Dorsal slit

A dorsal slit (often referred to in anthropology as superincision or supercision) is a single incision along the upper length of the foreskin from the tip to the corona, exposing the glans without removing any tissue. An ancient practice,^[1] it has been a traditional custom among a number of peoples, particularly Filipinos and Pacific Islanders, probably for thousands of years.

The dorsal slit

In Western medicine, it was used as an alternative to circumcision to relieve conditions such as failure of the foreskin to retract (phimosis) or failure to cover the glans penis (paraphimosis), although a perception of poor appearance limited its popularity. While it is a less invasive surgery than circumcision, it is more invasive than preputioplasty since it leaves the incision open. It is still used when circumcision or other measures are considered impractical or undesirable.^{[citation needed]}

Traditional custom

Since superincision and circumcision are both forms of genital cutting that expose the glans, it can often be difficult to know which procedure is being described or depicted. Opinion is divided on whether a 4,000-year-old image from Egypt, often described as the first depiction of circumcision, may in fact be of a superincision.^[2]

Superincision has been widely practised by people of the Pacific, stretching from Hawaii to the Philippines.^[3][4] With increasing urbanisation, traditional rituals have been giving way in many places to medically performed circumcision, and almost entirely so among Islanders living in New Zealand, where a recent survey found there was "a strong cultural demand from parents".^[5] The most notable exception to Pacific superincision is the Māori of New Zealand, who do not circumcise or superincise,^[6] although they have an indigenous term for the latter (ure haea or "split penis") and their tradition is that they stopped the practice when they arrived in New Zealand.^[7]

Medical practice

Phimosis

Dorsal slit has a long history as a treatment for adult phimosis,^[1] since compared with circumcision it was relatively easy to perform, did not risk damage to the frenulum, and before the invention of antibiotics was less likely to become infected. However, the literature often indicates that despite being "a simple operation" it was "not liked by some",^[8] or refers to the "untidy apron-like appearance" it could produce.^[9]

Dorsal slit is now rare in Western countries as a treatment for phimosis. Standard guidelines suggest conservative approaches first and, should those fail, either circumcision or preputioplasty to both retain the foreskin and relieve the phimosis.^[10]

Paraphimosis and other conditions

In some cases the foreskin may become swollen as a result of paraphimosis (foreskin trapped behind the glans) or other conditions such as severe balanitis. Should reduction of the swelling by conservative methods be unsuccessful, a dorsal slit is a common intervention of choice since circumcision is almost always excluded in such cases.^[11][12] While it was formerly recommended that circumcision be subsequently performed once the originating condition has subsided,^[13] this appears to be no longer the case.^[14]

Dorsal genital slits in some African tribes

A variety of "dorsal slit" circumcision was once predominant amongst the Maasai tribe of Kenya and Tanzania, and is still practised and found in many of the more remote regions of the very large area known as "Maasailand" generally.^{[citation needed]}

However, the Maasai operation is different in this: rather than a dorsal slit from the opening of the prepuce to the corona, a heart shaped "oval" is excised from the dorsum of the prepuce and the glans is pushed through this hole. Later the edges of the cut prepuce will heal.^{[citation needed]}

The prepuce is first cut off, leaving only a small part where the main veins are located, which is pulled down and the small hole through which the glans in pushed through is created. The remaining part is left hanging down, but the glans exposed.^{[citation needed]}

Formerly tribes that copied the Maasai like the numerous Kikuyu of Kenya also practised the same form of circumcision. Photos of the operation and result are numerously found in specialized African books, such as Carol Beckwith and Tepelit Ole Saitoti's Maasai.^{[citation needed]}

There are words for the resultant "preputial flap" in the Maa and Gikuyu languages, and possibly in other African tongues. In Gikuyu the word, now archaic, is likely to be ngwati.^{[citation needed]}

