What to tell parents about circumcision

What to tell parents about circumcision

By Jane E. Anderson, MD, and Karl A. Anderson, MD

Whether to circumcise a newborn son is one of the firstdecisions parents must make for their child. Pediatricians can help themsort through the confusion and controversy surrounding the issue by providingaccurate information and answers to their questions.

Since the American Academy of Pediatrics stated in 1971 that there areno valid medical indications for circumcision in the neonatal period, thepractice has generated much controversy and confusion, both in the medicalcommunity and among families awaiting the birth of a child.¹The AAP modified its stand in 1989 to say, "Newborn circumcision haspotential medical benefits and advantages as well as disadvantages and risks."²Since then, more articles have appeared detailing the benefits and risksof circumcision as well as the benefits of giving anesthesia for the procedure.

Pediatricians need to keep abreast of the latest information so thatwe can answer parents' questions accurately and appropriately, especiallyin light of the fact that parents today have access to more medical informationof varying quality than in the past. Our role in talking to parents aboutcircumcision is similar to any other discussion we have with families. Itis our responsibility to provide accurate information in words that parentscan understand, answer their questions to the best of our ability, and thenallow them to make the final decision for their child.

Does circumcision have medical benefits?

Circumcision has been performed from very early times in many culturesaround the world (see Box "The history of circumcision"). Thetable ("Benefits and risks of neonatal circumcision") summarizesits benefits and risks according to current data. Studies suggest that neonatalcircumcision does play a role in preventing some medical conditions, includingpenile carcinoma and urinary tract infection, and may or may not reducethe incidence of sexually transmitted diseases and cervical cancer.

Penile carcinoma. The most certain benefit of neonatal circumcisionis that it prevents later development of squamous cell carcinoma of thepenis. Because of the high numbers of American men who have been circumcisedas infants since 1910, the incidence of squamous cell carcinoma is low,with only about 1,000 new cases identified each year. In 1980, Kochen andMcCurday calculated the lifetime risk at one in every 600 uncircumcisedmales, compared to one in 75,000 to 8 million circumcised males.⁵The risk for uncircumcised males is similar to the lifetime risk of testicularcancer, which is one in 450.

It has been suggested that good hygiene provides as effective protectionagainst penile carcinoma as neonatal circumcision. Although hygiene is important,it does not significantly decrease the risk of cancer. Six major studiesfrom the United States, reporting on more than 1,600 cases of penile cancer,found that no case occurred in a patient who had been circumcised as aninfant.⁶ Around 50,000 cases of penile cancer and 10,000 deathshave been reported in the US since 1930, but only 10 cases occurred in circumcisedmales, indicating that circumcision definitely decreases the risk of cancer.

Urinary tract infections. Circumcision decreases the risk of urinarytract infection (UTI) tenfold in the first year of life, and the decreasedrisk continues for the first five years of life. Ginsberg and McCrackenfirst reported a relationship between circumcision and UTI in 1982. Of 62male infants admitted to the hospital with UTI, they found that 95% wereuncircumcised.⁷ Wiswell's 1985 hospital-based study reportedfewer UTIs during the first year of life in circumcised males.⁸A much larger, two-part study by Wiswell and Roscelli the following yearconfirmed these initial findings.⁹

In the first part of the larger study, which included 3,924 infants bornat Brooke Army Medical Center, the frequency of UTI in uncircumcised maleswas 1.1%, ten times the frequency found in circumcised males (0.1%). Inthe second part of the study, of 422,328 infants born over a 10-year period,uncircumcised males made up only 19.3% of the study population but accountedfor 70.8% of the UTIs. Even more significant, as the rate of circumcisiondecreased over the years, the number of UTIs increased.

Data from 100,000 Swedish children confirmed Wiswell's findings, revealinga risk of 1.1% for uncircumcised males in the first year of life.¹⁰More recently, several reports have demonstrated that the risk of UTI islower for circumcised than uncircumcised males beyond the first year, atleast through 5 years of age. A study published in December by To and colleaguessupports the findings of decreased risk of UTI for circumcised males butnotes that the protective effect of circumcision may be less than previouslythought.¹¹

The physiologic basis for the decreased risk of UTI in circumcised infantsappears to be lower rates of urethral colonization. Several studies, includingsome using electron photomicrographs, demonstrate preferential binding ofuropathogens such as fimbriated Escherichia coli,Pseudomonas, and Klebsiellato the sticky mucosa of the prepuce with no attachment to the outer skin.¹²When Wiswell followed 50 boys from birth through 12 months of age, obtainingurethral cultures at every well visit, he found that uncircumcised boyshad significantly higher total colony counts of uropathogenic gram-negativeorganisms at all ages except 12 months.¹³

As the uncircumcised foreskin becomes increasingly retractable duringthe first year of life, one would expect the differences in colonizationrates between uncircumcised and circumcised boys to decrease. Other issuesto consider when discussing the relationship between circumcision and UTIswith parents include the increased risk of UTIs in children with known urogenitalmalformations and the decreased risk associated with breastfeeding.

