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Circumcision Update—2009

John S. Wiener, MD, FAAP, FACS; Haywood Brown, MD, FACOG

The decision to circumcise a male newborn may be based on religious, medical, hygienic, or sexual reasons. Circumcision should be discussed with the female patient during pregnancy so that an informed decision can be made. In all cases where circumcision is chosen, penile anesthesia should be used.

History

Male circumcision was performed as early as 12,000 years ago. Typically a rite of passage into manhood, the Jewish religion introduced it as a rite of infancy. It was decreed in the early days of Christianity that circumcision was not necessary for a non-Jew or infant to become a Christian. Subsequently, circumcision remained an uncommon procedure in the Western world, mostly confined to those of the Jewish faith, until modern times.1

The late 19th century brought changes to modern medical practices and public health. Physicians began promoting circumcision as a means for a healthier society. In 1914, Abraham Wolbarst wrote in the Journal of the American Medical Association (currently JAMA) that circumcision was “a great aid to cleanliness,” was a “prophylaxis against a variety of venereal diseases,” and led to a “diminished tendency to masturbation” (prevalent thought of that time was that masturbation led to physical and moral decline). He furthermore proclaimed, “It is the moral duty of every physician to encourage circumcision in the young.”2 Approximately 30% of newborn males in the United States were circumcised by the 1930s, and the prevalence soared to 91% by the 1970s.3 This increase in circumcision occurred in parallel with the trend of nearly all US births taking place in hospitals. While obstetricians have become responsible for performing the majority of newborn circumcisions, the procedure is also performed by pediatricians, urologists, and other practitioners, with local variation depending on hospital practice patterns.3,4

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Benefits

An American Academy of Pediatrics (AAP) task force in 1975 concluded, “There is no absolute medical indication for routine circumcision of the newborn.”5 Yet, 14 years later, the AAP amended the statement, concluding that “newborn circumcision has potential medical benefits and advantages as well as disadvantages and risks.”6

Most compelling was evidence that circumcision reduced the risk of urinary tract infection (UTI) in boys. A recent meta-analysis of 12 studies with more than 400,000 children found an 87% reduction in the incidence of UTI in circumcised boys.7 Although an impressive reduction, the authors could not recommend routine circumcision, because only 1% to 2% of males experience UTI during childhood. However, they suggested that circumcision be considered in boys with a higher risk of UTI, such as those with congenital uropathies.

Early reports of a protective effect of circumcision against common sexually transmitted diseases, specifically syphilis, gonorrhea, and herpes, were flawed by selection bias. Whether circumcision is protective against infection with human papillomavirus (HPV) remains controversial, but the evidence slants toward a higher prevalence of HPV in uncircumcised men.8 In parallel, there has been an observed higher risk of cervical cancer among female partners of uncircumcised men.9 Penile cancer has a low prevalence in the United States and is exceedingly rare in males circumcised in childhood.

The debate over the protective effects of circumcision has recently been ignited by data from sub-Saharan Africa, suggesting a higher transmission rate of human immunodeficiency virus (HIV-1) to uncircumcised men. A recent meta-analysis of 13 studies investigating transmission rates of HIV to circumcised men found an odds ratio of 0.44 (or 56% reduction) compared with uncircumcised men.10 The protective effects appear to be limited to circumcised men having heterosexual sex, and this protection does not appear to be conferred to female partners.11

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Risks

Any potential benefits of neonatal circumcision must be weighed against the risks. The overall complication rate after newborn circumcision varies from 0.2% to 10%.12,13 Complications can occur with any of the techniques or devices (Table 1). The ultimate complication, death, was reported regularly in the early 20th century and was usually secondary to hemorrhage in unrecognized hemophiliacs. Bleeding requiring transfusion occurs infrequently in the present era. Infection can be local or systemic and is more common with the Plastibell device (Figure 1) because the plastic ring and necrotic edge of the prepuce is left at the completion of the procedure to fall off days later.12 Complete amputation of the penis has been reported from the application of electrocautery to a metal Gomco clamp (Figure 2). Partial amputation of the distal penis/glans can occur with the Mogen clamp, because the glans is not reliably protected below the clamp when closed as it is by the bell of the Gomco or Plastibell clamp. Skin separation and denuding of the shaft can occur, particularly with the Gomco or Mogen clamps; this has little to do with the device but is more related to the skill of the practitioner in retraction of the foreskin. Fortunately, skin separation is rarely a long-term concern, because the newborn skin grows rapidly to cover the gap.