Dorsal slit reversal

According to Goodwin, the dorsal slit operation may be reversed by suturing the cut ends together, which restores the tissue to its normal position and recreates the foreskin.^[15]

References

1. Christianakis E (March 2008). "Sutureless prepuceplasty with wound healing by second intention: an alternative surgical approach in children's phimosis treatment". BMC Urology. 8: 6. doi:10.1186/1471-2490-8-6. PMC 2311323. PMID 18318903.
2. Tasmania Law Reform Institute Non-Therapeutic Male Circumcision October 24, 2009, at the Wayback Machine Issues Paper, No. 14, 2009. (p. 14)
3. Diamond, Milton (2004). "Sexual Behavior in Pre Contact Hawai'i: A Sexological Ethnography". Revista Española del Pacifico (16): 37–58. Milton Diamond incorrectly terms the procedure subincision, though it is clear superincision is meant.
4. Boyle, G and Ramos, S (2000). Ritual and Medical Circumcision among Filipino boys: Evidence of Post-traumatic Stress Disorder 2016-08-15 at the Wayback Machine, Humanities & Social Sciences papers, Bond University (p. 5)
5. Afsari M, Beasley SW, Maoate K, Heckert K (March 2002). "Attitudes of Pacific parents to circumcision of boys". Pacific Health Dialog. 9 (1): 29–33. PMID 12737414.
6. Circumcision and Māori by Valentino Križanić
7. Young H, McGrath K (2001). "A review of circumcision in New Zealand". In Hodges FM, Denniston GC, Milos MF (eds.). Understanding circumcision: a multi-disciplinary approach to a multi-dimensional problem. New York: Kluwer Academic/Plenum Publishers. p. 130. ISBN 0-306-46701-1.
8. Editorial (December 1949). "A Ritual Operation". British Medical Journal. 2 (4642): 1458–9. doi:10.1136/bmj.2.4642.1458. PMC 2051965. PMID 20787713.
9. Welsh F (October 1936). "Indications for Infant Circumcision". British Medical Journal. 2 (3953): 714. doi:10.1136/bmj.2.3953.714. PMC 2457672. PMID 20780160.
10. Yachia D (2007). Text Atlas of Penile Surgery. Informa Healthcare. p. 16. ISBN 978-1-84184-517-3.
11. Thiruchelvam N, Nayak P, Mostafid H (April 2004). "Emergency dorsal slit for balanitis with retention". Journal of the Royal Society of Medicine. 97 (4): 205–6. doi:10.1177/014107680409700421. PMC 1079370. PMID 15056750.
12. Kessler CS, Bauml J (November 2009). "Non-traumatic urologic emergencies in men: a clinical review". The Western Journal of Emergency Medicine. 10 (4): 281–7. PMC 2791735. PMID 20046251.
13. Warner E, Strashin E (November 1981). "Benefits and risks of circumcision". Canadian Medical Association Journal. 125 (9): 967–76, 992. PMC 1862490. PMID 7037142.
14. McGregor TB, Pike JG, Leonard MP (March 2007). "Pathologic and physiologic phimosis: approach to the phimotic foreskin". Canadian Family Physician. 53 (3): 445–8. PMC 1949079. PMID 17872680.
15. Goodwin WE (November 1990). "Uncircumcision: a technique for plastic reconstruction of a prepuce after circumcision". The Journal of Urology. 144 (5): 1203–5. doi:10.1016/s0022-5347(17)39693-3. PMID 2231896. One patient presented with a dorsal slit because of an acute infection during childhood. All of the normal preputial skin was still present and the patient wished the skin restored to a normal appearance. An inverted V-shaped incision was made where the dorsal slit had been and the two edges were sutured together, thus, reproducing the normal prepuce. The patient was delighted with the results. It could be that this might be an answer to some critics of circumcision. A simple dorsal slit can be performed in patients who have phimosis or severe recurrent infections. At a later date, if they wished restoration, reconstruction to the uncircumcised appearance would be simple.