G:\USB 1G Docs\Teach\PEDI\wbn\Circumcision facts for
parents 2006.doc 1/29/06 11:13 PM
Thomas B. Newman, MD, MPH
Professor of Epidemiology
and Biostatistics and Pediatrics
Updated Jan 27, 2006
DISCLAIMER: This handout summarizes my
own assessment of the risks and benefits of circumcision. It is not official policy of the UCSF
Department of Pediatrics or the American Academy of Pediatrics. The only strong feelings I have about the
topic are that parents should be provided with accurate information and infants
should be provided with good anesthesia.
The bottom line:
Although I believe the medical benefits of
circumcision outweigh the medical risks, both are small and circumcision is not
entirely (or even mostly) a medical decision for most families. Most boys do fine either way, but whatever
decision parents make, there is a small chance they or their son will wish they
had made the other decision.
·
The benefits (although firmly established)[1]
are not compelling enough to recommend it.
·
The medical risks are not compelling enough to
recommend against it.
·
The decision is therefore based on parental
preferences.
·
No circumcision should be done without anesthesia.
·
Medi-Cal does not cover circumcision. Medi-Cal patients and others whose insurance
does not cover the procedure will be billed; the current charge at UCSF
(January, 2006) is $325.
·
Although the newborn period is the easiest time to
do circumcisions and some of the benefits occur in the first few months, it is
a lot easier to change your mind and get the circumcision later than to attempt
a foreskin reconstruction after a circumcision has been done.
What are the benefits of
circumcision in infancy?
·
Decreased risk
of urinary tract infections: Circumcision reduces the risk of urinary tract
infections in boys from about 1-2% in the first 2 years to about 0.1 to 0.2%.(2-5) (One way
to express this is to say the risk is reduced by 90%; another way is to say it
is reduced by 1 or 2%!) In the first
month or two after birth, urinary tract infections are more serious than later;
perhaps 1% are fatal.(6) Some urinary tract infections in infancy may also
damage the kidneys, but it is not clear whether uncircumcised boys have a
higher risk of kidney damage than circumcised boys.
·
Decreased
foreskin problems: these include phimosis
(when you can't retract foreskin -- normal until puberty, rarely a
problem), paraphimosis (when the foreskin gets retracted below the glans, but
then gets stuck there, a rare but painful problem that requires immediate
attention), and infections of the end
of the penis and foreskin. In one study (7) these problems were more common in the first year
in circumcised boys (5.5%) than uncircumcised boys (1.1%), but this reversed in
older boys, so that by age 8 cumulative rates were 5.6% in circumcised boys and
17.7% in uncircumcised boys. (These
numbers seem high to me.) Roughly 5% of
boys not circumcised as newborns are later circumcised(8, 9), about half of the time for the problems mentioned
above, the remainder because of parental preferences.
What are the later benefits
to adults?
I have not closely reviewed these data myself. The adult health benefits are somewhat less
compelling to me because the man can always decide he wants to be circumcised
later if he wants these benefits. (Not
many do.)
·
Decreased
penile cancer: Circumcision reduces the risk of penile cancer about 2- 3-fold(1, 10), and which otherwise has a lifetime risk of about 1
in 600.(11) A major risk factor appears to be phimosis
(foreskin that doesn't retract), which circumcision prevents.(10)
· Decreased sexually transmitted diseases (STDs)
including HIV: There is clear evidence from
observational studies(12) and a recent randomized trial(13) that circumcision prevents acquisition of HIV, reducing risk by at
least 60%. In parts of the world where
heterosexual transmission of HIV is frequent, this is a compelling potential
benefit. Circumcision may also prevent
gonorrhea and syphilis.(14)
What are risks of
circumcision?
Gee
and Ansell(15) reviewed complications of circumcision of 2896
infants circumcised with the Gomco clamp, which is what we generally use at
UCSF. Circumcisions were done by medical
students, housestaff, or attending physicians; proportions of each group aren't
provided but it was at a teaching hospital (University of Washington). This was an old study (1976); presumably no
anesthesia was used. Also, in those days
supervision by attending physicians may have been less. Nonetheless, it probably provides the best
estimate of the risks when circumcision is done in a teaching setting like at
UCSF.
