Male circumcision continues to be the subject of debate in Australia and internationally. The Australian College of Paediatrics'position is that there are no indications for neonatal circumcision, and if it is necessary, the procedure should be delayed until a general anaesthetic can be performed after six months of age. The NSW Department of Health has recommended that neonatal circumcision only be performed after informed parental consent and with adequate anaesthesia. The Canadian Paediatric Society's position statement of 1996 stated that "the overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns".
There are potential benefits from circumcision in the newborn period - mainly due to the reduction of urinary tract infections (UTI) and their sequelae. UTI's are however not common and many hundreds of boys would need to be circumcised to prevent one UTI. In adult life, the reduction in penile cancer, sexually transmitted diseases, including HIV, and the complications of the intact foreskin, indicate that there are advantages to being circumcised. However, these benefits are more evident in countries where personal hygiene is less effective.Informed parental consent is imperative. A parent's request for neonatal circumcision should be met with information not just of the complications, but also the potential benefits of the procedure.
What are Some of the Advantages of Circumcision?
Urinary Tract Infections (UTI)
Infections in the urinary tract are approximately 10 times more common in boys who are not circumcised. Uncircumcised males younger than six months have a higher incidence of UTI's than female infants. Studies of children of American armed service personnel have examined the complication rate of circumcision as compared to the health outcomes of the uncircumcised. Morbidity from urinary tract infections and their sequelae in both groups was compared. There is a significantly increased incidence of bacteraemia, renal failure and death in the uncircumcised group.
The absolute risk is small, however, with a renal failure or death rate of one in 17,000 (.006%) if uncircumcised versus zero in 100,000 in the circumcised group.1-3 Adult males are five times more likely to develop urinary tract infections if they are uncircumcised.4
Sexually Transmitted Diseases and HIV
Men who are circumcised have a lower rate of developing some sexually transmitted diseases including HIV, syphilis and gonorrhoea. Circumcision does not appear to reduce Herpes simplex virus type 2 infections and may be associated with increased genital warts 5-7 Human papilloma virus rates are similar in circumcised men compared to uncircumcised men, but penile intra epithelial neoplasia is doubled in the uncircumcised group. Studies analysing HIV infection and circumcision status in countries where HIV is endemic reveal that the uncircumcised state is associated with a three to five fold increased risk of HIV.9,10
American male homosexuals have a 2 fold increased risk of HIV if they are uncircumcised.11
It should be remembered that safe sexual practices and hygiene are an effective preventive and that circumcision per se is not sufficient to prevent STD's. Also the United States has a high circumcision rate and has the highest HIV rate of the developed world.
Human Papilloma Virus (HPV) and Genital Carcinoma
Relative to men circumcised at birth, smegma-related adenocarcinoma of the penis is 3.2 times more common in men never circumcised and three times more common in males circumcised after the neonatal period. It is commonly related to infection with HPV. It appears the presence of the foreskin causes men to be not only the vector but the victim of HPV related cancer of the penis.8,12,13
Cancer of the penis may be prevented by simple hygiene in the uncircumcised male.14
The lowest rates of penile cancer in the world literature appear in groups practising infant circumcision and in areas where standards of sexual hygiene are high. Circumcised males can develop squamous carcinoma of the penis in the circumcision scar but this is very 2 rare.16-18
Poor sexual hygiene is a more important aetiological factor than lack of male circumcision per se in the development of cervical cancer.19 In India where the incidence of cervical carcinoma is among the highest in the world and sexual promiscuity among women is virtually unknown, having sex with an uncircumcised male increases the risk of cervical carcinoma four fold.20
Complications of the Intact Foreskin
Approximately two in 100 males may need circumcision later in life if they are not done at birth. The reasons General Practitioners refer males for circumcision include ballooning of the foreskin during urination, non-retraction, balanoposthitis or a combination of these. Only one quarter of these patients are likely to require a circumcision.21
Balanitis xerotica obliterans occurs where scarring of the foreskin follows repeated infection and is an indication to circumcise. Simple infections of the foreskin are not a reason for circumcision. Inability to retract the foreskin is normal at birth and still common by the age of five yrs. If still non-retractile by the age of eight to 10 years it may be treated by application of topical hydrocortisone cream with daily attempts by the boy to retract the foreskin.22 Symptomatic adhesions of the foreskin may be managed by the use of eutectic mixture of local anaesthetic (EMLA) cream to provide anaesthesia and then separation of the adhesions by simple traction or the use of a blunt probe.
