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PEDIATRICS Vol. 103 No. 3 March 1999, pp. 686-693
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ABSTRACT |
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Abstract
References
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Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child. 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. If a decision for circumcision is made, procedural analgesia should be provided.
Although the exact frequency is unknown, it
is estimated that 1.2 million newborn males are circumcised in the
United States annually at a cost of between $150 and $270 million. This
practice has been advocated for reasons that vary from symbolic ritual to preventive health measure. Until the last half century, there has
been limited scientific evidence to support or repudiate the routine
practice of male circumcision.
Over the past several decades, the American Academy of Pediatrics has
published several policy statements on neonatal circumcision of the
male infant.1-3 Beginning in its 1971 manual,
Standards and Recommendations of Hospital Care of Newborn Infants, and reiterated in the 1975 and 1983 revisions, the
Academy concluded that there was no absolute medical indication for
routine circumcision.
In 1989, because of new research on circumcision status and urinary
tract infection (UTI) and sexually transmitted disease (STD)/acquired
immunodeficiency syndrome, the Academy concluded that newborn male
circumcision has potential medical benefits and advantages as well as
disadvantages and risks.4 This statement also recommended
that when circumcision is considered, the benefits and risks should be
explained to the parents and informed consent obtained. Subsequently, a
number of medical societies in the developed world have published
statements that do not recommend routine circumcision of male
newborns.5-7 In its position statement, the Australian
College of Paediatrics emphasized that in all cases, the medical
attendant should avoid exaggeration of either risks or benefits of this
procedure.5
Because of the ongoing debate, as well as the publication of new
research, it was appropriate to reevaluate the issue of routine neonatal circumcision. This Task Force adopted an evidence-based approach to analyzing the medical literature concerning circumcision. The studies reviewed were obtained through a search of the English language medical literature from 1960 to the present and, additionally, through a search of the bibliographies of the published studies.
The percentage of male infants circumcised varies by geographic
location, by religious affiliation, and, to some extent, by socioeconomic classification. Circumcision is uncommon in Asia, South
America, Central America, and most of Europe. In Canada, ~48% of
males are circumcised.8 Some groups such as followers of
the Jewish and Islamic faiths practice circumcision for religious and
cultural reasons.9,10
There are few data to help estimate accurately the number of newborn
males circumcised annually in the United States. According to the
National Center for Health Statistics (NCHS), 64.1% of male infants
were circumcised in the United States during 1995 (unpublished data,
1997). However, data from the NCHS are based on voluntary collection of
data from participating hospitals; <5% of hospitals in the United
States participate. Thus, NCHS data provide an inadequate sample to
estimate national circumcision frequency.
More specific data on circumcision rates are >1 decade old. Data
obtained from hospital records in metropolitan Atlanta, GA, document
circumcision rates of 84% to 89% in the period 1985 to 1986.11 This study demonstrated that hospital discharge data, which rely on medical record face sheet information,
underestimate the true incidence of neonatal circumcision. Using such
hospital discharge data, it was estimated that 45.5% of male infants
born in New York City and 69.6% of male infants born elsewhere in New York State were circumcised at birth during the year
1985.12 In addition, none of these sources included rates
for ritual circumcision or subsequent outpatient procedures, thus,
these rates of circumcision are even more likely to be underestimated.
Differences in circumcision rates related to demographic variables are
not well described. One study, which surveyed adult men, suggested that
in the United States, the frequency of circumcision varies directly
with maternal education, a marker for socioeconomic status.13 Circumcision rates also vary among racial and
ethnic groups, with whites considerably more likely to be circumcised
than blacks or Hispanics (81% vs 65% or 54%).13
Embryologically, the penis glans derives from the genital
tubercle, which has developed by 4 to 6 weeks' gestation. The
primitive urethral folds present in the male human embryo fuse to form
the penile urethra. The genital swellings, present early in
development, subsequently become the scrotum in males. The skin of the
body of the penis begins growing forward at about 8 weeks' gestation and covers the glans eventually. Initially, squamous epithelium has no
separation between the glans and the foreskin. Separation of epithelial
layers that may be only partially complete at birth progress with the
development of desquamated tissue in pockets until the complete
separation of tissue layers forms the preputial space. As a result of
this incomplete separation, the prepuce or foreskin may not be fully
retractable until several years after birth. In ~90% of
uncircumcised males, the foreskin is retractable by age 5 years.
