Thomas E. Wiswell, M.D., F.A.A.P.
Professor of Pediatrics, Division of Neonatology, Jefferson Medical College, Philadelphia, Pennsylvania
Neonatal circumcision is one of the most commonly performed surgical procedures in the United States. At least 1.2 to 1.8 million newborn boys are circumcised each year. Widespread sentiment against the procedure developed during the 1970s and 1980s. It was generally believed that there were limited or no potential medical benefits of the procedure (1,2). Ironically, as the anticircumcision movement grew and the circumcision frequency rate declined (3), evidence was gathered linking neonatal circumcision with numerous health related benefits (4,5). The 1989 American Academy of Pediatrics (AAP) Task Force on Circumcision report (4) was a striking revision of its predecessors and concluded there were "potential benefits and advantages" of neonatal circumcision.
Numerous scientific studies have been published concerning circumcision since the latter report, in contrast to the previous relative dearth of sound investigations. In this review, I will discuss recent developments concerning neonatal circumcision. It is difficult to find accurate data regarding the circumcision frequency rate (CFR) among neonates and older males in the United States as well as the rest of the world.
The published data are often anecdotal or "best guesses".
Most reports estimate an 85% to 98% CFR in the United States from mid-1940s through the mid-1970s (6). The National Center of Health Statistics (NCHS) has been referenced regarding approximations of the CFR in the United States since the mid 1980s.
Unfortunately, the NCHS only collects voluntary data from participating hospitals. Fewer than 5% of hospitals in the United States have their records reviewed by the HCHS.
Moreover, many of these institutions do not document neonatal circumcision as a specific procedure on the medical record. For such centers, despite having performed circumcisions on the majority of newborns males, the NCHS would assess a CFR of 0%.
The HCHS data reveal an apparent decline in the national CFR from approximately 68% to 62% during the mid-1980s. I have been fortunate to have access to the comprehensive database of the United States Army Patient Administration Systems and Biostatistics Activity at Ft. Sam Houston, Texas.
During various investigations, I have compared their data concerning newborn circumcisions with the information physically recorded on the hard copies of the infants' medical records. I have found their data to be highly accurate.
The United States Army hospitals are located nationwide and there are a number of hospitals overseas. The first reports linking UTI and the uncircumcised state appeared in the 1980s (8,11,12).
However, the 1989 AAP task force report concluded this evidence was only preliminary (4). Subsequent to the 1989 statement, numerous other studies have appeared linking the the presence of a prepuce to UTI (at least 11 total publications) (7,13).
A meta-analysis of the published reports found at least a 12-fold increased risk for UTI among uncircumcised male infants. The risk is also increased among male children between 1 and 16 years of age (13) and adult males (14).
There are no contrary data. Urinary tract infections are not benign. A high proportion of infants may have concomitant bacteremia (11,15), whereas renal scarring and its sequelae are not uncommon (16). Circumcision categorically prevents penile cancer. Of approximately 50,000 men with cancer of the penis from 1932 through 1986, only 10 were known to have been circumcised as newborns (17). Recent reports confirm the relationship between this malignancy and the presence of the prepuce (18,19).
Opponents of the procedure claim the incidence of this malignancy is too rare to be of concern, claiming an incidence in the United States of 1 per 100,000 males. However, the overall incidence of penile cancer is 1 per 100,000 per year of life, or approximately 75 per 100,000 during each man's lifetime. Moreover, this represents the overall incidence for all men in the United States (approximately 70% of whom are circumcised).
Because the malignancy virtually only occurs in the 30% of men who are uncircumcised, the incidence of the malignancy would be 75 per 30,000 uncircumcised males, or 1 per 400 for a lifetime risk. This is similar to the 1:600 risk estimated by Kochen and McCurdy (20). Human papillomavirus (HPV) has been implicated in the pathogenesis of this malignancy (21). Epidemiologic evidence links cervical cancer and the uncircumcised status of the affected woman's primary partner (22-24). Furthermore, HPV has similarly been linked to the development of cervical cancer. The latter virus is sexually transmitted.
