Report of the Task Force on Circumcision (RE9148)
Report of the Task Force on Circumcision
AMERICAN ACADEMY OF PEDIATRICS
Task Force on Circumcision
The 1971 edition of Standards and Recommendations of Hospital Care of
Newborn Infants by the Committee on the Fetus and Newborn of the American
Academy of Pediatrics (AAP) stated that "there are no valid medical indications
for circumcision in the neonatal period." [1(p110)] In 1975, an Ad Hoc Task
Force of the same committee reviewed this statement and concluded that "there
is no absolute medical indication for routine circumcision of the newborn."
[2(p87)] The 1975 recommendation was reiterated in 1983 by both the AAP and
the American College of Obstetrics and Gynecology in the jointly published
Guidelines to Perinatal Care. 
Large-scale studies of US hospitals indicate that most male infants born in
this country are circumcised in the newborn period,  although the
circumcision rate recently appears to be decreasing.  Since the 1975
report, new evidence has suggested possible medical benefits from newborn
circumcision. Preliminary data suggest the incidence of urinary tract infection
in male infants may be reduced when this procedure is performed during the
newborn period. There is also additional published information concerning the
relationship of circumcision to sexually transmitted diseases and, in turn, the
relationship of viral sexually transmitted diseases to cancer of the penis and
DEFINITIONS, PENILE HYGIENE, AND LOCAL
The penis consists of a cylindrical shaft with a rounded tip (the glans).
The shaft and glans are separated by a groove called the coronal sulcus. The
foreskin, or prepuce, is the fold of skin covering the glans. At birth, the
prepuce is still developing histologically, and its separation from the glans
is usually incomplete. Only about 4% of boys have a retractable foreskin at
birth, 15% at 6 months, and 50% at 1 year; by 3 years, the foreskin can be
retracted in 80% to 90% of uncircumcised boys. 
Phimosis is stenosis of the preputial ring with resultant inability to
retract a fully differentiated foreskin. Paraphimosis is retention of the
preputial ring proximal to the coronal sulcus, creating a tension greater than
lymphatic pressure resulting in subsequent edema of the prepuce and glans
distal to the ring. Balanitis is inflammation of the glans, and posthitis is
inflammation of the prepuce; these conditions usually occur together
(balanoposthitis). Meatitis is inflammation of the external urethral
Newborn circumcision consists of removal of the foreskin to near the
coronal sulcus performed in early infancy (before age 2 months). The procedure
prevents phimosis, paraphimosis, and balanoposthitis. Meatitis is more common
in circumcised boys. There is no evidence that meatitis leads to stenosis of
the urethral meatus.
It is particularly important that uncircumcised boys be taught careful
penile cleansing. As the boy grows, cleansing of the distal portion of the
penis is facilitated by gently, never forcibly, retracting the foreskin only to
the point where resistance is met. Full retraction may not be achieved until
age 3 years or older.
A small percentage of boys who are not circumcised as newborns will later
require the procedure for treatment of phimosis, paraphimosis, or
balanoposthitis. When performed after the newborn period, circumcision may be
a more complicated procedure. 
CANCER OF THE PENIS
The overall annual incidence of cancer of the penis in US men has been
estimated to be 0.7 to 0.9 per 100 000 men and the mortality rate is as high as
25%. [8-11] This condition occurs almost exclusively in uncircumcised men.
[12-14] In five major reported series since 1932, not one man had been
circumcised neonatally. [11,15-19] The predicted lifetime risk of cancer of
the penis developing in an uncircumcised man has been estimated at 1 in 600 men
in the United States ; in Denmark, the estimate is 1 in 909 men.  In
developed countries where neonatal circumcision is not routinely performed, the
incidence of penile cancer is reported to range from 0.3 to 1.1 per 100 000 men
per year.  This low incidence is about half that found in uncircumcised US
men, but greater than that in circumcised US men.
