Circumcision
Circumcision or "tuli" is a surgical procedure where some or all of the skin covering the tip of the penis, called the “prepuce”, is surgically removed to expose the head of the penis. It is the most commonly performed urology surgery in the world. ​
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While "tuli" is an important part of Filipino culture, it is also a surgical procedure with its own risks and benefits. Read on for some frequently asked questions about circumcision.
You may also find helpful our section on foreskin problems to know if your child need a circumcision.
What are the benefits of circumcision?
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The penis becomes easier to clean because it exposes the "glans" or head, which helps reduce the risk of infection
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There is decreased risk of later HIV infection
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Partial protection against some sexually transmitted infections
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Decreased risk of urinary tract infection in young boys (especially those at higher risk for UTI because of other reasons)
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Reduced risk for inflammatory conditions of the foreskin or prepuce and glans (posthitis and balanitis)
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Protective against invasive penile cancer
What are the risks of circumcision?
Circumcision is a relatively safe procedure when performed properly. However, there is still a risk of complications:
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Bleeding
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Infection
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Scarring
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Not enough prepuce removed
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Other rare complications
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Some parents are worried that circumcision will affect future sexual function or penis sensitivity. While this is a valid concern, existing evidence does not support this, and parents and patients are encouraged to speak with their urologists or surgeons on an individual basis to be able to discuss this further.
Is circumcision actually necessary?
Generally, circumcision is not medicaly necessary*.
Parents may choose to have their kids circumcised because of the medical benefits of circumcision, or due to cultural or social reasons. However, it is not universally recommended and the decision should be made in partnership with your doctor or health professional.
*In some patients, circumcision is necessary for other reasons. Boys with phimosis (where the foreskin cannot be retracted); paraphimosis (when the foreskin constricts the tip of the penis while it is retracted); recurrent urinary tract infections; and other conditions may need circumcision for medical reasons.
"Supot" and other slurs
Filipinos often consider circumcision to be a rite of passage.
Uncircumcised school-age boys may experience a lot of pressure and may be called names like “supot!”.
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But because circumcision is not universally recommended, boys and men should not be criticized or pressured to be circumcised if they are not willing or ready.
Who should not be circumcised?
Some patients should not have routine circumcision, and should be referred for specialist care instead:
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patients with more complex urologic problems, like abnormal placement of the urethral opening (hypospadias or epispadias) or a webbed penis
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Very premature infants
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Patients with history of bleeding problems
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Other congenital anomalies
At what age can an elective (not medically necessary) circumcision be offered?
It is commonly performed in newborns and young infants…
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maximizes benefits offered by circumcision
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has lower risk of side effects at this age and may not need a general anesthetic
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…But can be done at any age.
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Parents of older children are encouraged to schedule it when the patient is ready and able to assent.
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overly anxious children may not be able to handle the procedure under local anesthetic and may require general anesthesia.
What "cut" is the best?
There are many different techniques for circumcision, and some terms like "German cut" and "ordinary cut" have been popularized among Filipinos.
It may be easier to consider two broad types--the basic dorsal slit and those techniques that require actual cutting off of the foreskin.
Making a dorsal slit on a model penis.
Image source here.
The simple dorsal slit involves making a cut on the foreskin to expose the head, and sewing the skin edges together.
Technically this is not really a "circumcision" since there is no skin removed, but this is the most common type of "tuli" that Filipinos undergo.
It is also the usual type of circumcision done by non-urologists and non-surgeons in medical missions and circumcision drives, which are popular during the summer.
The pros:​
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It is a very short procedure, typically over in a few minutes.
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​Because there is no cutting of the skin, the swelling and bleeding are also typically less.
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It can be done in lower-resource areas and with less anesthetic.
The cons:​
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While long-term appearance is usually quite acceptable, many parents and patients may be bothered by the rim of skin that this leaves behind, since no foreskin is actually removed.
Other techniques involve cutting of the foreskin in different ways. These include the "sleeve" technique, as pictured below. Each technique will have their own differences in operating time, risk of bleeding, and final appearance, and it's best to talk to your surgeon about which technique they typically use.
In general however, since some foreskin is removed, there can be more swelling, and a little more bleeding compared to the simple dorsal slit.
The result of having the excess foreskin removed is what lay persons may also call the "German cut."
Some parents and individuals prefer this result, since there is less leftover skin.
The sleeve technique involves removing a "sleeve" of foreskin.
Image source here.
What about circumcision for newborns?
Circumcision for newborns looks slightly different from the techniques above.
It is typically easier to use special devices or clamps, like the "Plastibell" or the "Gomco" clamp, to do circumcision in babies.
The clamps allow the surgeon to remove the excess foreskin by crushing the skin edges with the clamp they use. While this sounds harsh, it's actually very effective to keep the skin edges together and to avoid bleeding. This means that most circumcisions for newborns may not need additional stitching.
Please discuss with your surgeon about which type of clamp or device they may opt to use for your newborn, since the aftercare for each type will be slightly different.
What about Lasers?
Using lasers, like a CO2 (carbon dioxide) laser, is a relatively new addition to the world of circumcision techniques.
The laser is an alternative way to cut through skin and to control bleeding.
Whether the laser is superior to conventional techniques is controversial. Some studies say that patients would have less pain, shorter surgeries, and less bleeding. Other studies say that there is no difference in operating time, bleeding, infection, and rates of the wound opening up. It also results in more cost.
It is hard to make a solid conclusion on whether the laser circumcision is superior, but talking to your surgeon may help you have a better idea about their data and how their patients have fared after the conventional or laser circumcision.
Caring for your child after circumcision
Different surgeons do circumcision in different ways, and this may mean some differences in the way that parents or caregivers are instructed to care for the wound after the surgery.
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Please click here to access our free, downloadable PDF file on common things to expect after circumcision.
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Please don't be afraid to ask your surgeon your questions about your child's specific care!
The information in this infographic is for general information purposes only.
We encourage you to seek an individualized consult for the most appropriate management. You may book an appointment with us or with your preferred pediatric urologist or pediatric surgeon.
Please feel free to send us a message for questions on pediatric urologic health!
