New data indicating that uncircumcised men acquire the
human papillornavirus more easily than circumcised men has reopened the question of a
possible relationship. The issue will most likely remain unresolved, however, because
women today are more likely to have other risk factors for cervical carcinoma, including
lower age at first intercourse and multiple partners.
What are the benefits & risks of circumcision?
1. Benefits:
- Prevents cancer of the penis
- Decreases risk of urinary tract infection in infants and children under
age 5
- Avoids later circumcision for medical indications
- Prevents paraphimosis
- Prevents recurrent balanitis
- Decreases risk of acquiring HIV (in African studies)
- May decrease risk of acquiring other STDs
2. Risks:
- Operative complications
- Bleeding
- Infection
- Poor cosmetic outcome
- Excessive skin loss
- Hidden penis syndrome
- Complications of anesthesia
- Postoperative complications Fibrous bands Phimosis if not enough foreskin
removed Meatal stenosis Adhesions, cysts
The most comprehensive study of complications from
circumcision remains Gee's and Ansell's 1976 report of 5,521 males circumcised between
1963 and 1972 at the University of Washington, half with the Gomco clamp and half with the
Plastibell device (described below).17 The study found complications in 2% of patients,
with a significant complication in 0.2%, or I patient in 500.
Since circumcision is a surgical procedure, the most
recognizable complications are bleeding and infection. The most common problem reported by
Gee and Ansell was hemorrhage (1%) defined as any excessive bleeding requiring treatment.
Infection occurred in 23 infants (0.4%), more commonly in those circumcised with the
Plastibell (0.72% vs. 0.14%). Additional studies have confirmed the rate of local
infection to be approximately 0.5%, with systemic infection occurring in perhaps one in
4,000 patients.
Among the more serious complications reported by Gee and
Ansell were life-threatening hemorrhage in one patient with hemophilia, infection
requiring antibiotics (four patients), circumcision performed despite hypospadias (eight
patients), and complete denudation of the penile shaft (one patient). Other major
complications reported in the literature include sepsis, pulmonary abscess, femoral
osteomyelitis, necrotizing fasciitis, and urethrocutaneous fistulas. One 4month-old whose
surgeon used an electrocautery over a Gomco clamp developed sloughing of the entire penile
shaft and was eventually surgically transformed into a female.
The mortality rate from circumcision is around one death
per 2 million patients. Between 1953 and 1993, three boys died from complications of
circumcision. During that same period, between 9,000 and 12,000 uncircumcised men died of
penile cancer. 18
Some complications of circumcision are rarely
acknowledged, the most common being a poor cosmetic result. A study from Australia
revealed that 9.5% of circumcisions were actually repeat procedures to correct
inadequately performed initial surgery.
If too little foreskin is removed, the patient may
appear to be uncircumcised and may develop phimosis caused by the scarring that occurs
with healing. If too much skin is removed, the shaft of the penis may be denuded. No data
concerning the eventual outcome are available, but it is theoretically possible that the
scarring that occurs when the shaft is denuded may later cause pain during erections. Such
complications may be reduced by using a surgical marking pen to delineate the corona of
the penile shaft, which is easily visible beneath the foreskin, before surgery.
Poor surgical technique can also lead to
"concealed" or "hidden penis" in which too much of the outer layer of
the prepuce is removed, but little of the inner layer. This causes a tethering effect that
pulls the penis in toward the fat pad while covering the glans with the foreskin.
Another common, but seldom mentioned, complication of
neonatal circumcision is meatal stenosis, probably caused by ulceration of the urethral
meatus with subsequent scarring. The urinary stream deviates, often prompting the mother
to complain that her son "misses the bowl," so the pediatrician who observes the
patient voiding can easily make the diagnosis. Once stenosis is diagnosed, obtain a
urinalysis to assure that there is no ongoing irritation or infection and consider a
post-void bladder ultrasound, which will demonstrate residual volume if the obstruction is
significant.