Sexually transmitted diseases. Some studies suggest that uncircumcisedmen are less likely to become infected with sexually transmitted diseasessuch as syphilis and human papillomavirus despite exposure to the causativeorganism. The studies often have been contradictory and difficult to interpret,however.

The most intriguing studies concern an increased risk of human immunodeficiencyvirus (HIV) infection among uncircumcised men in Africa. Early in the AIDSepidemic, studies from Africa suggested that uncircumcised, heterosexualmen were four to eight times more likely than circumcised men to contractHIV when exposed. Moses and colleagues reported in 1994 that 22 of 30 studiesconfirmed this association and recommended adult circumcision to decreasethe spread of AIDS.¹⁴

When Caldwell and Caldwell evaluated the factors that might contributeto the 25% infectivity rate in the "AIDS belt," the only factorthey found that differed in the affected populations was lack of circumcision.¹⁵There have been no similar studies from western countries, so the impactof circumcision on the incidence of AIDS among American men is not known.

Cervical cancer. In the 1940s, it was recognized that Jewish womenhad a markedly lower incidence of cervical cancer (2.2/100,000) than non-Jewishwomen (44/100,000). Many researchers attempted to assess whether this wasbecause the Jewish women's partners were circumcised, but most studies yieldedconflicting data. Aitken-Swan and Baird seemingly presented the definitivedata in 1963 when they examined the partners of women with cervical cancerand found no relationship between cancer and circumcision status.¹⁶

New data indicating that uncircumcised men acquire the human papillomavirusmore easily than circumcised men has reopened the question of a possiblerelationship. The issue will most likely remain unresolved, however, becausewomen today are more likely to have other risk factors for cervical carcinoma,including lower age at first intercourse and multiple partners.

What are the risks of circumcision?

The most comprehensive study of complications from circumcision remainsGee's and Ansell's 1976 report of 5,521 males circumcised between 1963 and1972 at the University of Washington, half with the Gomco clamp and halfwith the Plastibell device (described below).¹⁷ The study foundcomplications in 2% of patients, with a significant complication in 0.2%,or 1 patient in 500.

Since circumcision is a surgical procedure, the most recognizable complicationsare bleeding and infection. The most common problem reported by Gee andAnsell was hemorrhage (1%), defined as any excessive bleeding requiringtreatment. Infection occurred in 23 infants (0.4%), more commonly in thosecircumcised with the Plastibell (0.72% vs. 0.14%). Additional studies haveconfirmed the rate of local infection to be approximately 0.5%, with systemicinfection occurring in perhaps one in 4,000 patients.

Among the more serious complications reported by Gee and Ansell werelife-threatening hemorrhage in one patient with hemophilia, infection requiringantibiotics (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, pulmonaryabscess, femoral osteomyelitis, necrotizing fasciitis, and urethrocutaneousfistulas. One 4-month-old whose surgeon used an electrocautery over a Gomcoclamp developed sloughing of the entire penile shaft and was eventuallysurgically transformed into a female.

The mortality rate from circumcision is around one death per 2 millionpatients.Between 1953 and 1993, three boys died from complications of circumcision.During that same period, between 9,000 and 12,000 uncircumcised men diedof penile cancer.¹⁸

Some complications of circumcision are rarely acknowledged, the mostcommon being a poor cosmetic result. A study from Australia revealed that9.5% of circumcisions were actually repeat procedures to correct inadequatelyperformed initial surgery.¹⁹

If too little foreskin is removed, the patient may appear to be uncircumcisedand 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 dataconcerning the eventual outcome are available, but it is theoretically possiblethat the scarring that occurs when the shaft is denuded may later causepain during erections. Such complications may be reduced by using a surgicalmarking pen to delineate the corona of the penile shaft, which is easilyvisible beneath the foreskin, before surgery.

Poor surgical technique can also lead to "concealed" or "hiddenpenis" 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 pullsthe penis in toward the fat pad while covering the glans with the foreskin.