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TABLE 1. Common Complications of Newborn Circumcision

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FIGURE 1. Plastibell device for circumcision.

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FIGURE 2. Gomco clamp for circumcision.

Poor cosmesis is the most common complication and source of parental dissatisfaction. Typically, this is the result of congenitally loosely attached shaft skin, which allows the skin to telescope back over part or all of the glans, giving the appearance that not enough foreskin was removed. In the most severe cases, the circumcision scar can slide beyond the glans and constrict into a cicatrix that conceals the penis. Skin can adhere to the denuded glans as either simple adhesions that will resolve spontaneously or thick skin bridges that must be surgically excised. Stenosis of the urethral meatus may be considered a delayed complication of circumcision.

An issue of both academic and medicolegal debate is the effect of circumcision on penile sensation. One study in the urologic literature found no significant alteration in somatosensory testing on the glans penis in neonatally circumcised men, whereas another found decreased sensitivity of the glans in circumcised men and noted that circumcision ablated the most sensitive parts of the penis.14,15 A recent report of male sexual satisfaction and function after circumcision in adulthood as part of HIV prevention trials in Uganda showed no adverse effect.16 In the only study to compare sexual satisfaction in female partners of circumcised versus uncircumcised men, all measures were more favorable with uncircumcised men.17

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Current Prevalence

The medical community and lay press continue to debate the relative merits and risks of circumcision. This has further confused parents who, while ambivalent about the procedure, typically make the decision for or against circumcision based on personal, rather than medical, reasoning.18 Circumcision is no longer an automatic part of the postnatal stay in American hospitals. Increased immigration from parts of the world where neonatal circumcision is the exception has contributed to a significant drop in the prevalence of circumcision. Current estimates of the prevalence of circumcision in males older than 15 are 75% in the United States, compared with 30% worldwide.19 The most recent US data analyzing hospital births noted the nationwide proportion of newborn males undergoing circumcision was 56%, with regional variation from 31% in the West to 78% in the Midwest.20

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Circumcision Techniques

The most common techniques in the United States involve the Gomco clamp and the Plastibell device, but there is also significant use of the Mogen clamp. The Gomco and Plastibell clamps are size-based on the diameter of the newborn’s glans penis (Gomco: 1.1, 1.3, 1.45, and 1.6 cm; Plastibell: 1.1, 1.2, 1.3, 1.4, 1.5, and 1.7 cm). When properly performed, there is little difference in outcome between the devices.12 The potential for specific complications are somewhat related to the nature of each device. Bleeding is less problematic with the Plastibell device because the tourniquet effect on the skin remains after the procedure. Those who favor the Mogen clamp cite speed and ease as reasons for it being the least painful, but the absence of a bell to protect the glans makes it more risky for damage to the glans.

The first step in neonatal circumcision is obtaining informed consent. According to the latest AAP guidelines, “To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision.”21 Ideally, this conversation should occur during the prenatal period. (The AAP Web site includes a short balanced presentation at www.aap.org/publiced/BR_Circumcision.htm.)

The same AAP guidelines also state, “If a decision for circumcision is made, procedural analgesia should be provided.” There is unequivocal evidence that circumcision is a painful event to newborns, and measures should be undertaken to minimize discomfort (Table 2). Soothing measures, such as touch therapy, music therapy, and use of a pacifier dipped in glucose solution, are all helpful. Administration of acetaminophen before and 6 hours later is prudent. Penile anesthesia should be used in all cases. A randomized controlled trial of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision found that ring block with 1% lidocaine (without epinephrine) was superior in minimizing pain, as measured by neonatal heart rate and high-pitched crying during the procedure (Figure 3).22

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TABLE 2. Analgesia Algorithm for Newborn Circumcision

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FIGURE 3. Technique of ring block. Use 1% plain lidocaine 0.5 mL/kg up to 2 mL. Using a 27-gauge needle, inject one-quarter of total amount in each of 4 quadrants as shown. A single dorsal puncture site can be used to instill the lidocaine into the first 2 quadrants. Separate lateral injections are preferred to avoid urethra injury. Direct the needle path in the subcutaneous (dartos) layer to create a skin wheal. Direct injections as proximal as possible on the penile shaft to prevent distortion of the shaft. Allow several minutes for the nerve block to become effective.