If any redundant foreskin remains after circumcision,
boys less than 3 years of age may develop adhesions associated with a partially or
completely covered glans. Epithelial cellular debris may collect underneath the remaining
foreskin and present as firm pearly nodules. Based on his findings of adhesions in
circumcised boys, Van Howe recommended that parents gently pull back any skin overlying
the glans until a circumcised child is 15 to 18 months of age to prevent adhesions from
developing.
Anecdotal reports cite lower complication rates and
improved cosmetic results with the Mogen clamp, which is used by most Jewish mohels, but
no research has been published comparing outcomes with the Mogen clamp, Plastibell, and
Gomco devices. Such a study is currently ongoing at San Francisco General Hospital.
Because the foreskin appears to protect the glans and
urethral meatus from ammoniacal injury during the diaper period, some have advocated
delaying circumcision until the child is out of diapers. The later procedure, however,
would have to be performed in the operating room by a urologist, with higher costs and
potentially higher morbidity. Wiswell and colleagues
evaluated 476 boys circumcised after the newborn period
and found complications in eight: excessive bleeding in three patients; malignant
hyperthermia in two; and aspiration pneumonia, postoperative fever, and a large hematoma
in one each.
is circumcision genital mutilation? Some people
argue that circumcision should not be performed because it constitutes genital mutilation.
The American Academy of Pediatrics released a statement on "female genital
mutilation" in July 1998, encouraging its members to "decline performing all
medically unnecessary procedures to alter female genitalia." The heightened world
awareness of female genital mutilation has raised the question of whether male
circumcision should also be considered genital mutilation. The fact that both procedures
are often performed for religious reasons lends weight to the comparison.
Female genital mutilation partially or completely
excises the clitoris, thus significantly decreasing or eliminating future sexual pleasure.
The subsequent scarring often makes sexual intercourse difficult and painful, if not
impossible. Since male circumcision does not contribute to such significant sexual
difficulties, many argue that it does not fall into the category of mutilation. In
addition, unlike ritual clitorectomies, newborn circumcisions are generally performed by
physicians or mohels trained in the procedure.
Opponents of circumcision emphasize that there is no
medical necessity for neonatal circumcision and that removing the protective covering of
the sexually sensitive glans during childhood may lead to desensitization with subsequent
decrease in sexual pleasure. These factors, some argue, support the contention that male
circumcision does meet the criteria for mutilation. Some urge that the surgery be
postponed until the patient can make his own informed decision.
How is circumcision performed?
Circumcision can be performed using the Gomco clamp
(preferred by most obstetricians), the Plastibell, or the Mogen clamp. "Three ways to
perform circumcision," When using the Gomco clamp or the Plastibell-the two
instruments most often used in the US-a "dorsal slit" is made to separate the
foreskin from the underlying glans. The bell of the Gomco clamp or the ring of the
Plastibell is then placed over the glans and the foreskin is brought up over the bell or
ring. The Gomco clamp compresses the foreskin between the metal clamp and bell, allowing
it to be cut and removed with minimal bleeding. The Plastibell uses a surgical ligature,
which is tied in a groove around the ring. The foreskin is excised and the ring with the
suture left in place until avascular necrosis causes it to fall off.
The Mogen clamp is less cumbersome than the Gomco and
Plastibell devices. The foreskin is stretched, brought through the clamp, and surgically
excised. The beveled underedge of the clamp protects the glans from injury.
Whether the physician is using a Gomco clamp, Plastibell
device, or Mogen clamp to perform circumcision, the penis can first be anesthetized using
a dorsal penal nerve block. Wait at least five minutes for the anesthetic to take affect.
To administer the block, draw 0.7 mL of 1% lidocaine without epinephrine
into a tuberculin syringe with a 27G needle. When the syringe is completely filled switch
to a 30G needle. With the baby lying in a crib or on a pillow with his knees flexed and
thighs abducted by an assistant, give him a sugared pacifier, prep the skin with a warm
alcohol swab, and insert the needle I cm distal to the base of the penis at 10 o'clock and
2 o'clock. Advance it about 1 cm toward the penile abdominal junction with the tip just
under the skin as shown below. Slowly inject 0.25 to 0.35 mL of lidocaine on each side of
the penis, which will cause subcutaneous swelling at the needle tip.