Factors other than circumcision are important in the etiology of penile
cancer. The incidence of penile cancer is related to hygiene. In developing
nations with low standards of hygiene, the incidence of cancer of the penis in
uncircumcised men is 3 to 6 per 100 000 men per year.  The decision not to
circumcise a male infant must be accompanied by a lifetime commitment to
genital hygiene to minimize the risk of penile cancer developing. Recently,
human papillomavirus types 16 and 18 DNA sequences have been found in 31 of 53
cases of penile cancer, suggesting the importance of these viruses in the
development of this condition.  Poor hygiene, lack of circumcision, and
certain sexually transmitted diseases all correlate with the incidence of
URINARY TRACT INFECTIONS
A 1982 series of infants with urinary tract infections noted that males
preponderated, contrary to female preponderance later in life, and that 95% of
the infected boys were uncircumcised.  Beginning in 1985, studies
conducted at US Army hospitals involving more than 200 000 infant boys showed a
greater than tenfold increase in urinary tract infections in uncircumcised
compared with circumcised male infants; moreover, as the rate of circumcision
declined throughout the years, the incidence of urinary tract infection
increased. [5,25] In another army hospital study, infants were examined in the
first month of life and it was concluded that the high incidence of urinary
tract infection in uncircumcised boys was accompanied by a similarly increased
incidence of other significant infection, including bacteremia and meningitis
; however, the authors of that study did not distinguish between
bacteriuria secondary to septicemia and primary urinary tract infection. Still
another recent army hospital study lends support to a 1986 hypothesis that
circumcision prevents preputial bacterial colonization and thus protects male
infants against urinary tract infection. [27,28] It should be noted that these
studies in army hospitals are retrospective in design and may have methodologic
flaws. For example, they do not include all boys born in any single cohort or
those treated as outpatients, so the study population may have been influenced
by selection bias.
Evidence regarding the relationship of circumcision to sexually transmitted
diseases is conflicting. Early series indicated a higher risk of gonococcal
and nonspecific urethritis in uncircumcised men, [29,30] whereas one recent
study shows no difference in the incidence of gonorrhea and a higher incidence
of nonspecific urethritis in circumcised men.  Although published reports
suggest that chancroid, syphilis, human papillomavirus, and herpes simplex
virus type 2 infection are more frequent in uncircumcised men, methodologic
problems render these reports inconclusive. [29,30,32-34]
There appears to be a strong correlation between squamous cell carcinoma of
the cervix and sexually transmitted diseases. Human papillomavirus types 16
and 18 are the viruses most commonly associated with cancer of the cervix
[35-38]; Herpes simplex virus type 2 has also been linked with cervical cancer.
[36,39] Although human papillomavirus types 16 and 18 are also associated with
cancer of the penis, [23,37] evidence linking uncircumcised men to cervical
carcinoma is inconclusive. The strongest predisposing factors in cervical
cancer are a history of intercourse at an early age and multiple sexual
partners. The disease is virtually unknown in nuns and virgins.
PAIN AND BEHAVIORAL CHANGES
Infants undergoing circumcision without anesthesia demonstrate physiologic
responses suggesting that they are experiencing pain.  The observed
responses include behavioral, cardiovascular, and hormonal changes. Pain
pathways as well as the cortical and subcortical centers necessary for pain
perception are well developed by the third trimester. Responses to painful
stimuli have been documented in neonates of all viable gestational ages.
Behavioral changes include a cry pattern indicating distress during the
circumcision procedure and changes in activity (irritability, varying sleep
patterns) and in infant-maternal interaction for the first few hours after
circumcision. [41-43] These behavioral changes are transient and disappear
within 24 hours after surgery. 
SURGICAL TECHNIQUES AND LOCAL
Circumcision is a safe surgical procedure if performed carefully by a
trained, experienced operator using strict aseptic technique. The procedure
should be performed only on a healthy, stable infant. Clamp techniques (eg,
Gomco or Mogen clamps) or a Plastibell give equally good results. 
Techniques that may reduce postoperative complications include (1) using a
surgical marking pen to mark the location of the coronal sulcus on the shaft
skin preoperatively; (2) identifying the urethral meatus; (3) bluntly freeing
the foreskin from the glans with a flexible probe; (4) completely retracting
the foreskin; and (5) identifying the coronal sulcus, all before applying the
clamp or Plastibell and before excising any foreskin.  Electrocautery
should not be used in conjunction with metal clamps. At the initial health
supervision visit following hospital discharge, the penis should be carefully
examined and the parents given instructions concerning on-going care.
Dorsal penile nerve block using no more than 1% lidocaine (without
epinephrine) in appropriate doses (3 to 4 mg/kg) may reduce the pain and stress
of newborn circumcision. [41,46-49] However, reported experience with local
anesthesia in newborn circumcision is limited, and the procedure is not without
risk (see "Complications").