·
Excessive
bleeding, defined as instances 4-72 hours after circumcision in which a note in
the chart indicated that the physician had done something to stop the bleeding
occurred in 29 (1.0%) of the circumcisions.
Most commonly this was stopped by applying a gauze sponge soaked in
adrenaline.
·
Dehiscence, occurring in 8 infants, described
as complete separation of the penile skin from the mucous membrane in
(0.2%). I have not seen this and am
having trouble picturing it. In any
case, these were all uneventfully repaired by suturing (stitches).
·
Circumcision
of hypospadias occurred in 5 infants (0.17%).
Hypospadias means the opening of the urethra is on the shaft of the
penis, rather than at the end. It's
better not to circumcise in that case, because the foreskin is sometimes needed
for the repair. This number seems high
to me -- we always check for this -- but it is what was reported.
·
Infection, diagnosed by pus and
redness at the site of the circumcision, occurred in 4 (0.14%) circumcisions;
all were treated topically.
·
"Denudation
of the penile shaft" occurred in 3 patients. (I assume this means they took off too much
skin.) Two of them healed spontaneously
and the other needed a skin graft from the scrotum.
Additional risks not noted
in the study above:
·
Pain: We do pretty well controlling pain using a dorsal penile nerve block or ring block (an injection of local
anesthetic one each side of the base of the penis with or without EMLA (a
topical anesthetic). A few drops of
cherry syrup on a pacifier seem to work remarkably well to calm the infant. Nonetheless, some infants (perhaps 5-10%) may
still feel significant pain during the procedure. (We can give additional anesthetic if this
seems to be the case.) Occasionally
we'll give some acetaminophen (Tyenol) drops for apparent pain afterwards, but
usually the infants do not seem to need it.
·
Anesthetic
complications: Because we use an anesthetic, there is a risk of an adverse reaction to
it. It is common to get some bruising at
the anesthetic site; any other complication is probably extremely rare.
·
Vomiting, Choking, Apnea (stopping breathing): I do not know of good data on this, but have
seen it happen.[2] It is more likely when the anesthesia is not
good. We keep suction and oxygen handy
just in case. Death from
circumcision is very rare -- perhaps 1 in a million.
·
Urethral meatal stenosis. Circumcision, by removing
the protective foreskin, may increase irritation of the urethral meatus (the
hole at the end of the penis that urine comes out of), sometimes leading to
narrowing or blockage of the urinary stream.
I have not found any reliable estimates of the frequency of this
complication; a strong opponent of circumcision estimates it occurs in about 7%
of circumcised boys(16); my guess would be a lot less.
·
Poor cosmetic
result/psychological trauma: I don’t know of any data on this, but there are
definitely some poor cosmetic results and some men who wish that they had not
been circumcised. Dissatisfaction
related to not enough foreskin being removed seems to be more common than
dissatisfaction from taking off too much.
The National Organization of Circumcision Information Resource Centers
(NO-CIRC) has a referral service for men who want to get foreskin
reconstructions.
·
Impact on sexual functioning: There are strong opinions on this, especially
from people opposed to circumcision, but it is difficult to prove. Circumcised men do not have a higher
prevalence of sexual dysfunction than uncircumcised men.(17) Most studies of men circumcised as adults have mixed results, with
some reporting improvement and some worsening.(18, 19)
[1] The language in the American Academy of Pediatrics statement (1) is not as clear as it might be on this point. The statement says there are "potential" medical benefits of circumcision. In fact, the benefits aren't in doubt scientifically; they are only "potential" in the same way as other treatments proven to prevent disease. Not everyone would otherwise get the disease, therefore not everyone benefits. But the benefits of circumcision are no more "potential" than the benefits of car seat use or measles vaccine.
[2] I think I've had to use suction or oxygen a few times, and have had stop the procedure entirely once for this in several hundred circumcisions