CHAPTER 27

Male Circumcision

Jung Sook (Stella) Hwang, DO, FAAP, and Lynne M. Smith, MD, FAAP

Male circumcision, a procedure in which the foreskin of the penis is removed, has been performed for more than 6,000 years. It is routinely performed in certain groups, most notably among Jewish and Muslim people. In some other cultures (eg, Australian [Aborigine], Polynesian), circumcision is presumably performed to facilitate intercourse. Circumcision can be viewed as a ritual procedure, but its role as a medical procedure has long been controversial.

The benefits of male circumcision have been debated for years. In the past 20 years, even the American Academy of Pediatrics (AAP) has changed its official position on the medical indications for circumcision. The AAP stated in 1999 and reaffirmed in 2005 that circumcision carried potential benefits, although the procedure was not medically indicated. However, in 2012 the AAP released an updated policy stating that the health benefits of circumcision outweigh the risks of the procedure. This statement was based on a systematic evaluation of peer-reviewed literature that demonstrated preventive health benefits of elective male circumcision, including reductions in the risk of urinary tract infections (UTIs) in the first year after birth, decreased risks of heterosexual acquisition of HIV and other sexually transmitted infections, and a decreased incidence of penile cancer. Additionally, the statement noted that male circumcision does not adversely affect penile sexual function/sensitivity or sexual satisfaction and that complications related to circumcision are infrequent and rarely severe.

Disadvantages of routine circumcision in newborns include expenses associated with the procedure and the risk of complications; however, some analyses have demonstrated that neonatal male circumcision is cost-effective in that it reduces the risk for future disease. The procedure is sometimes criticized as an archaic and maiming ritual. Female circumcision, which may involve clitori-dectomy or resection and closure of the labia minora or majora, is infrequently practiced in Western culture and is not discussed in this chapter other than to emphasize that female circumcision has no medical benefit.

Circumcision in newborns has been performed in a routine and preventive manner, much the same way immunizations are administered. Primary care physicians should be aware of the risks and benefits of the procedure to enable them to counsel parents and make referrals to consultants should certain medical conditions arise.

Epidemiology

The prevalence of neonatal circumcision, a procedure that became increasingly popular in the United States in the 1950s and 1960s, once ranged from 69% to 97% depending on cultural mores. In the United States, the procedure is commonly performed during the newborn period, and it is the most common surgical procedure performed in the country. During the past decade, the circumcision prevalence in males aged 14 to 59 years increased from 79% to 81%; specifically, 91% in white males, 76% in black males, and 44% in Hispanic males. The estimated prevalence of circumcision for Australian-born men is 59% (newborn rate estimated 10%–20%); in Canada, 32% of men; and in the United Kingdom, 15% of men. A reported 10% of uncircumcised newborn males ultimately require circumcision as adults because of complications of phimosis and balanitis. Uncircumcised males with diabetes are particularly prone to these complications.

Clinical Presentation

Most often, parents will query their child’s pediatrician about the advisability of circumcision, and the newborn will not have any clinical symptoms suggestive of a need for the procedure. Older infants and children in need of circumcision may present with symptoms of phimosis, in which the foreskin balloons out on urination; paraphimosis, in which a retracted foreskin cannot be returned to its normal position; or recurrent problems of infection or inflammation of the foreskin (posthitis), glans (balanitis), or both (balanoposthitis).

Pathophysiology

In uncircumcised males, the foreskin adheres to the glans until approximately age 6 years, after which a gradual, normal lysing of the adhesive bands connecting the foreskin to the underportion of the glans occurs. Nonphysiologic phimosis occurs as a result of scarring of the preputial wing. Lysing of adhesions in an attempt to treat the phimosis usually results in additional adhesions. If the foreskin is retracted and remains in that position, paraphimosis occurs.

Differential Diagnosis

The differential diagnosis relates to conditions that may be managed with circumcision, including phimosis, paraphimosis, and infection and inflammation of the penis. Conditions such as hypospadias may be mistaken for a partially circumcised penis, because the condition is associated with absence of the ventral foreskin. A careful patient history will differentiate hypospadias from a circumcision.

Evaluation

History

In cases involving newborns, the history should include the presence of any coagulopathies among family members, which would preclude the performance of circumcision. In older infants and children, the history should include problems related to voiding, such as ballooning of the foreskin or difficulty initiating the urinary stream.

Physical Examination

The physical examination should assess the genitalia, with particular emphasis on determining whether evidence exists of hypospadias, in which the urethral orifice is not located at the tip of the glans. In such a situation, circumcision should be delayed because the foreskin is used to reconstruct the urethra. In the patient with phimosis, the degree of phimosis also should be assessed.

Laboratory Tests

Routine laboratory tests are not indicated, although a urinalysis may be obtained in children with a history of a prior UTI. Coagulation studies are appropriate in the case of a family history of a bleeding disorder.

