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LATEST MEDICAL EVIDENCE

Circumcision: Rates, Risks, and Benefits
Cornelius W. Van Niel, MD reviewing Morris BJ et al. Mayo Clin Proc 2014 May.
National rates are 77% to 81%, and medical benefits outweigh risks.

The 2012 American Academy of Pediatrics (AAP) policy statement on neonatal circumcision notes the procedure's health benefits and recommends that it be covered by health insurance (NEJM JW Pediatr Adolesc Med Sep 19 2012). A 2013 CDC report based on National Health and Nutrition Examination Survey data estimated a small increase (from 79% to 81%) in the prevalence of circumcised males aged 14 to 59 years between the periods 19992004 and 20052010. Researchers compared these data with prevalence based on national hospital discharge data, using a correction factor for unrecorded circumcisions performed after discharge. According to their calculations, circumcision prevalence decreased slightly from 83% in the 1960s to 77% in 2010.

A risk-benefit analysis of high-quality studies showed increases among uncircumcised infants and boys in urinary tract infections (up 10-fold in infants, from ~0.1%-~1%), sexually transmitted infections (~12-fold), and phimosis (100-fold). Risks associated with the procedure itself included local infection in 0.2% and need for surgical revision in 0.1%. The authors estimate that during a lifetime, problems related to having a foreskin will lead 50% of uncircumcised males to seek medical attention.


EVERYTHING YOU SHOULD KNOW ABOUT CIRCUMCISION

CDC Releases First Guidelines on Circumcision

Uncircumcised adolescent and adult males who have sex with women should be counseled about circumcision following an assessment of their HIV risk, according to new circumcision guidelines from the CDC.

These males should be told of the potential benefits and harms: Adult male circumcision has been shown to reduce the risk for HIV infection acquired through heterosexual sex by 50% to 60%, based on data from sub-Saharan Africa. In addition, the risk for genital herpes and some strains of human papillomavirus are reduced by roughly 30%. Rates of adverse events (e.g., pain, bleeding) range from 2% to 4%.

Click here to read the Full Article.


NEW: August 27, 2012: The American Academy of Pediatrics (AAP) formed a multidisciplinary task force of AAP members and other stakeholders to evaluate the recent evidence on male circumcision and update the Academy's 1999 recommendations in this area.

Male circumcision is a common procedure, generally performed during the newborn period in the United States. In 2007, the American Academy of Pediatrics (AAP) formed a multidisciplinary task force of AAP members and other stakeholders to evaluate the recent evidence on male circumcision and update the Academy's 1999 recommendations in this area. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure's benefits justify access to this procedure for families who choose it. Specific benefits identified included prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV. The American College of Obstetricians and Gynecologists has endorsed this statement. Pediatrics 2012;130:585-586

The CDC notes that no definitive data exist on whether circumcision reduces the risk for HIV and other sexually transmitted infections for men who only have sex with men.

Circumcision is not explicitly recommended for newborns. Parents should be told of the potential benefits and risks: Circumcised infants are less likely to experience urinary tract infections, a relatively uncommon event. In childhood, balanitis and balanoposthitis are less common in circumcised boys. Complication rates are roughly 0.5% in infants and increase as the child gets older. - See more at: http://www.jwatch.org/fw109590/2014/12/03/cdc-releases-first-guidelines-circumcision?query=pfw#sthash.paS7oKYp.dpuf

Click here to read the Journal Article.

The decision of parents, whether or not to circumcise their son, is one of the most controversial and sometimes difficult decision to make. There is most likely more in the medical literature about the pros and cons of circumcision than almost any other medical or surgical procedure. Emotions escalate when discussing this, and often decisions and opinions are based primarily on myths and intuition rather than on fact or reality.

Hopefully, this article will dispel some myths and allow the parent to make an informed decision or ask the important questions regarding circumcision.

The common reasons expressed for circumcision are:

  • cosmetic appearance
  • to have their son the same as his father or older brother
  • to prevent some complications of not being circumcised
  • to avoid the postoperative discomfort of circumcision at a later point in life
  • Religious reasons
On the other hand, others feel that circumcision is a barbaric and cruel procedure and is fraught with risks and causes extreme discomfort for the infant.