Another common, but seldom mentioned, complication of neonatal circumcisionis meatal stenosis, probably caused by ulceration of the urethral meatuswith subsequent scarring. The urinary stream deviates, often prompting themother to complain that her son "misses the bowl," so the pediatricianwho observes the patient voiding can easily make the diagnosis. Once stenosisis diagnosed, obtain a urinalysis to assure that there is no ongoing irritationor infection and consider a post-void bladder ultrasound, which will demonstrateresidual volume if the obstruction is significant.

If any redundant foreskin remains after circumcision, boys less than3 years of age may develop adhesions associated with a partially or completelycovered glans. Epithelial cellular debris may collect underneath the remainingforeskin and present as firm pearly nodules. Based on his findings of adhesionsin circumcised boys, Van Howe recommended that parents gently pull backany skin overlying the glans until a circumcised child is 15 to 18 monthsof age to prevent adhesions from developing.²⁰

Anecdotal reports cite lower complication rates and improved cosmeticresults with the Mogen clamp, which is used by most Jewish mohels, but noresearch has been published comparing outcomes with the Mogen clamp, Plastibell,and Gomco devices. Such a study is currently ongoing at San Francisco GeneralHospital.

Because the foreskin appears to protect the glans and urethral meatusfrom ammoniacal injury during the diaper period, some have advocated delayingcircumcision until the child is out of diapers. The later procedure, however,would have to be performed in the operating room by a urologist, with highercosts and potentially higher morbidity. Wiswell and colleagues evaluated476 boys circumcised after the newborn period and found complications ineight: excessive bleeding in three patients; malignant hyperthermia in two;and aspiration pneumonia, postoperative fever, and a large hematoma in oneeach.²¹

Is circumcision genital mutilation?

Some people argue that circumcision should not be performed because itconstitutes genital mutilation. The American Academy of Pediatrics releaseda statement on "female genital mutilation" in July 1998, encouragingits members to "decline performing all medically unnecessary proceduresto alter female genitalia."²² The heightened world awarenessof female genital mutilation has raised the question of whether male circumcisionshould also be considered genital mutilation. The fact that both proceduresare 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. Thesubsequent scarring often makes sexual intercourse difficult and painful,if not impossible. Since male circumcision does not contribute to such significantsexual difficulties, many argue that it does not fall into the categoryof mutilation. In addition, unlike ritual clitorectomies, newborn circumcisionsare generally performed by physicians or mohels trained in the procedure.

Opponents of circumcision emphasize that there is no medical necessityfor neonatal circumcision and that removing the protective covering of thesexually sensitive glans during childhood may lead to desensitization withsubsequent decrease in sexual pleasure. These factors, some argue, supportthe contention that male circumcision does meet the criteria for mutilation.Some urge that the surgery be postponed until the patient can make his owninformed decision.

How is circumcision performed?

Circumcision can be performed using the Gomco clamp (preferred by mostobstetricians), the Plastibell, or the Mogen clamp. (See Box, "Threeways to perform circumcision".) When using the Gomco clamp or the Plastibell­­thetwo instruments most often used in the US­­a "dorsal slit"is made to separate the foreskin from the underlying glans. The bell ofthe Gomco clamp or the ring of the Plastibell is then placed over the glansand the foreskin is brought up over the bell or ring. The Gomco clamp compressesthe foreskin between the metal clamp and bell, allowing it to be cut andremoved with minimal bleeding. The Plastibell uses a surgical ligature,which is tied in a groove around the ring. The foreskin is excised and thering with the suture left in place until avascular necrosis causes it tofall 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.

What about pain control?

Physicians once believed that infants through 6 weeks of age could undergocircumcison without feeling pain, but it is now clear that the fetus feelspain as early as 20 weeks gestation. Infants who have experienced pain withcircumcision appear to have increased responses to pain, such as the painassociated with immunizations.²³ Whenever a circumcision is performed,therefore, the infant should receive appropriate analgesia that does notsignificantly increase the risk of the procedure.

A number of studies have documented a decrease in infant crying and heartrate when a dorsal penile nerve block (DPNB), with or without 5% lidocaine-prilocainecream (EMLA), is used to provide anesthesia during circumcision. (EMLA isnot approved by the Food and Drug Administration for babies under 6 monthsof age, although no adverse effects have been reported when it is used duringcircumcision.)