What are Some of the Disdvantages of Circumcision?
The operation of circumcision has some possible complications. In infants that have been discharged from hospital prior to surgery, infection occurs about one in every 30 operations, requiring antibiotic therapy.8 This is usually caused by Staph. Aureus. It is possible for a bacteraemia to occur. Bleeding may occur. This may be from tearing of the frenulum. If this doesn't settle with packing and pressure, it may require the ring to be removed and the bleeding point sutured under general anaesthetic. Rarely, serious blood loss or haemorrhage may occur and blood transfusion may be required but this is very rare (approx. 1 in 30,000)1
The incidence of serious bleeding requiring hospital admission is less than one per 1500.a Injury to the penis is rare if the operator is skilled. Re-operation may be necessary if insufficient foreskin is removed. The use of adrenaline in local anaesthetic injection is contraindicated and has been associated with gangrene of the penis. The use of unipolar diathermy on the penis may cause electrical burn and loss of the penis.
The foreskin is protective to the glans penis and removing it increases the risk of injury to the penis. A stricture of the urethral meatus can arise from damage to the frenular artery during circumcision.
General anaesthetia is best avoided in the newborn period for elective procedures due to its attendant risks. An alternative method of anaesthesia and sedation used at John Hunter Hospital since 1995 includes: EMLA cream applied to the penis; a dorsal penile nerve block with 1% lignocaine injection; chloral hydrate 100mg orally and paracetamol 90mg orally. With a practised operator anaesthesia is usually complete. Most babies settle quickly after the surgery.23,24
There is an association between being circumcised without anaesthesia and displaying an increased pain response during the 4 and 6-month immunisations.25
It is very rare but babies have died of the complications of circumcision, including haemorrhage and infection. However in one study comparing mortality in relation to circumcision status of 136,086 boys born in US Army hospitals from 1980 to 1985, the only deaths were in the uncircumcised group (two in 35,929).
These were from complications of urinary tract infection
The Management of the Intact Foreskin
Some parents feel it is more hygienic to be circumcised. It should be remembered that the skin and secretions of the penis are not in themselves 'dirty', and are kept clean by simple washing.
The foreskin is usually attached to the glans penis in early life so there is no need for cleaning. Smegma builds up and separates the foreskin over the first few years of life, so that from about three to five years onwards boys should be taught to pull back the foreskin themselves in the bath or shower, give it a good clean with water, and pull it forward again. They could also pull back the foreskin to urinate. As long as they are performing daily washing under their foreskin by puberty, removing all smegma build up, they are maintaining appropriate genital hygiene. It should not be the parent's task to keep the area clean.
By the age of three most boys enjoy genital exploration and encouraging them to clean the area is not difficult.
How Common is Circumcision?
The Australian College of Paediatrics suggested that the national figures in 1996 were that one in 10 boys were circumcised.
Current Newcastle figures are approximately 2 in 10.
Most newborn Australian males are now different to their fathers as far as circumcision is concerned. Since the 1940's Australia has followed USA and Canada and some Pacific island nations where circumcision is routinely practised.
Our rates have been steadily rising over the past 10 years. The Australian rate for 2009 was 12.9 %. NSW was 21% circumcised in 2009. The rate is slowly increasing.
Circumcision is almost never performed in the newborn period in Great Britain, Scandinavia, Europe or Asia except for specific religious reasons. The majority of men in the world are NOT circumcised.
Why do parents request circumcision?
In a survey of 100 consecutive families attending John Hunter Hospital's circumcision, the following were stated as reasons for requesting circumcision:
father is circumcised 56%
Are All Boys Suitable for Circumcision?
Circumcision is not advisable with:
active infection anywhere, particularly in the napkin region.
increasing or severe jaundice. Circumcision is contraindicated for boys with: any congenital abnormality of the penis
a family history of haemophilia until appropriate investigations are undertaken at approximately 10 to 12 months of age.
a buried or inconspicuous penis. These boys have a large pre pubic fat pad and a relatively short penis.26,27 Ideally the ventral length should be approximately 1cm long for the Plastibell method to be performed
It is a Difficult Decision for Parents to Make.