The interaction between HPV, an intact foreskin, and the two malignancies (penile and cervical cancer) is an intriguing one. There is ongoing research evaluating these relationships. Similar to HPV, virtually every sexually transmitted disease (STD) has been found to be more common among uncircumcised men (26-30).Moreover, reports during the past 6 years have revealed a 5- to 10-fold increased risk for HIV conversion among uncircumcised men (31-37). Theories (27) regarding the increased risk for STDs include: trauma of the intact foreskin or frenulum during intercourse causing microabrasions that facilitate infection; a more "hospitable" environment under the prepuce conducive to survival and multiplication of organisms causing STDs; a relatively "thinner" epithelium on the glans of uncircumcised men may represent less of a physical barrier; and acute or chronic balanitis (rare in circumcised men) may predispose to STDs. An additional possible mechanism for HIV infection relates to the presence of a high concentration of Langerhans cells in the human prepuce (35, 38). These are intraepithelial cells that are a component of the immune system. These cells are known to be target cells for simian immunodeficiency virus (39) and may play a similar role in human HIV infection. Weiss et al, (38) speculate about the role of Langerhans cells in the pathophysiology of penile cancer. Balanitis and posthitis are exquisitely painful infections that are virtually limited to uncircumcised males (15, 40-43, 46). Chronic balanoposthitis may result in scarring, which can cause a secondary phimosis (42, 44). Pathologic phimosis may result in acute urinary retention, vesicoureteral reflux, and hypertension (45). Although conservative medical therapy may be used for these disorders, they frequently recur and ultimately necessitate removal of the prepuce (42, 43). There are other problems uniquely associated with the uncircumcised state.
Uncircumcised boys may catch and entrap their foreskin in the process of zipping or unzipping their clothes. Considerable trauma, swelling, and scarring of the injured prepuce may result. This painful predicament typically is managed by circumcision. However, Nolan et al,(47) have recommended the use of a heavy bone cutter or wire snippers to cut the bars of the zipper to release the foreskin. Nursing home caregivers have stated that uncircumcised elderly men have more problems with infection and pain (from balanoposthitis, phimosis, and paraphimosis) than their circumcised peers (48). Moreover, it is more difficult to achieve optimal hygiene among gentlemen who have prepuces. Boys and men with foreskins often do not retract the tissue during micturition (R.Jarrett and A.Fink, personal communications as well as my personal experience). The resultant "splatter" phenomenon typically leads to urine all over the toilet and floor, rather than into the toilet.
Although this process generally does not bother men, the women (mothers and partners) who clean up after them are often enraged. There are no scientific data substantiating that circumcised males have any long-term problems compared with their uncircumcised peers (e.g., psychological, social, emotional, sexual function, or sexual pleasure). By contrast, there may be psychosocial effects from being uncircumcised. Schlossberger et al, (49) recently have found that uncircumcised adolescent boys were more likely to be dissatisfied with their circumcision status than their circumcised colleagues. Moreover, in July 1994 at an institution affiliated with my university, a 14 year old boy was admitted with bleeding and other complications after he performed a "self circumcision." The child apparently had grown tired of being ridiculed by schoolmates because he had a prepuce. He tried to resolve the issue of the tissue himself. Informed consent concerns a patient's rights of self-determination for medical or surgical treatment. The ability to make medical decisions requires the intellectual and emotional capacity to understand risks and benefits. Parents are the logical surrogates to give proxy consent for their children. Parents have the legal right to authorize medical care and treatment for their children, including surgical procedures. It has never been otherwise. The overriding bioethical principle is to act in the childs best interest. Thus, parents may only give proxy consent for interventions they believe will further the childs well-being. For them to make such a decision they need unbiased, full disclosure of information. For any type of informed consent (including circumcision), patients (or parents) need to be told in comprehensive language the nature and purpose of the treatment, the risks and the benefits of such therapy, prognosis if treatment is declined, and any alternative methods of therapy. The counseling physician is required to disclose all information that any reasonable physician would disclose under similar circumstances, as well as all information that a reasonable patient (or parent) might want to know. The information must be objective, not subjective, in nature. Inspired by the anticircumcision movement, I am aware of a handful of lawsuits filed by the families of circumcised boys years after the procedure. The family claims that the child did not give his personal informed consent (although the parents gave theirs before the procedure). The plaintiffs have invariably lost cases in which the parents gave their informed consent as legal proxies at the time of the original counseling. The fact that they apparently changed their minds later does not change the fact that their original consent was legally binding. What specific risks and benefits of neonatal circumcision do I include during informed consent counseling? I have combined data from many resources to come up with reasonable approximations that I quote to the parents.