Regardless of what method is used to perform circumcision, keep in mind
that the cosmetic result can be improved by marking the location of the coronal sulcus on
the penile shaft with a surgical marking pen before surgery. The coronal sulcus is easily
visible beneath the foreskin.
Gomco clamp
The Gomco device consists of a metal bell and a clamp with a plate and
yoke. Make a dorsal slit and retract the foreskin from the glans. Place the bell portion
of the clamp over the glans, pull the foreskin over the bell through the plate and yoke of
the clamp, and screw the clamp tightly onto the bell so that it holds the foreskin in
place, as shown below. Excise the foreskin, remove the clamp and bell, and apply a
Vaseline gauze dressing.
Plastibell
Make a dorsal slit and retract the foreskin from the glans. The
Plastibell consists of grooved rings of various sizes with handles. Select the proper size
ring and place it over the glans. Pull the foreskin over the edge of the ring so that the
edge is at the coronal sulcus. Tie a silk suture tightly around the ring in the groove.
Excise the foreskin at the edge of the ring, as shown below, and leave the ring in place.
It usually falls off in three to seven days.
Mogen clamp
Attach a hemostat to the dorsal foreskin to indicate the portion to be
removed. Pull the prepuce forward so that the foreskin stretches and the glans retracts
slightly. Slide the clamp across the redundant foreskin and excise the foreskin (the
beveled under edge of the clamp protects the glans). Retract the skin to free any
remaining adhesions and apply a Vaseline gauze dressing.
What about pain control?
Physicians once believed that infants through 6 weeks of
age could undergo circumcison without feeling pain, but it is now clear that the fetus
feels pain as early as 20 weeks gestation. Infants who have experienced pain with
circumcision appear to have increased responses to pain, such as the pain associated with
immunizations. Whenever a circumcision is performed, therefore, the infant should receive
appropriate analgesia that does not significantly increase the risk of the procedure.
Physicians using these methods must take care with drug
dosages and administration to avoid the possible complications associated with systemic
lidocaine, such as cardiac arrhythmias and seizures. A dose of 0.7 mL of 1%
lidocaine-without epinephrine, which can cause dangerous side effects-can be used safely
for DPNB.
Sucrose solution given orally on a pacifier, for
example-has been found to decrease infant pain responses to heel sticks, immunizations,
and circumcisions and certainly does not add to the risk of the circumcision procedure.
Additional analgesia, such as oral acetaminophen suspension (10 to 15 mg/kg every six
hours as needed) should also be considered.
When is circumcision contraindicated?
Any anatomic abnormality of the penis that might require
later use of the foreskin in reconstructive surgery is an absolute contraindication to
circumcision. The most common abnormality is hypospadias, which occurs in at least 1:235
male births but has recently been increasing in frequency. A complete exam of the
genitalia, looking carefully along the ventral surface for second, third, or fourth degree
hypospadias, is essential before performing circumcision.
Since the foreskin is not retractable, first degree
hypospadias may not be noted until the dorsal slit has been made. Two physical findings,
however, may alert the physician to the possibility of an underlying hypospadias. First,
there is often an associated malformation of the prepuce, termed a "dorsal
hood," which leaves the ventral surface of the glans exposed. A chordee, a band of
fibrous tissue of corpus spongiosum along the ventral surface of the shaft, causing a
curvature of the penis, may also, though not always, accompany hypospadias.
Infants with ambiguous Infants with ambiguous genitalia and those who
are ill or significantly premature should not undergo circumcision. Excessive oozing of
blood after the heel stick is another contraindication since it may indicate a hemorrhagic
diathesis that could cause severe bleeding after circumcision.
Ideally, circumcision should NOT be performed in the
first 24 hours after delivery, when the infant is still adjusting to extrauterine life and
neonatal illness may not yet be apparent. Obviously, it should never be done without
parental consent.
Is circumcision ever medically necessary?