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CONCLUSION

Neonatal circumcision has limited medical benefits as well as potential risks. Parents should be apprised of these prior to giving informed consent. Many American parents are uninformed of the risks and the limited benefits because of the universality of circumcision a generation ago. All efforts should be made to minimize discomfort to the newborn. A variety of techniques are available to perform circumcision; proper training and competence in the various techniques, as well as an appreciation for the complications, is a must for any practitioner.

The authors report no actual or potential conflicts of interest in relation to this article.

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John S. Wiener, MD, FAAP, FACS, is Associate Professor of Surgery and Pediatrics and Head, Section of Pediatric Urology; and Haywood Brown, MD, FACOG, is Professor and Chair, Department of Obstetrics and Gynecology; both at Duke University Medical Center, Durham, NC.

References

1. Glick LB. Marked in Your Flesh. New York, NY: Oxford University Press; 2005.
2. Wolbarst AL. Universal circumcision as a sanitary measure. JAMA. 1914;62(2):92-97.
3. Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States: prevalence, prophylactic effects, and sexual practice. JAMA. 1997;277(13):1052-1057.
4. Stang HJ, Snellman LW. Circumcision practice patterns in the United States. Pediatrics. 1998;101(6):e5.
5. Thompson HC, King LR, Knox E, Korones SB. Report of the ad hoc task force on circumcision. Pediatrics. 1975;56(4): 610-611.
6. Schoen EJ, Anderson G, Bohon C, Hinman F Jr, Poland RL, Wakeman EM. Report of the 1987-88 Task Force on Circumcision. Pediatrics. 1989;84:388-391.
7. Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Arch Dis Child. 2005;90(8):853-858.
8. Hernandez BY, Wilkens LR, Zhu X, et al. Circumcision and human papillomavirus infection in men: a site-specific comparison. J Infect Dis. 2008;197(6):787-794.
9. Castellsagué X, Bosch FX, Muñoz N, et al. Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. N Engl J Med. 2002;346(15): 1105-1112.
10. Byakika-Tusiime J. Circumcision and HIV infection: assessment of causality. AIDS Behav. 2008;12(6): 835-841.
11. Wawer M, Kigozi G, Serwadda D, et al. Trial of male circumcision in HIV+ men and in women partners in Rakai, Uganda. 15th Conference on Retroviruses and Opportunistic Infections. February 3-6, 2008; Boston, MA.
12. Gee WF, Ansell JS. Neonatal circumcision: a ten-year overview: with comparison of the Gomco clamp and the Plastibell device. Pediatrics. 1976;58(6):824-827.
13. Williams N, Kapila L. Complications of circumcision. Br J Surg. 1993;80(10):1231-1236.
14. Bleustein CB, Fogarty JD, Eckholdt J, Arezzo JC, Melman A. Effect of neonatal circumcision on penile neurologic sensation. Urology. 2005;65(4):773-777.
15. Sorrells ML, Snyder JL, Reiss MD, et al. Fine-touch pressure thresholds in the adult penis. BJU Int. 2007;99(4):864-869.
16. Kigozi G, Watya S, Polis CB, et al. The effect of male circumcision on sexual satisfaction and function, results from a randomized trial of male circumcision for human immunodeficiency virus prevention, Rakai, Uganda. BJU Int. 2008;101(1):65-70.
17. O’Hara K, O’Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int. 1999;83 suppl 1:79-84.
18. Ahaghotu C, Okafor H, Igiehon E, Gray E. Psychosocial factors influence parental decision for circumcision in pediatric males of African American descent. J Natl Med Assoc. 2009;101(4):325-330.
19. Male circumcision: global trends and determinants of prevalence, safety and acceptability. World Health Organization and Joint United Nations Programme on HIV/AIDS, 2007. Available at: www.who.int/hiv/pub/malecircumcision/globaltrends/en/index.html. Accessed August 5, 2009.
20. Kozak LJ, Lees KA, DeFrances CJ. National Hospital Discharge Survey: 2003 annual summary with detailed diagnosis and procedure data. Vital Health Stat 13. 2006; (160):1-206.
21. American Academy of Pediatrics; Task Force on Circumcision. Circumcision policy statement. Pediatrics. 1999; 103(3):686-693.
22. Lander J, Brady-Fryer B, Metcalfe JB, Nazarali S, Muttitt S. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision: a randomized controlled trial. JAMA. 1997;278(24):2157-2162.