Partial adhesions with smegma accumulation may persist in small numbers
of uncircumcised males through childhood and even into
adolescence.14-16
Epidermal keratinization occurs on the skin of the penile shaft but not
on the mucosal surface of the foreskin.15 One study
suggests that there may be a concentration of specialized sensory cells
in specific ridged areas of the foreskin but not in the skin of the
penile shaft.17 There are conflicting data regarding the
immune capabilities of preputial tissue. Studies differ on the number,
distribution, and location of Langerhans' cells in the
foreskin.18,19 No controlled scientific data are available
regarding differing immune function in a penis with or without a
foreskin.
Penile problems may develop in both circumcised and uncircumcised
males. The true frequency of these problems is unknown. In one 8-year
study of a cohort of 1948 uncircumcised Danish schoolboys between 6 and
17 years of age, 4% of the boys had phimosis (which prevented the
foreskin from being retracted by gentle manipulation) and 2% had
"tight prepuce" so that the foreskin could be retracted but with
slight difficulty.16
The only longitudinal study to address this issue in both circumcised
and uncircumcised boys followed a birth cohort of 500 New Zealand boys
until the age of 8 years; it was noted that the relationship between
risks of penile problems and circumcision status varied with the
child's age.20 The majority of these problems were
described as penile inflammation and were noted to be relatively minor.
In this study, circumcised infant boys had a significantly higher risk
of penile problems (such as meatitis) than did uncircumcised boys,
whereas, after infancy, the rate of penile problems (such as balanitis
and inflammation of the foreskin) were significantly higher in older
uncircumcised boys.
A retrospective survey conducted at two inner city clinics asked
parents of boys 4 months to 12 years of age to recall whether their
sons had ever developed any penile problems. Hispanic parents constituted 73% of those responding. Although parents of uncircumcised boys reported an increased number of medical visits for penile problems, the frequency of balanitis and irritation was not
significantly different between circumcised and uncircumcised
boys.21 In addition, most of the problems reported were
minor. Case reports suggest an increased frequency of paraphimosis in
uncircumcised elderly men who require intermittent or chronic bladder
catheterization.22-24 Other case reports indicate that
balanitis occurs more frequently in uncircumcised men than in
circumcised men and suggest an increased frequency of balanitis in men
with diabetes and in uncircumcised soldiers during
wartime.25
Chronic inflammation of the foreskin may result in a secondary phimosis
caused by scarring.23,26 Medical therapy has been
successful in resolving both secondary phimosis and paraphimosis, but
surgical intervention is sometimes indicated.22,2326-28
Circumcision has been suggested as an effective method of
maintaining penile hygiene since the time of the Egyptian dynasties, but there is little evidence to affirm the association between circumcision status and optimal penile hygiene.
In one study, appropriate hygiene decreased significantly the incidence
of phimosis, adhesions, and inflammation, but did not eliminate all
problems.29 In this study, 60% of parents remembered
receiving instructions on the care of the uncircumcised penis, and most
followed the advice they were given. Various studies suggest that
genital hygiene needs to be emphasized as a preventive health topic
throughout a patient's lifetime.16,21,29,30
A survey of adult males using self-report suggests more varied
sexual practice and less sexual dysfunction in circumcised adult
men.13 There are anecdotal reports that penile sensation
and sexual satisfaction are decreased for circumcised males. Masters
and Johnson noted no difference in exteroceptive and light tactile
discrimination on the ventral or dorsal surfaces of the glans penis
between circumcised and uncircumcised men.31
There are three methods of circumcision that are commonly used in
the newborn male. These all include the use of devices: the Gomco
clamp, the Plastibell device, and the Mogen clamp (or variations
derived from the same principle on which each of these devices is
based).
The elements that are common to the use of each of these devices to
accomplish circumcision include the following: estimation of the amount
of external skin to be removed; dilation of the preputial orifice so
that the glans can be visualized to ensure that the glans itself is
normal; bluntly freeing the inner preputial epithelium from the
epithelium of the glans; placing the device (at times a dorsal slit is
necessary to do so); leaving the device in situ long enough to produce
hemostasis; and amputation of the foreskin.