Is circumcision ever medically necessary? There
are no medical indications for neonatal circumcision. As a child matures, however, he may
develop phimosis, requiring surgical correction to relieve the obstruction. Paraphimosis,
the persistent retraction of the foreskin along the shaft of the penis, causes lymphatic
and venous obstruction, which can lead to arterial compromise. Surgical relief may be
provided by a dorsal slit in the foreskin, so the patient can choose to have a
circumcision or to have the dorsal slit sutured after the swelling has resolved.
Recurrent episodes of balanitis (inflammation of the
glans) would be an indication for circumcision, but balanitis is rarely seen except in
tropical countries or older patients with diabetes.
More common in the US is posthitis, inflammation of the
outer layer of the foreskin, which is often caused by gram-negative bacteria and
Candida
albicans. Since the prepuce is composed of two layers, inflammation of the outer layer
does not injure the underlying glans, which is protected by the inner layer. Thus,
circumcision may not be indicated for patients who have recurring episodes of posthitis.
What care do uncircumcised boys need?
Parents of uncircumcised infants should be instructed
NOT to attempt to retract the foreskin or use cotton swabs to clean underneath it. As
Gairdner demonstrated in 1949, the clefts in the stratified squamous epithelium between
the glans and foreskin develop gradually and very few newborns have retractable foreskins.
By I year of age, 50% of boys have partially retractable foreskins. The foreskin is
completely retractable in 80% of 3-year-old boys and 99% of 17-year-olds.
Normal bathing maintains cleanliness until the foreskin
becomes easily retractable. Once it does, the parent, and later the child, can gently pull
it back, wash the glans, and replace the foreskin over the glans.
In light of the natural development of the foreskin, the
historic pediatric in-office procedure of "freeing adhesions" by passing a probe
between glans and foreskin is medically unfounded. Moreover, it can cause pain, bleeding,
and adhesions.
Phimosis has been inaccurately diagnosed in newborns
simply because the foreskin is unretractable. The diagnosis should be reserved for boys
whose preputial ring (the opening of the foreskin) has become stenosed by scarring. This
obstructs voiding and can easily be recognized (often by a parent) by observing whether
the foreskin "balloons" when the child urinates. "He puffs out when he
pees" has been listed as a chief complaint by several of our patients' mothers.
True phimosis cannot develop until after the foreskin
has separated from the glans, and thus cannot be present at birth. Oster's data on 1,968
uncircumcised Danish boys between 6 and 17 years of age who were examined annually for up
to eight years demonstrated that uncircumcised boys have a small incidence of preputial
adhesions and true phimosis, which appears to decrease normally with age.
An interesting recent observation is that 5- and
6-year-old boys who were circumcised for phimosis were noted to have lichen sclerosis et
atrophicus on pathological review. Lichen sclerosis in prepubertal girls responds well to
topical corticosteroid treatment. In 1995, Wright published a prospective study of ill
boys referred for surgical treatment of phimosis who were instead treated with topical
betamethasone cream for one month. Treatment was successful and circumcision was avoided
in 80%. A more recent evaluation of the costs associated with treating phimosis showed
topical steroid therapy using betamethasone 0.05% cream for four to six weeks to be so
effective that the author recommends trying treatment with the cream before considering
circumcision.
Is circumcision cost-effective?
Several authors have attempted to calculate the
cost-benefit ratio of circumcision, but most have used inaccurate or old data. In 1987,
approximately 1.95 million infant boys were born, and if they had all been circumcised at
$100 per procedure, the total cost would have been $195 million. Based on these figures,
Ross and Elder calculated the cost of preventing one urinary tract infection by
circumcision at $2,000 to $8,000 and the cost of preventing one case of penile cancer at
around $45,000.
A report from Ontario, Canada, estimated that the cost
of universal neonatal circumcision would be twice the cost of medically indicated
circumcisions performed in adult men. When the figures were adjusted for days lost from
work and cost of hospitalization, however, neonatal circumcision was the more economical
approach.
What role for the doctor?
