Circumcision has been practiced since ancient times for various religious and cultural reasons. Circumcision is common in both the Jewish and Muslim faiths as a religious rite and occurs at different ages depending on religious traditions. In the United States, areas of Africa, Australia, and portions of the Middle East, there is a high prevalence of circumcision. In contrast, routine circumcision is rarely performed in Europe, Asia, and Central and South America ( Fig. 58.1 ). This regional variation likely reflects religious and cultural differences.

This global map depicts the prevalence of male circumcision among various countries and continents. The countries marked in blue have a prevalence rate of circumcision between 0% and 20%, the countries marked in yellow have a prevalence between 20% and 80%, and the countries marked in orange have a prevalence rate >80%.

Map lines delineate study areas and do not necessarily depict accepted national boundaries.

There continues to be controversy regarding elective or routine circumcision in infants. Proponents of routine newborn circumcision argue that circumcision reduces the risk of urinary tract infection (UTI), balanitis and balanitis xerotica obliterans (BXO), paraphimosis, sexually transmitted diseases (STDs), and certain cancers.

For UTI in particular, it is believed that the mechanism of infection is colonization of the preputial epithelium with bacterial flora. Removing the prepuce with circumcision exposes the glans, which causes a change in the glanular epithelium from moist glabrous transitional tissue, which is a favorable environment for survival of urinary pathogens, to dry squamous tissue. Randomized controlled studies have also demonstrated that the keratinization of the glans that occurs after circumcision can also increase the relative resistance to sexually transmitted infections in adult men.

Data regarding the effect of circumcision on the risk of UTI is largely retrospective and from case-control studies. A Cochrane Review in 2012 investigating the effect of routine neonatal circumcision for the prevention of UTI in infancy showed there were no randomized controlled trials to date. In general, males who are uncircumcised have an approximately 1% risk of UTI during the first year of life, whereas for circumcised males, the risk is 0.1%. Furthermore, studies have shown that the pediatric groups with the highest prevalence of UTI are uncircumcised male infants less than 3 months of age and females less than 12 months of age. Another systematic review showed that circumcision significantly reduces the risk of UTI with an odds reduction of 90%. However, in normal boys, the risk of UTI is low at roughly 1%, so the number-needed-to-treat to prevent one UTI is 111 circumcisions. With a circumcision complication rate of 2%, a risk-benefit analysis did not favor routine circumcision for reducing the risk of UTI alone, and the study authors only recommended circumcision in boys with recurrent UTIs. In infant males with physiologic phimosis, risk of UTI can also be decreased by nonsurgical means with treatment using steroid cream.

Given the mixed data regarding circumcision and risk reduction of infant UTI, the most recent policy statement from the American Academy of Pediatrics (AAP) on circumcision states, “Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns.”

The policy statement advises that clinicians should routinely educate parents on the health benefits and risks of newborn circumcision using an accurate and unbiased approach. Furthermore, the AAP underscores that the procedure is well tolerated with rare complications when performed by experienced providers using proper sterile technique and pain management.

For male infants with congenital urinary tract anomalies that increase the likelihood of urinary stasis, namely hydronephrosis, vesicoureteral reflux (VUR), and posterior urethral valves (PUV), circumcision can be considered as an effective option to decrease the risk of recurrent UTI and long-term renal damage.

In male infants with PUV, circumcision is typically performed at the time of endoscopic valve ablation to decrease the risk of UTI. The Circumcision and Risk of Febrile Urinary Tract Infection in Boys with Posterior Urethral Valves (CIRCUP) randomized controlled trial found that in a study group of 91 male infants with PUV, the circumcised group had a 3% risk of febrile UTI over the first 2 years of life, compared to a 20% risk in the uncircumcised group. In response to these findings, the AAP issued an article that acknowledged that neonatal circumcision in boys with PUV does reduce the risk of febrile UTI, but did not show a difference in renal scarring between groups on DMSA, likely due to insufficient study power. Thus, the AAP recommended that the CIRCUP trial findings be used to help inform caregiver decision making, but did not go so far as to recommend routine circumcision in these patients.

Regarding the management of VUR, findings from the prospective cohort studies Randomized Intervention for Vesicoureteral Reflux (RIVUR) trial and the Careful Urinary Tract Evaluation (CUTIE) study showed that uncircumcised males were at significantly higher risk of developing UTI than circumcised males, with a UTI incidence rate of 4.9% in uncircumcised boys compared to 0.84% in circumcised boys. Similarly, circumcision is typically recommended for infants with severe hydronephrosis, especially if also presenting with UTI.

Considering these findings, circumcision is strongly encouraged, but not required, in males with congenital urinary tract anomalies, and shared decision making with consideration of caregiver preference should be employed.

Unlike physiologic phimosis of infancy, pathologic phimosis occurs in older children when a fibrotic ring of scar tissue prevents the prepuce from being able to be retracted. Pathologic phimosis can be due to persistent irritation, recurrent forceful retraction of the prepuce, or BXO. Balanoposthitis is inflammation of the glans and foreskin and is a relatively common cause of irritation that can lead to phimosis, with a reported incidence of 6% in uncircumcised boys. The etiology of balanoposthitis is variable and can be due to bacterial or candida infection, contact irritation or allergic response, mechanical trauma, or STDs. Patients typically present with pain and an edematous, erythematous prepuce. There may or may not be discharge from the preputial opening on exam.