It is important that those who practice circumcision become
sufficiently skilled at the technical aspects of the procedure so that
complications can be minimized. Those performing circumcision should be
adept at suturing to ensure that hemostasis can be secured when
necessary and that skin edges can be brought together if they should
separate widely. If circumcision is done in the newborn period, it
should be performed only on infants who are stable and healthy.
The true incidence of complications after newborn circumcision is
unknown.32 Reports of two large series have suggested that
the complication rate is somewhere between 0.2% and
0.6%.33,34 Most of the complications that do occur are
minor.35 The most frequent complication, bleeding, is seen
in ~0.1% of circumcisions.35 It is quite rare to need
transfusion after a circumcision because most bleeding episodes can be
handled quite well with local measures (pressure, hemostatic agents,
cautery, sutures). Infection is the second most common of the
complications, but most of these infections are minor and are manifest
only by some local redness and purulence.33 There also are
isolated case reports of other complications such as recurrent
phimosis, wound separation, concealed penis, unsatisfactory cosmesis
because of excess skin, skin bridges, urinary retention, meatitis,
meatal stenosis, chordee, inclusion cysts, and retained Plastibell
devices.35 Case reports have been noted associating
circumcision with such rare events as scalded skin syndrome,
necrotizing fasciitis, sepsis, and meningitis, as well as with major
surgical problems such as urethral fistula, amputation of a portion of
the glans penis, and penile necrosis.32,35
Should circumcision become necessary after the newborn period
because problems have developed, general anesthesia is often used and
requires a more formal surgical procedure necessitating hemostasis and
suturing of skin edges. Although the procedural complications are
generally the same as those of newborn circumcision, there is the added
risk attendant to general anesthesia if it is used. Additionally, there
is morbidity in the form of time lost from school or work to be
considered.
There is considerable evidence that newborns who are circumcised
without analgesia experience pain and physiologic stress. Neonatal
physiologic responses to circumcision pain include changes in heart
rate, blood pressure, oxygen saturation, and cortisol levels.36-39 One report has noted that circumcised
infants exhibit a stronger pain response to subsequent routine
immunization than do uncircumcised infants.40 Several
methods to provide analgesia for circumcision have been evaluated.
Eutectic Mixture of Local Anesthetics (EMLA Cream)
EMLA cream, containing 2.5% lidocaine and 2.5% prilocaine,
attenuates the pain response to circumcision when applied 60 to 90 minutes before the procedure. Compared with placebo groups, neonates
who had EMLA cream applied spend less time crying and have smaller
increases in heart rate during circumcisions.41-43 The
analgesic effect is limited during the phases associated with extensive
tissue trauma such as during lysis of adhesions and tightening of the
clamp.42,43
Ideally, 1 to 2 g of EMLA cream is applied to the distal half of
the penis, which then is wrapped in an occlusive dressing. There is a
theoretic concern about the potential for neonates to develop
methemoglobinemia after the application of EMLA cream, because a
metabolite of prilocaine can oxidize hemoglobin to methemoglobin. When
measured, blood levels of methemoglobin in neonates after the
application of 1 g of EMLA cream have been well below toxic levels.42-46 Two cases of methemoglobinemia in infants
occurred after Dorsal Penile Nerve Block (DPNB)
DPNB is very effective in reducing the behavioral and physiologic
indicators of pain caused by circumcision. Compared with control
subjects who received no analgesia, neonates with DPNB cry 45% to 76%
less,3949-51 have 34% to 50% smaller increases in
heart rate,50,52 and have smaller decreases in oxygen
saturation during the procedure.39,52 Additionally, DPNB
lidocaine attenuates the adrenocortical stress response compared with
control subjects who received no injections or injections of
saline.49 The technique of Kirya and Werthmann is used
most commonly to perform the block.53 A 27-gauge needle is
used to inject the 0.4 mL of 1% lidocaine, to be administered at both
the 10- and 2- o'clock positions at the base of the penis. The needle
is directed posteromedially 3 to 5 mm on each side until Buck's fascia
is entered. After aspiration, the local anesthetic is injected.
