Male circumcision reduces the abundance of bacteria living on the penis and might help explain why circumcision offers men some protection against HIV, according to a study led by the Translational Genomics Research Institute.

Removing the foreskin caused a significant shift in the bacterial community or microbiome of the penis, according to a study published today by the online journal mBio.

This international collaboration focused on 156 men in Rakai, Uganda – part of the world’s largest randomized-controlled trial on male circumcision. Researchers showed that men who were circumcised as part of the study had 33.3 percent less bacteria on their penis than those who remained uncircumcised one year after the study began.

Researchers further showed that the decrease was primarily found in 12 types of bacteria, most of which were intolerant to oxygen.

Past studies have shown that circumcision reduces female-to-male HIV transmission, among other benefits. This study suggests a possible mechanism for HIV protection – the shift in the number and type of bacteria living on the penis. Further studies will have to be done to demonstrate that a change in the penis microbiome can help reduce the risk of HIV transmission, according to the authors.

A recent innovation is the creation of a protective housing covering the entire surgical area. This is called a genital shield. The semi flexible absorbent shield protects the penis and scrotum from direct contact with the diaper or nappy. This reduces pressure and friction on the surgical area whilst also limiting faecal contact with the wound dressings.

The benefits in reducing possible penile pressure and swelling are obvious as is the benefit for the comfort of the baby. This latter factor is frequently under played as most patients are not yet able to verbalise pain and discomfort.

This genital shield is also of benefit to infants undergoing circumcision. The newly exposed penile glans following the circumcision, as well as the actual surgical area is naturally sensitive. The device assists by holding the nappy away form the surgical dressing. The device provides a natural healing environment.

Various other risk factors include early menarche in the mother, threatened miscarriage, low placental weight and exposure to progestins. There may be an increased incidence of hypospadias in pregnancies resulting from in vitro fertilization due to the hormonal manipulation that forms part of the IVF process.

However, environmental factors may also play a part. Exposure to chemicals from plastic bottles and pesticides on fruit and vegetables for example, may play a role in increasing the risk of hypospadias.

There is however a trend emerging of an increase in the severity of the cases. Hypospadias usually occurs in isolation but occasionally there are other congenital defects. About 15% of major hypospadias cases have other birth defects.

The most common associated defects are undescended testes and inguinal hernias. Hypospadias was commonly thought to occur at higher frequency amongst populations in Europe. It is now however recognised as being as prevalent amongst African populations as well.

The objective is to relocate the urethral opening to its normal position on the tip of the penis and to correct any abnormal penile curvature.

There is also the goal to produce an aesthetic result as close to resemblance of a normal penis as possible.

The surgery can range from relatively simple to complicated. Severe cases may require multiple visits to theatre producing progressive repair results. The principle objective is however to achieve a single stage repair in order to avoid the risks associated with multiple operations.

The reconstructive nature of the repair, depending on its severity, may utilises the foreskin. For this reason it is imperative that a circumcision not be carried out on the child until the hypospadias repair takes place.

This requirement must be carefully balanced with religious requirements. For example, the Jewish bris should be coordinated with the hypospadias repair. This is achievable by attendance of the mohel in theatre to ensure religious observance takes place.

The timing of the surgery is important to avoid memory of the event and associated psychological factors. Depending on each case, and relative severity, this is carried out between 6 to 18 months. Earlier interventions reduce the likely impact from a psychological point of view.

The repair requires administration of a general anaesthetic and the overall health of the child is assessed for this risk.

The most common complications are bleeding, haematoma, swelling, wound infection, skin necrosis, fistula and penile torsion (twisting). Complications depend on the type of hypospadias, the severity, surgical technique and age of the child. In order of frequency postoperative fistula is the commonest followed by swelling and penile torsion.