Physicians using these methods must take care with drug dosages and administrationto avoid the possible complications associated with systemic lidocaine,such as cardiac arrhythmias and seizures.A dose of 0.7 mL of 1% lidocaine­­withoutepinephrine, which can cause dangerous side effects­­can be usedsafely for DPNB.²⁴

Sucrose solution given orally­­on a pacifier, for example­­hasbeen found to decrease infant pain responses to heel sticks, immunizations,and circumcisions and certainly does not add to the risk of the circumcisionprocedure. Additional analgesia, such as oral acetaminophen suspension (10to 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 ofthe foreskin in reconstructive surgery is an absolute contraindication tocircumcision. The most common abnormality is hypospadias, which occurs inat least 1:235 male births but has recently been increasing in frequency.A complete exam of the genitalia, looking carefully along the ventral surfacefor second, third, or fourth degree hypospadias, is essential before performingcircumcision.

Since the foreskin is not retractable, first degree hypospadias may notbe 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, termeda "dorsal hood," which leaves the ventral surface of the glansexposed. A chordee, a band of fibrous tissue of corpus spongiosum alongthe ventral surface of the shaft, causing a curvature of the penis, mayalso, though not always, accompany hypospadias.

Infants with ambiguous genitalia and those who are ill or significantlypremature should not undergo circumcision. Excessive oozing of blood afterthe heel stick is another contraindication since it may indicate a hemorrhagicdiathesis that could cause severe bleeding after circumcision.

Ideally, circumcision should NOT be performed in the first 24 hours afterdelivery, when the infant is still adjusting to extrauterine life and neonatalillness may not yet be apparent. Obviously, it should never be done withoutparental consent.

Is circumcision ever medically necessary?

There are no medical indications for neonatal circumcision. As a childmatures, however, he may develop phimosis, requiring surgical correctionto relieve the obstruction. Paraphimosis, the persistent retraction of theforeskin along the shaft of the penis, causes lymphatic and venous obstruction,which can lead to arterial compromise. Surgical relief may be provided bya dorsal slit in the foreskin, so the patient can choose to have a circumcisionor to have the dorsal slit sutured after the swelling has resolved.

Recurrent episodes of balanitis (inflammation of the glans) would bean indication for circumcision, but balanitis is rarely seen except in tropicalcountries or older patients with diabetes.

More common in the US is posthitis, inflammation of the outer layer ofthe foreskin, which is often caused by gram-negative bacteria and Candidaalbicans.Since the prepuce is composed of two layers, inflammation of theouter layer does not injure the underlying glans, which is protected bythe inner layer. Thus, circumcision may not be indicated for patients whohave recurring episodes of posthitis.

What care do uncircumcised boys need?

Parents of uncircumcised infants should be instructed NOT to attemptto retract the foreskin or use cotton swabs to clean underneath it. As Gairdnerdemonstrated in 1949, the clefts in the stratified squamous epithelium betweenthe glans and foreskin develop gradually and very few newborns have retractableforeskins.²⁵ By 1 year of age, 50% of boys have partially retractableforeskins. The foreskin is completely retractable in 80% of 3-year-old boysand 99% of 17-year-olds.

Normal bathing maintains cleanliness until the foreskin becomes easilyretractable. Once it does, the parent, and later the child, can gently pullit back, wash the glans, and replace the foreskin over the glans.

In light of the natural development of the foreskin, the historic pediatricin-office procedure of "freeing adhesions" by passing a probebetween glans and foreskin is medically unfounded. Moreover, it can causepain, bleeding, and adhesions.

Phimosis has been inaccurately diagnosed in newborns simply because theforeskin is unretractable. The diagnosis should be reserved for boys whosepreputial 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 complaintby several of our patients' mothers.

True phimosis cannot develop until after the foreskin has separated fromthe glans, and thus cannot be present at birth. Oster's data on 1,968 uncircumcisedDanish boys between 6 and 17 years of age who were examined annually forup to eight years demonstrated that uncircumcised boys have a small incidenceof preputial adhesions and true phimosis, which appears to decrease normallywith age.²⁶

An interesting recent observation is that 5- and 6-year-old boys whowere circumcised for phimosis were noted to have lichen sclerosis et atrophicuson pathological review. Lichen sclerosis in prepubertal girls responds wellto topical corticosteroid treatment. In 1995, Wright published a prospectivestudy of 111 boys referred for surgical treatment of phimosis who were insteadtreated with topical betamethasone cream for one month. Treatment was successfuland circumcision was avoided in 80%.²⁷ A more recent evaluationof the costs associated with treating phimosis showed topical steroid therapyusing betamethasone 0.05% cream for four to six weeks to be so effectivethat the author recommends trying treatment with the cream before consideringcircumcision.²⁸

Is circumcision cost-effective?