Systemic lidocaine levels obtained with use of this technique
demonstrated peak concentrations at 60 minutes, well below toxic
ranges.52 Several studies evaluating the efficacy of DPNB
reported bruising as the most frequent
complication.49,50,54,55 Hematomas were rarely seen and
caused no long-term injury.50,56 A single report of penile
necrosis may have been secondary to the surgical technique rather than
to the DPNB.57
Subcutaneous Ring Block
A subcutaneous circumferential ring of 0.8 mL of 1% lidocaine
without epinephrine at the midshaft of the penis was found to be more
effective than EMLA cream or DPNB in a recent study.43 Although all treatment groups experienced an attenuated pain response, the ring block appeared to prevent crying and increases in heart rate
more consistently than did EMLA cream or DPNB throughout all stages of
circumcision. In another study, after a subcutaneous injection of
lidocaine had been given at the level of the corona, it was noted that
fewer infants cried during the dissection of the foreskin, placement of
the bell, and clamping of the Gomco, compared with those infants with a
DPNB.58 Additionally, the cortisol response was diminished
in the subcutaneous group compared with the DPNB group.58
No complications of this simple and highly effective technique have
been reported.
Others
Sucrose on a pacifier has been demonstrated to be more effective
than water for decreasing cries during circumcision.59 Acetaminophen may provide analgesia after the immediate postoperative period.60 Neither technique is sufficient for the
operative pain and cannot be recommended as the sole method of
analgesia. A more physiologic positioning of the infant in a padded
environment also may decrease distress during the
procedure.61
In summary, analgesia is safe and effective in reducing the procedural
pain associated with circumcision and, therefore, adequate analgesia
should be provided if neonatal circumcision is performed. EMLA cream,
DPNB, and a subcutaneous ring block are options, although the
subcutaneous ring block may provide the most effective analgesia.
There have been several studies published in the medical
literature over the past 15 years that address the association between circumcision status and UTI.62-68 Because the majority of
UTI in males occur during the first year of life, almost all the
studies that examine the relationship between UTI and circumcision
status focus on this period. All studies have shown an increased risk
of UTI in uncircumcised males, with the greatest risk in infants
younger than 1 year of age.
Initial retrospective studies suggested that uncircumcised male infants
were 10 to 20 times more likely to develop UTI than were circumcised
male infants.62 A review published in 1993 summarized the
data from nine studies and reported that uncircumcised male infants had
a 12.0-fold increased risk of UTI compared with circumcised infant
males.69 More recent studies using cohort and
case-control design also support an association, although reduced in
magnitude.63,64,6770-72 These studies have found a three
to seven times increased risk of UTI in uncircumcised male infants
compared with that in circumcised male infants. This consistent
association was found in samples from populations in which circumcision
rates varied from low (<20%),67 to medium
(45%),72 to high (75%).63,64 One of these,
a population-based cohort study of 58 000 Canadian infants, found that
the hospital admission rate for UTI in infant males younger than 1 year
of age was 1.88 per 1000 in circumcised infants and 7.02 per 1000 in
uncircumcised infants, for a relative risk of 3.7.72
The proportion of male infants who have symptomatic UTI during the
first year of life is somewhat difficult to estimate because the rate
varies among studies. A study at an urban emergency department found
that 2.5% of febrile male infants <60 days of age had
UTI.71 Data from Europe, based on a largely uncircumcised
population, report UTI rates of 1.2% for infant boys.73
The number is similar to the rates of 0.7% to 1.4% reported for
uncircumcised males in the United States and Canada.72,74 In comparison, UTI rates for circumcised male infants in the United States and Canada are reported to be 0.12% to
0.19%.72,74 Although these cross-cultural data do not
provide information on specific individual risk factors, the similarity
of European and American UTI rates for uncircumcised male infants
support an association between circumcision status and UTI. Using these rates and the increased risks suggested from the literature, one can
estimate that 7 to 14 of 1000 uncircumcised male infants will develop a
UTI during the first year of life, compared with 1 to 2 of 1000 circumcised male infants.
Although all these studies have shown an increased risk of UTI in
uncircumcised male infants, it is difficult to summarize and compare
the results because of differences in methodology, samples of infants
studied, determination of circumcision status, method of urine
collection, UTI definition, and assessment of confounding variables.
Furthermore, in some studies, methods for determining the reliability
of the data were not described.