It is difficult, but to summarise:
Australia is now only circumcising less than one in 10 boys in the newborn period.
There are risks of surgery including infection, bleeding, blood transfusion and injury.
It is a painful operation in the newborn period if adequate anaesthesia is not used.
The main benefit in childhood is reduced urinary infections and their sequelae.
Other benefits in adulthood include avoidance of balanitis and phimosis, reduced genital infections and the rare penile cancer.
If circumcision is not performed in the newborn period and future complications occur, surgery may be required later. The procedure can be performed under general anaesthetic. There are the small risks of general anaesthesia to be considered.
Most of the benefits of circumcision are obtainable by adequate genital hygiene and safe sexual practices.
How are Circumcisions Organised at:
Newcastle Private Hospital
Newborn circumcisions are available there by arrangement through Dr Milton Sales
There are a number of GP’s in the lower Hunter and Newcastle doing circumcision, and private arrangements should be made. Some Hunter Obstetricians are still performing circumcision. Patients should check with their obstetric carer.
State Health has prohibited newborn circumcision in public hospitals.
Circumcision may also be performed by paediatric and urological surgeons. This is usually performed after six months of age under general anaesthetic and may not use the Plastibell.
Revised M Sales 2013
a: John Hunter Clinic figures
1. Wiswell TE, Geschke DW. Risks from circumcision during the first month of life compared with those for uncircumcised boys [see comments]. Pediatrics 1989; 83:1011-5.
2. Wiswell TE, Enzenauer RW, Holton ME, Cornish JD, Hankins CT. Declining frequency of circumcision: implications for changes in the absolute incidence and male to female sex ratio of urinary tract infections in early infancy. Pediatrics 1987; 79:338-42.
3. Wiswell TE, Hachey WE. Urinary tract infections and the uncircumcised state: an update. Clin Pediatr (Phila) 1993; 32:130-4.
4. Spach DH, Stapleton AE, Stamm WE. Lack of circumcision increases the risk of urinary tract infection in young men [see comments]. JAMA 1992; 267:679-81.
5. Cook LS, Koutsky LA, Holmes KK. Circumcision and sexually transmitted diseases. Am J Public Health 1994; 84:197- 201.
6. Donovan B, Bassett I, Bodsworth NJ. Male circumcision and common sexually transmissible diseases in a developed nation setting. Genitourin Med 1994; 70:317-20.
7. Bassett I, Donovan B, Bodsworth NJ, et al. Herpes simplex virus type 2 infection of heterosexual men attending a sexual health centre. Med J Aust 1994; 160:697-700.
8. Aynaud O, Ionesco M, Barrasso R. Penile intraepithelial neoplasia. Specific clinical features correlate with histologic and virologic findings. Cancer 1994; 74:1762-7.
9. Hunter DJ, Maggwa BN, Mati JK, Tukei PM, Mbugua S. Sexual behavior, sexually transmitted diseases, male circumcision and risk of HIV infection among women in Nairobi, Kenya. Aids 1994; 8:93-9.
10. Bwayo J, Plummer F, Omari M, et al. Human immunodeficiency virus infection in long-distance truck drivers in east Africa. Arch Intern Med 1994; 154:1391-6.
11. Kreiss JK, Hopkins SG. The association between circumcision status and human immunodeficiency virus infection among homosexual men. J Infect Dis 1993; 168:1404-8.
12. Boon ME, Susanti I, Tasche MJ, Kok LP. Human papillomavirus (HPV)-associated male and female genital carcinomas in a Hindu population. The male as vector and victim. Cancer 1989; 64:559-65.
13. Maden C, Sherman KJ, Beckmann AM, et al. History of circumcision, medical conditions, and sexual activity and risk of penile cancer [see comments]. J Natl Cancer Inst 1993; 85:19-24.
14. Brinton LA, Li JY, Rong SD, et al. Risk factors for penile cancer: results from a case-control study in China. Int J Cancer 1991; 47:504-9.
