate instructions to both the patient and her husband. When the anatomic problem is borderline, this instruction should be given before performing a circumcision in order to avoid unnecessary surgery.
FIGURE 1. Questionnaire Sent To PatientsPatient's Number ___________
This questionnaire will be used as the statistical basis for a medical report. Your name will not be used. Kindly check in blanks and mail in enclosed envelope.
Surgery: Circumcision done on _____________________________
1. Could you have an orgasm prior to surgery: Yes _____ No _____
If your answer is yes:
a. Were you improved? Yes _____ No _____
If your answer is no:
b. Are you able to have an orgasm now? Yes _____ No _____
The woman should be taught to develop voluntary control of the vaginal constrictor muscles. The judicious use of testosterone or stenedial to increase the sensitivity and size of the clitoris might be indicated.
Advice concerning the male and female "libido curve" (Kinsey report) often helps to relieve a common worry of young wives. The interest and cooperation of the patient might be stimulated by a few words expressing the fact that it is a privilege (not a duty) to enjoy one of the greatest physical pleasures.
FIGURE 2. Questionnaires Received: 112
73 had never experienced an orgasm:
9 Not Successful (12.4%)
64 Successful (87.6%)
39 had experienced an orgasm with difficulty:
5 Not Improved (12.5%)
34 improved (87.5%)
The husband must be instructed in female anatomy, proper body position, trituration. to develop desire, and such psychologic considerations as patience, atmosphere, kindness, affection, foreplay and other pointers suggested by his personality.
Instrument for Female Circumcision
figure 3: Jaws open
figure 4: Jaws closed
Technique of Circumcision
It seems that such a relatively minor procedure should not require much detailed description. However, the fear of scar tissue formation, bleeding and the lack of a descriptive technique in the usual surgery texts, might prevent some physicians from attempting it. A few lines will be devoted to my previous technique, then a more simplified technique will be described.
Allow two weeks before the next menstrual period. Give 3/4 gr. seconal one-half hour prior to surgery. Trilene inhalation makes the injection of 2 per cent Xylocaine or Nesacaine less painful. Most of the injection for adequate anesthesia can be made from one point, starting at the mid-line, about one inch anterior to the edge of the prepuce. The first injection is made three-eighths inch deep, to each side of the clitoris (Figure 5). Without removing the needle from the skin, the anesthetic is then injected subcutaneously to the base of the lateral attachment of the prepuce. The needle is then removed and injections are directed cephalad, as close as possible to the sides of the clitoris (Figure 6). This latter injection reduces the discomfort of separating the phimosis. The clitoris itself is not injected.
The prepuce is then freed with a blunt probe. More Trilene is occasionally needed at this time, but the rest of the surgery should be painless. The operative area is resterilized.
In the past, two long mosquito forceps were used to help perform the circumcision. They maintained the proper relationship of the internal and external skin layers and controlled the bleeding prior to suturing. Because the procedure was technically difficult and time consuming, I developed a clamp to be used for the procedure
Clamp for Procedure
This instrument is seen with jaws open Figure 4 and closed in Figure 3. It is simply a "vice-grip" pliers with strong, specially designed jaws for this procedure. After opening, the lower triangular plate or jaw (which is not perforated), is placed under the prepuce and the jaws are partially closed. A tooth thumb forceps is then used to reach through the hole in the upper jaw and pull the desired amount of prepuce into the clamp (Figure 7). The adjusting screw on the handle of the pliers can be turned to adjust for the various thicknesses of prepuce before the pliers are clamped. The cam action not only exerts adequate pressure to compress the tissues at the narrow lower edge of the upper jaw, but also sets itself so that no more force is needed by the operator.
After a lapse of five minutes, the surgeon uses a scalpel to excise the prepuce within the upper jaw, being careful to stay close to the inner wall of the clamp (Figure 8). After the triangular piece of excised prepuce is removed, only the lower blade can be seen (Figure 9). The jaws are then opened and the clamp removed. On a thin prepuce, sutures are not necessary (Figure 10). When there is a doubt whether they are needed, however, the edge is reinforced with a few 5-0 plain catgut sutures on an atraumatic needle. This technique is extremely simple, accurate and bloodless. It has given excellent results because of the reduced healing time and absence of sear tissue. Postoperative Treatment
To prevent recurrence of the phimosis until the raw surfaces are healed, a special preparation is applied to these surfaces after surgery. This is a wax containing Benzocaine 5 per cent and Terramycin 3 per cent. This preparation is heated to the melting point in its containing tube before being used.
The patient is seen every two or three days for the purpose of keeping the adhesions free. Empirin and codeine, or Percodan, is given for postoperative discomfort. If the surgery is done on Friday morning, the patient can return to work on Monday. Complete recovery requires approximately ten to 14 days.