These estimates of potential risks and benefits are presented in Tables 1 and 2.
The most commonly used devices for neonatal circumcision are the GOMCO clamp, the MOGEN clamp, and the PlastiBell. To date, there are no scientific data demonstrating that any of these are the best method. My advice for the health care professional who performs circumcisions is to become competent with one of these instruments and only use that one. I conclude that the best time to perform the procedure is during the neonatal period. The child will not need ligatures or general anesthesia, nor will the boy need additional hospitalization. The pain lasts, at most, for 12-24 hours. The complication rate is low at 0.2% (15), and there is no evidence the child remembers the procedure. The cost is low (approximately $100-$150). Older children (aged 4 months to 15 years) usually have general anesthesia (with its own attendant risks) and require ligatures (9). The child is often hospitalized overnight.
There may be substantial complications (9), although their occurrence is infrequent (1.7%). The postoperative pain lasts for days, and the children older than 1-2 years may remember the incident. It is more expensive to circumcise an older child (approximately $1000). In adults, ligatures are used and overnight hospitalization generally is required (although occasionally it is performed on an outpatient basis). The procedure may be performed under local or general anesthesia ( the latter is still most commonly used). The frequency of complications is unknown. Adult males are typically "laid-up" for at least a week and miss work or school for this period. The pain generally lasts for 1-2 weeks, and the procedure is more expensive in adults (at least $2000-$4000). A child generally is tightly strapped down flat on a "papoose board" while undergoing neonatal circumcision . A more "humane" approach would be to bind the infant more loosely to swaddle and ensure warmth.
A pacifier should be provided (the act of suckling may provide antinociception). I am intrigued by the restraint system recently invented by pediatrician, Dr. Howard J. Stang. In my experience using this apparatus, children seem to be more comfortable while undergoing the procedure. I believe all boys undergoing circumcision should receive analgesia, a topic I will discuss next. General anasthesia and systemically administered narcotics may be associated with devastating side effects and should be avoided in neonates. Oral ethanol is the most commonly used analgesic in London Ontario, (53). There are, however, no scientific studies of ethanol's efficacy as an anesthetic in newborns. Because ethanol can be associated with substantial toxicity, I would avoid its use. The 1975 Ad Hoc Task Force on Circumcision stated that "... good personal hygiene would offer all the advantages or routine circumcision without the attendant surgical risk" (2). Many have interpreted this statement as meaning that lifelong dedication to "optimal" penile hygiene would serve equally well to prevent penile cancer, balanitis, UTIs, STDs, etc. The statement sounds reasonable. Nonetheless, it is only a conjecture.
There are absolutely no published investigations to support it. Although I certainly support a commitment to adequate genital cleaning in uncircumcised individuals, I cannot yet say that it will mitigate or prevent any of the aforementioned disorders, even to a small extent. At the height of the anti-circumcision sentiment during the early 1980's formal groups opposed to the procedure were formed. These incude BUFF (Brotherhood United for Future Foreskins). INTACT (Infants Need To Avoid Circumcision Trauma), and the largest organization, NOCIRC (National Organization of Circumcision Information Resources Center). The latter group sends out a newsletter periodically to its members and to physicians. In addition, it has sponsored several symposia on circumcision. These latter meetings have been forums for anticircumcision advocates to vocalize their positions. Members of the anticircumcision movement generally refer to the procedure as "rape, butchering, amputation, or torture." During the past decade, the literature and letters I have received from these organizations have made many claims. These include: that circumcision encodes the brain with violence...which is why America is the "murder capital" of the world; that long-term effects of the procedure include suicide, sudden infant death syndrome, and homosexuality; that male circumcision should be considered equivalent to elective removal of the clitoris and labia in female children: that men without prepuces feel a loss, relive the violence, are not "whole" and have a "diminished penis"; that the loss of erotic tissue in the prepuce diminishes sexual pleasure and function; and that the reasons physicians advocate neonatal circumcision are twofold-to make money and to "pay back" for the pain they had when they were circumcised themselves. If a circumcised man feels naked without a prepuce, there are several suggested methods to attempt restoration.The most radical of these is a multistaged surgical procedure (62) in which the penile shaft is denuded of skin, which is pushed forward to create a new foreskin. The denuded penis is surgically buried in the scrotum. Months later, "Z-plasty" is performed and scrotal skin is used to form the penile shaft skin. I am aware of other types of attempting foreskin restoration that are variants of stretching the penile shaft skin forward by means of tape, cones, or weights (known as "foreballs"). There are no scientific data concerning the success of these latter methods. The many issues surrounding neonatal circumcision are complex and controversial. A great deal of information concerning the subject has been published during the past 10 years. Pediatricians generally deal more with the untoward complications of circumcision (bleeding, infection, etc.) than with the potential benefits of the procedure (prevention of penile cancer, STDs, AIDS, etc.), which accrue over a lifetime. Health care providers who deal with children need to familiarize themselves with the most current literature concerning circumcision and to be able to objectively assess it.