Imaging Studies

Imaging studies are not indicated in most children undergoing circumcision. Such studies are relevant, however, should concern exist that the urogenital anatomy might be abnormal.

Benefits

It has been stated that circumcision facilitates penile hygiene by removing the foreskin, which may serve as a repository for bacteria, smegma, and dirt. Ability to retract the foreskin increases with age (Table 27.1); thus, penile hygiene is easier to achieve in older children. The term phimosis refers to inability to retract the foreskin. In male infants beyond the newborn period, phimosis is the major indication for circumcision. Phimosis is normal in children up to approximately 6 years of age but is nonphysiologic if urination results in ballooning of the foreskin, regardless of age. When the retracted foreskin acts as a tourniquet in the mid-shaft of the penis, paraphimosis occurs, preventing the return of lymphatic flow. Paraphimosis is commonly related to traumatic retraction of the foreskin, typically during cleaning or by medical personnel during bladder catheterization. Because of this, parents are no longer advised to retract the foreskin in an effort to lyse adhesions. The incidence of paraphimosis is increasing in adults secondary to body piercing. Newly placed penile rings can cause pain sufficient to prevent foreskin retraction.

Balanitis, or inflammation of the glans, is not uncommon in infants. It is frequently associated with Candida infection, and the glans is swollen and erythematous. Posthitis, or inflammation of the foreskin, is also often secondary to Candida infection. Other organisms, including gram-negative microbes, may be associated with balanitis. The presence of recurrent balanitis is an indication for circumcision. In older males, indications for circumcision include phimosis, paraphimosis, balanitis, posthitis, and balanoposthitis.

Urinary tract infections reportedly occur 10 times more often in uncircumcised infants than circumcised infants (1 in 100 and 1 in 1,000, respectively). In young uncircumcised boys, UTIs are directly related to colonization of the foreskin with urotoxic organisms. Pyelonephritogenic, fimbriated Escherichia coli bind to the inner lining of the foreskin within the first few days after birth. Other bacteria preferentially bind to this mucosal surface, including fimbriated strains of Proteus mirabilis and nonfimbriated Pseudomonas, Klebsiella, and Serratia species. According to several studies, the rate of UTIs has increased as the rate of circumcision has. A 2012 meta-analysis of 22 studies examining the incidence of UTIs in males found a 23% lifetime risk of UTI in uncircumcised males compared with 8.8% in circumcised males. Thus, the lifetime risk of UTI markedly exceeded the 1.5% circumcision complication rate; most of these complications were minor. Complications associated with UTIs have been reported, in particular, bacteremia, meningitis, and death.

The annual incidence rate of penile cancer is 0.58 per 100,000 men in the United States but is 2.9 to 6.8 per 100,000 men in Brazil. These regional differences are thought to be related to lack of circumcision of the penis. Only a few isolated cases of cancer of the penis occur in circumcised men. Phimosis is strongly associated with invasive penile cancer, with other cofactors such as human papillomavirus (HPV) infection and poor hygiene possibly contributing. Smoking is consistently associated with penile cancer and is further reason to strongly advocate for smoking cessation programs.

Cervical carcinoma among the partners of uncircumcised men is increasingly being reported. In addition, current partners of circumcised men with a history of multiple sexual partners have a lower risk of cervical cancer than partners of uncircumcised men. Circumcision in adolescent boys and men in Uganda was associated with a marked decreased incidence of HPV and human herpesvirus 2 infection. Circumcision has also been associated with a reduced risk for HIV infections. Three randomized, controlled trials conducted in South Africa, Kenya, and Uganda confirmed the findings of observational studies that circumcision is protective against HIV infection. In addition, circumcision was not associated with increased HIV risk behavior. Based on these findings, in 2007 the World Health Organization stated that male circumcision should be part of a comprehensive strategy for HIV prevention. Since the World Health Organization made this recommendation, nearly 15 million voluntary male circumcision have been performed for HIV prevention in 14 countries of eastern and southern Africa, which is estimated to help prevent more than 500,000 new HIV infections through 2030. It remains critical, however, to promote the practice of safe sex, because circumcision confers only partial protection against HPV, human herpesvirus 2, and HIV.

Risks

Risks related to circumcision are related to complications of the procedure (Box 27.1) and are discussed in the Management section of this chapter. Elective circumcision should be performed only if the newborn is stable and healthy.

Parental Counseling

Parents of Newborns

In the newborn period, proper counseling of parents is important, including a discussion of the risks and benefits of circumcision. Opponents to neonatal circumcision cite psychological trauma to neonates from such a painful procedure. Local anesthesia minimizes this effect. Parents should be informed about the benefits of circumcision, including a reduction in the occurrence of UTIs, sexually transmitted infections, and cancer of the penis and cervix. Problems related to the foreskin itself, such as phimosis, paraphimosis, posthitis, and balanitis, also should be discussed.

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