Initial treatment of pathologic phimosis is often a course of topical therapy with low-dose steroid cream for a number of weeks to months. Randomized controlled trials have demonstrated successful treatment of phimosis in 50%–74% of cases when using topical betamethasone. If topical therapy is not effective, circumcision can be performed as a curative therapy for pathologic phimosis.

In some cases, pathologic phimosis may be due to BXO, which is a variant of lichen sclerosis. BXO should be considered in patients presenting with a ring-like distal sclerosis of the prepuce with whitish discoloration or plaque formation that may involve the prepuce, glans, or urethral meatus. Since BXO is a progressive disease process, it can lead to meatal stenosis and/or urethral strictures and should be treated if suspected. Some small studies have demonstrated possible improvement in phimosis due to BXO with topical steroid or tacrolimus ointment, but circumcision is indicated for BXO if caregivers prefer or after failure of topical therapy.

Paraphimosis occurs when the prepuce has been retracted behind the corona and is unable to be brought back over the glans. Unlike pathologic phimosis, paraphimosis is considered a medical emergency as it can lead to glans necrosis if not promptly addressed. Some patients may also present with urinary retention. Patients with paraphimosis present with pain, inflammation, and edema of the distal penis and glans due to the constriction effect of the retracted prepuce below the glans. In the majority of cases, paraphimosis can be manually reduced, but often requires a lidocaine penile block, oral or parenteral pain medication, and/or sedation in children. If conservative methods to manually reduce the paraphimosis are unsuccessful, dorsal slit and/or circumcision is indicated.

As discussed above, circumcision does decrease the risk of UTI, but routine newborn circumcision is not recommended for UTI prophylaxis. However, recurrent UTI in boys is an indication for circumcision. Studies have found that in boys with recurrent UTI and no urinary tract anatomic abnormalities, the risk of UTI recurrence is 10% and the number-needed-to-treat to prevent one UTI is 11 circumcisions. There is also evidence that the incidence of subsequent bacteremia and long-term renal scarring in boys with recurrent UTI is as high as 10%, further supporting the benefit of circumcision in patients at high risk for recurrent UTI.

Other potential benefits of circumcision to consider include reducing the incidence of certain STDs and cancers. There are many studies examining the relationship between circumcision and STDs. Studies have shown that uncircumcised individuals have an increased risk of acquiring human immunodeficiency virus (HIV), human papillomavirus (HPV), and genital herpes.

There is a substantial amount of evidence linking uncircumcised men with an increased risk of HIV infection. The inner surface of the prepuce contains Langerhans cells with HIV receptors, and researchers have argued that removal of the prepuce via circumcision results in decreased risk of HIV infection in men. Studies in the United States have found that uncircumcised men who have sex with men have a twofold increase in the risk of HIV infection. ^, An uncircumcised male partner also appears to be associated with an increased risk of transmission of HIV to female contacts.

For HPV, uncircumcised men have been found to have a 5- to 10-fold increase in the likelihood of infection compared to circumcised men. There is also evidence that circumcision is beneficial for reducing cancer risk in female partners, with women who had circumcised male partners having a lower risk of cervical cancer than women whose partners were uncircumcised.

Possible mechanisms for disparate rates of STDs related to circumcision status include a more easily traumatized mucosa and epithelium of the uncircumcised phallus, the preputial environment being more hospitable to pathogens, and nonspecific inflammation (balanitis) in uncircumcised men predisposing to certain STDs. Overall, behavior and sexual practice still represent the greatest risk factors for STD transmission.

Additionally, men with HIV and HPV have been found to have higher rates of malignant penile lesions. Being uncircumcised (circumcision status) is an independent risk factor for development of penile cancer. ^, In general, malignant penile lesions can arise from the squamous epithelium of the prepuce, the glans, or the penile shaft. While penile cancer is rare, with an estimated 2050 new cases diagnosed in the United States in 2023, uncircumcised men are at higher risk. One study found that the lifetime risk of developing penile cancer in uncircumcised US men is 1/400 compared to 1/100,000 for circumcised US men, amounting to a 22-fold risk reduction. It is important to note that the protective benefit of circumcision against penile cancer has been demonstrated to be greatest for newborn circumcision, with higher prevalence rates of penile cancer in men who undergo circumcision after the neonatal period. That being said, local chronic inflammation from phimosis, balanitis, BXO, and accumulation of smegma are all additional risk factors associated with development of penile cancer and can be mitigated with circumcision, even if done after the newborn period.

There is some data to suggest that circumcision may also reduce the risk of developing prostate cancer. Several studies have argued that prostate cancer may have an infectious etiology, with one meta-analysis finding that men with a history of any STD have an increased risk of prostate cancer. In studies examining prostatic tissue for microorganisms, sexually transmitted organisms, including HPV and HIV, have been identified. One study found that in men who were circumcised before their first sexual encounter, there was a 15% relative risk reduction in prostate cancer. As such, some researchers have argued that since circumcision can reduce the risk of acquiring an STD, it may also reduce the risk of developing prostate cancer, given the possible infectious pathway of prostate carcinogenesis.