Permission: Mosby-Year Book, Inc., Focus & Opinions: Pediatrics, Volume 1, number 2, 1995.
Introduction
Circumcision Frequency Rate
I believe this database information to be the most accurate available reflecting the CFR, and it may best approximate true CFR trends in the United States.
There have been more than 450,000 boys born in the Army hospitals from 1970 to 1994. We found a decline in the CFR (3,7) from approximately 88% in the early 1970s to 70% in 1984. I believe this reflected the influence of the general anticircumcision AAP position of 1971 to 1975 (1,2).
Army pediatricians during that period (of which I was one) generally counseled against the procedure. However as data became available linking urinary tract infection (UTI) and the presence of a prepuce (7,8), as well as the 1989 AAP statement regarding other potential medical benefits of the procedure (4), the circumcision frequency rate had subsequently increased to a level greater than 80% by 1992 (7,9).
Lyon reported a similar increase in the CFR of neonates in Alaska since 1985 (10).Urinary Tract Infections
Penile Cancer
Cervical Cancer
Sexually Transmitted Diseases
Balanitis, Posthitis and Phimosis
Other Issues in Uncircumcised Males
Risks, Benefits, and Informed Consent Counseling
Table 1.-Risks of Neonatal Circumcision
-Subsequent surgery is needed in approximately 1 per 1,000 boys. This is typically for skin bridges or for having too much or too little foreskin removed.
Note: Estimates were compiled from myriad resources.
*Information from Schoen EJ, Aderson G, Bohon C, et al: Pediatrics 84:388-391, 1989.
(Courtesy of Dr. Wiswell.)Table 2.-Benefits of Neonatal Circumcision
Note: Estimates were compiled from myriad resources. All rates are substantially higher than in circumcised individuals. (Courtesy of Dr. Wiswell.)
Devices
Best Time in Life to Perform Circumcision
A More "Humane" Approach
Analgesia
Children experience pain during circumcision and for the first few hours afterward (50-52). They react appropriately with behavioral, physiologic, and hormonal changes. Historically, however, the procedure has been performed with little attention to pain alleviation. Nonetheless, Wellington and Reider (53) found that fewer than 25% of practitioners use any form of analgesia.
Personally, I have good success with the most widely used method of analgesia, the dorsal penile nerve block (54-56). In my experience during the past decade, approximately 80% of boys achieve good analgesia. Complications from nerve block are rare. Ryan and Finer (56) quote a series of more than 3,800 boys undergoing the procedure, none of whom had serious complications. A spontaneously resolving hematoma at the site of anesthetic injection is the only commonly seen sequela.
Howard and colleagues (57) recently reported a study of acetaminophen for analgesia before and after neonatal circumcision. Acetaminophen was not found to ameliorate either the intraoperative or the immediate postoperative pain of circumcision.
Masciello (58) described the use of local infiltration of lidocaine into the prepuce at the level of the corona of the glans penis. Although it appeared to be efficacious, only 10 patients were studied. Blass and Hoffmeyer (59) noted a sucrose-flavored pacifier to reduce crying time during circumcision in a small number of children. Finally, Weatherstone et al,(65) as well as Benini and colleagues (61) recently examined the use of topical anasthetic creams (30% lidocaine and EMLA, respectively) in relatively small numbers of newborns. Both groups of investigators found these creams to provide some degree of analgesia. The preliminary work regarding the different methods of analgesia mentioned in this paragraph warrant further investigation.Hygiene
Claims of Anti-Circumcision Groups
There is no scientific foundation for any of these claims or for the myriad other assertions of these organizations. The groups attempt to support their conjectures with a handful of testimonials.Foreskin restoration
Summary
References