Few of the studies that have evaluated the association between UTI in
male infants and circumcision status have looked at potential
confounders (such as prematurity, breastfeeding, and method of urine
collection) in a rigorous way. For example, because premature infants
appear to be at increased risk for UTI,75-77 the
inclusion of hospitalized premature infants in a study population may
act as a confounder by suggesting an increased risk of UTI in
uncircumcised infants. Premature infants usually are not circumcised because of their fragile health status.78
In another example, breastfeeding was shown to have a threefold
protective effect on the incidence of UTI in a sample of uncircumcised infants. However, breastfeeding status has not been evaluated systematically in studies assessing UTI and circumcision
status.79
One study suggested that the method used to obtain urine for culture
may influence the rate of infection,64 with the greatest
risk for infection noted in uncircumcised male infants who had samples
obtained by catheterization, compared with those who had samples
obtained by suprapubic aspiration. The three methods of urine
collection in male infants (suprapubic aspiration vs catheterization vs
bag) vary significantly in their accuracy of diagnosing UTI. Suprapubic
aspiration is considered the "gold standard" but may not be used in
clinical practice for reasons of parent and physician preference as
well as for efficiency.80,81 No studies addressing the
association between UTI and circumcision status have used suprapubic
aspiration exclusively; one study, however, did use suprapubic
aspiration in 92% of urine collections and noted a 10-fold increased
risk of UTI in uncircumcised male infants compared with circumcised
infants.66 There are no studies comparing urine obtained
by suprapubic aspiration and urethral catheterization in uncircumcised
males. In the only study comparing the accuracy of catheterization and
suprapubic aspiration in a sample of 35 asymptomatic boys (1 uncircumcised, 28 circumcised, and 6 with circumcision status not
reported), the one false-positive urine sample with significant
bacterial growth was obtained by catheterization of a 1-year-old
uncircumcised male. A study in newborns demonstrated that urine sample
obtained by bag technique is inadequate for diagnosing UTI in an
uncircumcised male because of the high false-positive
rate82; however, a negative bagged urinalysis and culture
makes the diagnosis of UTI unlikely.
There is a biologically plausible explanation for the relationship
between an intact foreskin and an increased association of UTI during
infancy. Increased periurethral bacterial colonization may be a risk
factor for UTI.69 During the first 6 months of life, there
are more uropathogenic organisms around the urethral meatus of
uncircumcised male infants than around that of circumcised male
infants, but this colonization decreases in both groups after the first
6 months.65 In addition, it was demonstrated in an
experimental preparation that uropathogenic bacterial adhered to and
readily colonized the mucosal surface of the foreskin, but did not
adhere to the keratinized skin surface of the foreskin.70
In children, UTI usually necessitate a physician visit and may involve
the possibility of an invasive procedure and hospitalization. Studies
on the morbidity and mortality associated with UTI in infancy have been
confused by the inclusion of high-risk neonates and those with
congenital anomalies.83,84 The evidence that does exist
suggests that the incidence of bacteremia associated with UTI occurs
primarily during the first 6 months of life and is inversely related to
age.62-64,85 Although the overall incidence of bacteremia
associated with UTI is 2% to 10% during the first 6 months of life,
it has been noted to be as high as 21% in the neonatal
period.85,86
Symptomatic UTI in infancy is considered to be a marker for congenital
anomalies of the genitourinary tract; however, not all infants who have
UTI will have abnormal radiologic findings. A published review suggests
that the majority of children with UTI will have normal radiographic
examination results.87 There is a lack of information on
the sequelae of UTI in infants with a normal genitourinary system.
There may be a relationship between young age at first symptomatic UTI
and subsequent renal scar formation.88,89 Similarly, there
may be a relationship between young age ( Data from multiple studies suggest that uncircumcised male infants are
perhaps as much as 10 times more likely than are circumcised male
infants to experience a UTI in the first year of life. This means that
an uncircumcised male infant has an approximate 1 in 100 chance of
developing a UTI during the first year of life; a circumcised male
infant has an approximate 1 in 1000 chance of developing a UTI during
the first year of life. Published data from a population-based cohort
study of 58 000 Canadian infants suggest an increased risk of UTI in
uncircumcised infant males of lower magnitude than data from previous
studies. Using data from this study, an uncircumcised male infant has a
1 in 140 chance of being hospitalized for a UTI during the first year
of life; a circumcised male infant has an approximate 1 in 530 chance
of being hospitalized for a UTI during the first year of life.