15. Persky L. Epidemiology of cancer of the penis. Recent Results Cancer Res 1977:97-109.
16. Rogus BJ. Squamous cell carcinoma in a young circumcised man. J Urol 1987; 138:861-2.
17. Bissada NK, Morcos RR, el-Senoussi M. Post-circumcision carcinoma of the penis. I. Clinical aspects. J Urol 1986; 135:283-5.
18. Bissada NK. Post-circumcision carcinoma of the penis: II. Surgical management. J Surg Oncol 1988; 37:80-3.
19. Persaud V. Geographical pathology of cancer of the uterine cervix. Trop Geogr Med 1977; 29:335-45. 6
20. Agarwal SS, Sehgal A, Sardana S, Kumar A, Luthra UK. Role of male behavior in cervical carcinogenesis among women with one lifetime sexual partner. Cancer 1993; 72:1666-9.
21. Griffiths D, Frank JD. Inappropriate circumcision referrals by GPs. J R Soc Med 1992; 85:324-5.
22. Wright JE. Further to the further fate of the foreskin. Update on the natural history of the foreskin. Med J Aust 1994; 160:134-5.
23. Weatherstone KB, Rasmussen LB, Erenberg A, Jackson EM, Claflin KS, Leff RD. Safety and efficacy of a topical anesthetic for neonatal circumcision. Pediatrics 1993; 92:710-4.
24. Spencer DM, Miller KA, O'Quin M, et al. Dorsal penile nerve block in neonatal circumcision: chloroprocaine versus lidocaine. Am J Perinatol 1992; 9:214-8.
25. Taddio A, Goldbach M, Ipp M, Stevens B, Koren G. Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet 1995; 345:291-2.
26. Bergeson PS, Hopkin RJ, Bailey RB, Jr., McGill LC, Piatt JP. The inconspicuous penis [see comments]. Pediatrics 1993; 92:794-9.
27. Alter GJ, Horton CE, Horton CE, Jr., Horton CE, Jr. Buried penis as a contraindication for circumcision [published erratum appears in J Am Coll Surg 1994 Jun;178(6):636]. J Am Coll Surg 1994; 178:487-90.
Appendix to Chapter 29
DEALING WITH COMPLICATIONS OF PLASTIBELL CIRCUMCISION
String too loose - arterial bleeding may occur if the dorsal artery retracts behind the string. A haematoma will accompany the blood loss.
ACTION: Apply another string tie to the ring proximal to the original tie. Use Gauze wrapped around the penile shaft and ring as a pressure bandage with Tinc Benz Co.
Frenulum torn - blood oozes out from under the ring.
ACTION: Apply Tinc Benz Co under the ring and apply pressure. If continuing blood loss, pack under the ring with Tinc Benz Co dampened cotton wool and apply a pressure bandage. If bleeding continues despite the above measures, contact the operating doctor or the paediatric surgeon on call for further advice. It may be necessary to admit the child to hospital for adrenaline packs to the wound, or for removal of the ring under general anaesthetic to achieve haemostasis and suture the wound.
INFECTION Usually Staph. aureus or Strep. pyogenes Signs:
oedema of shaft
Treatment: EES 200mg per 5 ml: 2 ml BD or Cephalexin 62.5mg TDS. Consider removal of the ring if pressure of oedema causes the glans to extrude through the ring.
EXTRUDING GLANS The Plastibell ring needs removal if:
the glans is showing pressure effects or if the glans is through the ring, ie the ring is moving down the glans or penile shaft.
the glans beyond the ring has swollen to become wider than the ring.
ACTION: It is safe to remove the string and Plastibell ring after 24 hrs if necessary. The tissue distal to the string tie should not bleed after this time. Cut the string using a stitch cutter and unwind it from the ring. Apply pressure to the protruding glans to attempt reduction of oedema and removal of the ring.
If it is not possible to remove the ring that way, first remove the string and then cut off the ring using either scissors, a ring cutter or a scalpel blade using an upward cutting direction, and when cut through, open out the ring and slide it from the penis. If any bleeding is occurring after removal, apply Tinc Benz Co and a pressure bandage.
If bleeding persists, inject some 1% plain Xylocaine into the area and insert a catgut suture to suppress bleeding.