According to medical literature, the lifetime risk of an uncircumcised man requiring circumcision at some point is somewhere between 10 and 15%. This, on the surface, may be a low chance but, circumcising 10 to 15% of the male population is a large number. One problem that leads a parent to consider circumcision is care of the foreskin. Many well-meaning parents or grandparents feel that they should retract the infant's foreskin on a regular basis for routine hygiene. However, noting that the normal infant foreskin is usually unretractile is important and thus forcing it back to perform cleaning will cause tears. As these tears heal they will lead to scarring and subsequently, make further retraction of the foreskin more difficult. This is a cumulative process and eventually the foreskin is at some point found to be totally unretractile and the child or adolescent requires circumcision to correct the problem. This condition is called phimosis. A normal foreskin is not usually fully retractile until age five. Thus, refraining from cleaning under the foreskin area can prevent future problems. However, phimosis can occur naturally. Other problems include paraphimosis that is the inability of the foreskin to be brought forward from a retracted position. Infection of the head of the penis or balanitis can also occur. Balanitis will occur in 4% of uncircumcised males under the age of 14.

The medical literature also shows that the rate of urinary tract infection (UTI) is 0.2% in circumcised boys compared with 4% in uncircumcised boys in the first year of life. Complications of UTI are scarring of the kidney and subsequent kidney damage later in life. Cancer of the penis almost only occurs in uncircumcised men, however, it is exceedingly rare, approximately 1 in 100,000 would develop this condition. Consequently, justifying circumcision on this basis alone is difficult.

Recently, the Canadian Paediatric Society has issued their position stating that they do not recommend routine new-born circumcision. In other words, the risk, benefit and cost of routine circumcision does not outweigh the overall benefit.

There are three different ways to perform circumcision. One is the Mogan clamp that is used in Jewish ritual circumcision. Post circumcision infection rates with this technique have been reported as high as 30%. The Plastibel is a new technique that is easy and very cost efficient to use, however, the complications include increased bleeding, higher rates of infection and sometimes inadequate circumcision. This means that sometimes insufficient amount of foreskin is removed and the child can develop the same complications as uncircumcised males or may need a second circumcision. The third technique is the Gomco technique, it is the most widely accepted technique of choice among paediatric urologists. Advantages include:

  • the lowest complication rate
  • best cosmetic results
Clearly, when discussing circumcision, being aware of the different techniques and limitations of each is important. Obviously, if one is using a technique with a high complication rate, any apparent benefit would be lost due to the high complication rate. The opinion formed by the Canadian Paediatric Society compared all methods of circumcision grouped together rather than any one technique. Consequently, it is possible that there may be a benefit to routine circumcision if a technique with a low complication rate was universally used.

Circumcision itself is a short procedure, often taking from 5 to 30 minutes. It can be done with a nerve block. This is called the dorsal penile nerve block. Literature has shown that it dramatically reduces discomfort an infant will experience as measured by the decreased amount of crying and lower respiratory and heart rates. The nerve block itself is relatively safe. Complications include some bruising that does not harm the penis. However, allergic reaction can occur. Other techniques for pain control include anaesthetic creams and special oral solutions. The infant is often placed on a table specifically designed for circumcision that can restrain both the arms and legs during the procedure. After the circumcision, there is swelling of the penis that can last as long as a month. Occasionally, infants can be irritable and grumpy up to 2 days following the circumcision.

Complications include:

  • infection at the site 0.2%
  • bleeding 0.1%
  • reaction to the local anaesthetic if it is used
  • the possibility of scar tissue formation (adhesions)
If new-born circumcision is not undertaken within the first six weeks of life and complications do develop after this point in time, a referral would have to be made to a urologist. Circumcision would now require a general anaesthetic that in itself is fraught with risks often quoted at 1 in 10,000 chance of death. In addition, there is a significantly longer recovery that is about four to six weeks and there is a significant discomfort during this period of recovery.

Interestingly enough, circumcision rates have not changed very much in the province since the government stopped paying for the procedure through the Ministry of Health. The rate remains at 50%. However, circumcision rates in Kingston are the lowest in the entire Province of Ontario at about 30%. There is no clear explanation for this however, a strong anti circumcision bias exists among many professionals in the area that may influence these rates.

Although lifetime risks are only 10 to 15% for requiring a circumcision, there are some boys at a higher risk. Your family physician/pediatricain, or someone experienced in circumcision, would be helpful in advising you if your son is at particular high risk for complications later in life. If your son has an extra long or tight foreskin, he may be at even higher risk for requiring a circumcision later in life and it may be worth consideration in the new-born period.

As a result, there are many risks and benefits to be considered when deciding about this procedure and it is hoped that this article has been informative and clarifies some of these options for you.

For further information please contact drbaran@kingston.net

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