In summary, all studies that have examined the association between UTI
and circumcision status show an increased risk of UTI in uncircumcised
males, with the greatest risk in infants younger than 1 year of age.
The magnitude of the effect varies among studies. Using numbers from
the literature, one can estimate that 7 to 14 of 1000 uncircumcised male infants will develop a UTI during the first
year of life, compared with 1 to 2 of 1000 circumcised male infants.
Although the relative risk of UTI in uncircumcised male infants
compared with circumcised male infants is increased from 4- to as much
as 10-fold during the first year of life, the absolute risk of
developing a UTI in an uncircumcised male infant is low (at most,
~1%).
Cancer of the penis is a rare disease; the annual age-adjusted
incidence of penile cancer is 0.9 to 1.0 per 100 000 males in the
United States.91 In countries where the overwhelming majority of men are uncircumcised, the rate of penile cancer varies from 0.82 per 100 000 in Denmark92 to 2.9 to 6.8 per 100 000 in Brazil93 and 2.0 to 10.5 per 100 000 in
India.94
The literature on the relationship between circumcision status and risk
of squamous cell carcinoma of the penis (SCCP) is difficult to
evaluate. Reports of several case series have noted a strong
association between uncircumcised status and increased risk for penile
cancer95-97; however, there have been few rigorous
hypothesis-testing investigations. SCCP exists in both preinvasive
(carcinoma in situ) and invasive forms.98 Precancerous
SCCP lesions and in situ SCCP often occur primarily on the shaft of the
penis, whereas invasive SCCP may be more likely to involve the glans.
It is unclear whether preinvasive and invasive forms of SCCP are
separate diseases or whether invasive SCCP develops from preinvasive
SCCP.99 This uncertainty makes analyzing the literature
difficult. Uncircumcised status has been strongly associated with
invasive SCCP in multiple case series.
The major risk factor for penile cancer across three case-control
studies was phimosis. Other risk factors identified include "previous
genital condition," genital warts, >30 sexual partners, and
cigarette smoking.100-102 Two of the studies were
conducted in areas of the world that do not practice neonatal
circumcision. In the third study, in which 45% of the men in the
control group had been circumcised as neonates, the risk of SCCP among
men who were never circumcised was 3.2 times that of men circumcised at
birth. This study did not analyze in situ and invasive SCCP separately.
This study also used self-report to determine circumcision status.
Self-report may not be an accurate method of determining circumcision
status.103
The strength of the association between sexual behavior in the
development of penile cancer is unclear. Although there is an
association of human papilloma virus (HPV) DNA and genital warts with
penile cancer, the percentage of penile cancers with HPV DNA is lower
than that of four other anogenital tumors (anus, cervix, vulva,
vagina), implying that sexual transmission may be less of a factor in
the genesis of SCCP than of these other cancers.104 It may
be that HPV is a co-factor for penile cancer, but that other conditions
also must be present for progression to malignancy.
Neonatal circumcision confers some protection from penile cancer;
however, circumcision at a later age does not seem to confer the same
level of protection.105 There is at least a threefold
increased risk of penile cancer in uncircumcised men; phimosis, a
condition that exists only in uncircumcised men, increases this risk
further.92,106 The relationship among hygiene, phimosis,
and penile cancer is uncertain, although many hypothesize that good
hygiene prevents phimosis and penile cancer.92
An annual penile cancer rate of 0.9 to 1.0 per 100 000 translates to 9 to 10 cases of penile cancer per year per 1 million men. Although the
risk of developing penile cancer in an uncircumcised man compared with
a circumcised man is increased more than threefold, it is difficult to
estimate accurately the magnitude of this risk based on existing
studies. Nevertheless, in a developed country such as the United
States, penile cancer is a rare disease and the risk of penile cancer
developing in an uncircumcised man, although increased compared with a
circumcised man, is low.
Evidence regarding the relationship of circumcision to STD in
general is complex and conflicting.13107-110 Studies
suggest that circumcised males may be less at risk for syphilis than
are uncircumcised males.107,111 In addition, there is a
substantial body of evidence that links noncircumcision in men with
risk for HIV infection.19112-114 Genital ulcers related
to STD may increase susceptibility to HIV in both circumcised and
uncircumcised men, but uncircumcised status is independently associated
with the risk for HIV infection in several
studies.115-117 There does appear to be a plausible
biologic explanation for this association in that the mucous surface of
the uncircumcised penis allows for viral attachment to lymphoid cells
at or near the surface of the mucous membrane, as well as an increased
likelihood of minor abrasions resulting in increased HIV access to
target tissues. However, behavioral factors appear to be far more
important risk factors in the acquisition of HIV infection than
circumcision status.