Several authors have attempted to calculate the cost-benefit ratio ofcircumcision, but most have used inaccurate or old data. In 1987, approximately1.95 million infant boys were born, and if they had all been circumcisedat $100 per procedure, the total cost would have been $195 million. Basedon these figures, Ross and Elder calculated the cost of preventing one urinarytract infection by circumcision at $2,000 to $8,000 and the cost of preventingone case of penile cancer at around $45,000.⁴

A report from Ontario, Canada, estimated that the cost of universal neonatalcircumcision would be twice the cost of medically indicated circumcisionsperformed in adult men. When the figures were adjusted for days lost fromwork and cost of hospitalization, however, neonatal circumcision was themore economical approach.²⁹

What role for the doctor?

Although Patel demonstrated in 1966 that physicians can influence parentaldecisions, newer studies reveal that parents choose circumcision for twomajor reasons, neither of which is affected by medical information.^30,31The strongest factor associated with neonatal circumcision was the circumcisionstatus of the father. Another significant factor was religious beliefs.These influences notwithstanding, pediatricians should still provide familieswith accurate medical information to assist them in this important decision.Some of the questions a pediatrician might review with parents are discussedin the Parent Guide below.

The decision whether or not to circumcise a newborn son is especiallyimportant for parents, since it is usually the first decision that theymust make together for another human being. When parents have a difficulttime with this decision, it often indicates that they are having problemswith communication in other areas, and pediatricians should be reluctantto step in with advice. It is far better to help parents recognize theircommunication difficulties and provide supportive resources than to promotea decision that the family may later regret.

PARENT GUIDE

If your baby is a boy . . .

. . . you will be asked if you want him circumcised. This is a matteryou should think about very carefully before your baby is born. Circumcisionsare usually done soon after birth. Many parents prefer to discuss theirquestions with the pediatrician well in advance, so that they have timeto 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 sensitiveend (glans) of the penis. A circumcision is an operation to remove thisskin, leaving the end of the penis uncovered. The procedure takes about15 minutes to perform. Newborn babies can feel pain, so most doctors uselocal anesthesia (medicine to decrease pain). Ask your doctor about this.Even when local anesthesia is used, babies may feel some pain for a shorttime after the operation.

Why are circumcisions performed?

Circumcisions are done for many reasons. Moslems and Jews perform circumcisionsfor religious reasons. Other people choose to have their sons circumcisedso that the baby will look like his father. There are many countries inthe world where circumcision is almost never done.

Circumcision is not required by law and is not medically necessary. Itdoesn't affect future sexual enjoyment and won't prevent a man from becominginfected with most sexually transmitted diseases, although it may decreasethe chances of acquiring some of these diseases.

Circumcision of newborn boys does help prevent cancer of the penis. Therisk that an uncircumcised boy will develop cancer of the penis in laterlife is about 1 in 600. Careful attention to cleanliness may help decreasethe risk in men who are uncircumcised. Circumcision also decreases the riskthat a baby boy will develop a urinary tract infection during his firstfew years of life. Uncircumcised boys have a 1% risk of developing a urinaryinfection 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 largestudy found that about two babies out of every 100 had a problem followingsurgery. The most common problems are:

• Heavy bleeding, rarely requiring blood transfusion. Bleeding happens in 1 of 100 babies who are circumcised.
• Infection of the penis. This happens in 1 in 500 babies and, rarely, may require treating the baby with intravenous antibiotics.
• 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?

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 bathingyour baby, you are keeping the penis clean. After the baby is 1 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 placethe foreskin back over the end of the penis. If you cannot pull the foreskinback, don't worry. This is perfectly normal and you can try again in a fewmonths. 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 teachhim to clean his penis.

It is your decision

Before you decide to have your son circumcised, it is important thatyou understand what the operation is and what the possible problems are.Please ask your nurse or doctor any questions you may have before you signthe consent form. Your nurse or doctor will show you how to care for yourbaby after the operation.

THE AUTHORS:
DR. JANE ANDERSON is Associate Clinical Professor of Pediatrics at the UCSF/MountZion Medical Center, San Francisco.
DR. KARL ANDERSON is Chief, Department of Urology, The Permanente MedicalGroup, San Francisco.

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What to tell parents about circumcision. Contemporary Pediatrics 1999;0:087.