CONTRAINDICATIONS, COMPLICATIONS, INFORMED
Circumcision is contraindicated in an unstable or sick infant. Infants
with genital anomalies, including hypospadias, should not be circumcised
because the foreskin may later be needed for surgical correction of the
anomalies. Appropriate laboratory studies should be performed when there is a
family history of bleeding disorders. Infants who have demonstrated an
uncomplicated transition to extrauterine life are considered stable. Signs of
stability include normal feeding and elimination and maintenance of normal body
temperature without an incubator or radiant warmer. A period of observation
may allow for recognition of abnormalities or illnesses (eg,
hyperbilirubinemia, infection, or manifest bleeding disorder) that should be
addressed before elective surgery. It is prudent to wait until a premature
infant meets criteria for discharge before performing circumcision.
The exact incidence of postoperative complications is unknown,  but
large series indicate that the rate is low, approximately 0.2% to 0.6%.
[44,45,51,52] The most common complications are local infection and bleeding.
Deaths attributable to newborn circumcision are rare; there were no deaths in
500 000 circumcisions in New York City  or in 175 000 circumcisions in US
Army hospitals.  A communication published in 1979 reported one death in
the United States due to circumcision in 1973, and the authors' review of the
literature during the previous 25 years documented two previous deaths due to
this procedure. 
Complications due to local anesthesia are rare and consist mainly of
hematomas and local skin necrosis. [41,46-49,54] However, even a small dose of
lidocaine can result in blood levels high enough to produce measurable systemic
responses in neonates. [55,56] Local anesthesia adds an element of risk and
data regarding its use have not been reported in large numbers of cases.
Circumferential anesthesia may be hazardous. It would be prudent to obtain
more data from large controlled series before advocating local anesthesia as an
integral part of newborn circumcision.
When considering circumcision of their infant son, parents should be fully
informed of the possible benefits and potential risks of newborn circumcision,
both with and without local anesthesia. In addition to the medical aspects,
other factors will affect the parents' decisions, including esthetics,
religion, cultural attitudes, social pressures, and tradition.
Properly performed newborn circumcision prevents phimosis, paraphimosis,
and balanoposthitis and has been shown to decrease the incidence of cancer of
the penis among US men. It may result in a decreased incidence of urinary
tract infection. However, in the absence of well-designed prospective studies,
conclusions regarding the relationship of urinary tract infection to
circumcision are tentative. An increased incidence of cancer of the cervix has
been found in sexual partners of uncircumcised men infected with human
papillomavirus. Evidence concerning the association of sexually transmitted
diseases and circumcision is conflicting.
Newborn circumcision is a rapid and generally safe procedure when performed
by an experienced operator. It is an elective procedure to be performed only
if an infant is stable and healthy. Infants respond to the procedure with
transient behavioral and physiologic changes.
Local anesthesia (dorsal penile nerve block) may reduce the observed
physiologic response to newborn circumcision. It also has its own inherent
risks. However, reports of extensive experience or follow-up with the
technique in newborns are lacking.
Newborn circumcision has potential medical benefits and advantages as well
as disadvantages and risks. When circumcision is being considered, the
benefits and risks should be explained to the parents and informed consent
AAP TASK FORCE ON CIRCUMCISION
Edgar J. Schoen, MD, Chairman
Glen Anderson, MD
Constance Bohon, MD
Frank Hinman, Jr, MD
Ronald L. Poland, MD
E. Maurice Wakeman, MD
David T. Mininberg, MD, Urology Section Liaison
Jerome O. Klein, MD
Edward A. Mortimer, Jr, MD
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Infants. 5th ed. Evanston, IL: American Academy of Pediatrics; 1971
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circumcision. Pediatrics. 1975;56:610-611
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circumcision: implications for changes in the absolute incidence and male to
female sex ratio of urinary tract infection in early infancy.
6. Gairdner D. The fate of the foreskin: a study of circumcision. Br Med
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transmissible disease. Med J Aust. 1983;2:288-290
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mother-infant interaction. Early Hum Dev. 1982;7:367-374
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anesthetic during newborn circumcision. Pediatrics. 1983;71:36-40
48. Holve RL, Bromberger PJ, Groveman HD, et al. Regional anesthesia during
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52. King LR. Neonatal circumcision in the United States in 1982. J
53. Kochen M, McCurdy SA. Circumcision. Am J Dis Child.
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of the penis. Anaesth Intensive Care. 1985;13:79-82
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evoked responses in term infants. Am J Dis Child. 1988;142:160-161
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circumcision. Obstet Gynecol. 1987;70:415-419
The recommendations in this statement do not indicate an exclusive course of
treatment or serve as a standard of medical care. Variations, taking into
account individual circumstances, may be appropriate.
PEDIATRICS (ISSN 0031 4005). Copyright (c) 1989 by the American Academy of