The practice of medicine has long respected an adult's right to
self-determination in health care decision-making. This principle has
been operationalized through the doctrine of informed consent. The
process of informed consent obligates the physician to explain any
procedure or treatment and to enumerate the risks, benefits, and
alternatives for the patient to make an informed choice. For infants
and young children who lack the capacity to decide for themselves, a
surrogate, generally a parent, must make such choices.118
Parents and physicians each have an ethical duty to the child to
attempt to secure the child's best interest and
well-being.119 However, it is often uncertain as to what
is in the best interest of any individual patient. In cases such as the
decision to perform a circumcision in the neonatal period when there
are potential benefits and risks and the procedure is not essential to
the child's current well-being, it should be the parents who determine
what is in the best interest of the child. In the pluralistic society of the United States in which parents are afforded wide authority for
determining what constitutes appropriate child-rearing and child
welfare, it is legitimate for the parents to take into account cultural, religious, and ethnic traditions, in addition to medical factors, when making this choice.119
Physicians counseling families concerning this decision should assist
the parents by explaining the potential benefits and risks and by
ensuring that they understand that circumcision is an elective
procedure. Parents should not be coerced by medical professionals to
make this choice.
Existing scientific evidence demonstrates potential medical
benefits of newborn male circumcision; however, these data are not
sufficient to recommend routine neonatal circumcision. In the case of
circumcision, in which there are potential benefits and risks, yet the
procedure is not essential to the child's current well-being, parents
should determine what is in the best interest of the child. 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. It is legitimate for parents to take into account
cultural, religious, and ethnic traditions, in addition to the medical
factors, when making this decision. Analgesia is safe and effective in
reducing the procedural pain associated with circumcision; therefore,
if a decision for circumcision is made, procedural analgesia should be
provided. If circumcision is performed in the newborn period, it should only be done on infants who are stable and healthy.
TASK FORCE ON CIRCUMCISION 1998-1999
EPIDEMIOLOGY
EMBRYOLOGIC AND ANATOMIC CONSIDERATIONS
PENILE PROBLEMS
THE ROLE OF HYGIENE
SEXUAL PRACTICE, SENSATION, AND CIRCUMCISION STATUS
METHODS OF CIRCUMCISION
COMPLICATIONS OF THE CIRCUMCISION PROCEDURE
CIRCUMCISION AFTER THE NEWBORN PERIOD
ANALGESIA
3 g of EMLA cream was applied; in 1 of these cases,
the infant also was receiving sulfamethoxazole.47,48 EMLA
cream should not be used in neonates who are receiving other drugs
known to induce methemoglobinemia.
CIRCUMCISION STATUS AND UTI IN
INFANT MALES
3 years) at first episode of
pyelonephritis and decreased glomerular filtration rate.90
However, the relationship between renal scar formation and renal
function is not well defined, and the long-term clinical significance
of renal scars remains to be demonstrated.
CIRCUMCISION STATUS AND CANCER
OF THE PENIS
CIRCUMCISION STATUS AND STD INCLUDING HUMAN IMMUNODEFICIENCY VIRUS
(HIV)
ETHICAL ISSUES
SUMMARY AND RECOMMENDATIONS
Carole M. Lannon, MD, MPH, Chairperson
Ann Geryl Doll Bailey, MD
Alan R. Fleischman, MD
George W. Kaplan, MD
Craig T. Shoemaker, MD
Jack T. Swanson, MD
Donald Coustan, MD
American College of Obstetricians and Gynecologists
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
|---|
UTI, urinary tract infection; STD, sexually transmitted disease; NCHS, National Center for Health Statistics; DPNB, dorsal penile nerve block; SCCP, squamous cell carcinoma of the penis; HPV, human papilloma virus; HIV, human immunodeficiency virus.
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REFERENCES |
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Top
Abstract
References
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a painless procedure.
J Pediatr.
1978;
92:998-1000 [CrossRef][Medline]Statement of reaffirmation:
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