Although Patel demonstrated in 1966 that physicians can
influence parental decisions, newer studies reveal that parents choose circumcision for
two major reasons, neither of which is affected by medical information. The strongest
factor associated with neonatal circumcision was the circumcision status of the father.
Another significant factor was religious beliefs. These influences notwithstanding,
pediatricians should still provide families with accurate medical information to assist
them in this important decision. Some of the questions a pediatrician might review with
parents are discussed in the parent guide on the facing page.
The decision whether or not to circumcise a newborn son
is especially important for parents, since it is usually the first decision that they must
make together for another human being. When parents have a difficult time with this
decision, it often indicates that they are having problems with communication in other
areas, and pediatricians should be reluctant to step in with advice. It is far better to
help parents recognize their communication difficulties and provide supportive resources
than to promote a decision that the family may later regret.
The parent guide on circumcision may be photocopied and
distributed to families in your practice without permission of the publisher.
Parent Handout:
If you have a boy, you will be asked if you want him circumcised. This
is a matter you should think about very carefully before your baby is born. Circumcisions
are usually done soon after birth. Many parents prefer to discuss their questions with the
pediatrician well in advance, so that they have time to talk things over together and
reach a decision both are comfortable with. Here are some of the questions parents ask:
What is circumcision?
Baby boys are born with a covering (the foreskin) over the sensitive end
(glans) of the penis. A circumcision is an operation to remove this skin, leaving the end
of the penis uncovered. The procedure takes about 15 minutes to perform. Newborn babies
can feel pain, so most doctors use local anesthesia (medicine to decrease Pain). Ask your
doctor about this. Even when local anesthesia is used, babies may feel some pain for a
short time after the operation.
Why are circumcisions per-formed?
Circumcisions are done for many reasons. Moslems and Jews perform
circumcisions for religious reasons. Other people choose to have their sons circumcised so
that the baby will look like his father. There are many countries in the world where
circumcision is almost never done.
Circumcision is not required by law and is not medically necessary. it
doesn't affect future sexual enjoyment and won't prevent a man from becoming infected with
most sexually transmitted diseases, although it may decrease the chances of acquiring some
of these diseases.
Circumcision of newborn boys does help prevent cancer of the penis. The
risk that an uncircumcised boy will develop cancer of the penis in later life is about I
in 600. Careful attention to cleanliness may help decrease the risk in men who are
uncircumcised. Circumcision also decreases the risk that a baby boy will develop a urinary
tract infection during his first few years of life. Uncircumcised boys have a 1% risk of
developing a urinary infection in the first 12 months of life; circumcised boys have a 0.
1% risk.
What are the risks of circumcision?
Because circumcision is an operation, complications may occur. One large
study found that about two babies out of every 100 had a problem following surgery. The
most common problems are: 0 Heavy bleeding, rarely requiring blood transfusion. Bleeding
happens in I of 100 babies who are circumcised. 0 infection of the penis. This happens in
I in 500 babies and, rarely, may require treating the baby with intravenous antibiotics. 0
The foreskin may be cut too short or left too long or may heal improperly. In rare cases,
a second operation may be needed to correct the problem.
How do you keep the penis clean if your child is not circumcised?
How do you keep the penis clean if your child is not circumcised? When
you take your baby home, you do not need to do anything special. The foreskin of a newborn
cannot be pulled back, and so just by bathing your baby, you are keeping the penis clean.
After the baby is I year old, you can gently try to pull back the foreskin while you are
bathing him. If the foreskin moves easily, wash the end of the penis and carefully place
the foreskin back over the end of the penis. If you cannot pull the foreskin back, don't
worry. This is perfectly normal and you can try again in a few months. As your child
grows, the foreskin will gradually become retractable. just as you will teach your son to
wash his hands and face, you can teach him to clean his penis.
It is your decision
Before you decide to have your son circumcised, it is important that you
understand what the operation is and what the possible problems are. Please ask your nurse
or doctor any questions you may have before you sign the consent form. Your nurse or
doctor will show you how to care for your baby after the operation.
