Risk-Benefit Analysis of Circumcision
Debate on the wisdom of routine circumcision centers on the possible benefits offered by circumcision, and whether they medically justify the risks associated with the procedure. Properly performed circumcision protects against the development of phimosis, paraphimosis in elderly men requiring intermittent or chronic bladder catheterization, and balanitis.5 The only longitudinal study to address the former found a 4% incidence of phimosis in uncircumcised boys.15 The medical benefits suggested to accrue from circumcision are reduced incidence of urinary tract infection in infant males, decreased incidence of penile cancer in adult males, and possibly decreased susceptibility to certain sexually transmissible diseases, including human immunodeficiency virus (HIV).
Urinary Tract Infection: There is little doubt that the uncircumcised infant is at higher risk for urinary tract infection (UTI), although the magnitude of this risk is debatable. A meta-analysis of 9 studies published between 1984 and 1992 revealed a 12-fold increased risk of UTI in uncircumcised males.4 Most of the studies analyzed were case-control designs that analyzed the rate of UTI in the first year of life. A more recent population-based cohort found a relative risk of 3.7 for hospitalization for UTI in the first year of life in uncircumcised boys.16 A similar relative risk (4.8) was detected in another case-control study.17 The reliability of many studies examining circumcision status and UTI in infant males is weakened by lack of controls for potential confounders such as prematurity, extent of breastfeeding, and the method of urine collection used to identify bacteriuria. Despite the increased relative risk in uncircumcised infants, the absolute incidence of UTI is small in this population (0.4%-1%).18 Depending on the model employed, approximately 100 to 200 circumcisions would need to be performed to prevent 1 UTI.16,19 In this case, a large relative risk reduction translates into a small absolute risk reduction because the baseline prevalence is low. One model of decision analysis concluded that the incidence of UTI would have to be substantially higher in uncircumcised males to justify circumcision as a preventive measure against this condition.20
Penile Cancer: Penile cancer is a rare disease in the United States (0.9 to 1 per 100,000). Among uncircumcised men the incidence is estimated to be 2.2/100,000.21 Six case series published between 1932 and 1986 found that all penile cancers occurred in uncircumcised individuals.11,22 Results of one case control study provide an exception to this general rule, although circumcision status was determined by self-report.23 Nevertheless, this study also found that the absence of neonatal circumcision increased the risk for penile cancer by a factor of 3.2 Other identified risk factors for penile cancer are phimosis (occurring exclusively in uncircumcised males), genital warts, infection with human papilloma virus, large number of sexual partners, and cigarette smoking.23-25 Nevertheless, because this disease is rare and occurs later in life, the use of circumcision as a preventive practice is not justified.
Human Immunodeficiency Virus Infection and Sexually Transmissible Diseases: The data on circumcision status and susceptibility to HIV infection and other sexually transmissible diseases have been recently reviewed.5,26,27 Five of 7 prospective studies involving heterosexual transmission of HIV-1 found a statistically significant association between lack of circumcision and elevated risk for acquisition of HIV (relative risks 2.3-8.1). In the other 2 studies the relative risk exceeded 3 in uncircumcised males, but a low proportion of uncircumcised men and a small percentage of seroconversion limited the statistical power of these studies.
At least 16 studies have examined the relationship between circumcision and sexually transmissible diseases other than HIV.27 In general, circumcised individuals appear to have somewhat lower susceptibility to acquiring chancroid and syphilis, possibly genital herpes, and gonorrhea compared to individuals in whom the foreskin is intact. The available data on nongonococcal urethritis and genital warts are inconclusive. Regardless of these findings, behavioral factors are far more important risk factors for acquisition of HIV and other sexually transmissible diseases than circumcision status, and circumcision cannot be responsibly viewed as "protecting" against such infections.
Complications of Circumcision
Two large series detected a complication rate between 0.2% and 0.6% in circumcised infants.28,29 Bleeding and infection, occasionally leading to sepsis, are the most common adverse events requiring treatment. In the majority of cases, bleeding is minor and hemostasis can be achieved by pressure application. Other untoward events can result from taking too much skin from the penile shaft causing denudation or rarely, concealed penis, or from not removing sufficient foreskin, producing an unsatisfactory cosmetic result or recurrent phimosis.30,31 Other postoperative complications include formation of skin bridges between the penile shaft and glans, meatitis and meatal stenosis, chordee, inclusion cysts in the circumcision line, lymphedema, hypospadias and epispadias, and urinary retention.32 Case reports have associated circumcision with other rare but severe events including scalded skin syndrome, necrotizing fasciitis, sepsis and meningitis, urethrocutaneous fistulas, necrosis (secondary to cauterization), and partial amputation of the glans penis.5,30,32
Summary and Comment
Virtually all current policy statements from specialty societies and medical organizations do not recommend routine neonatal circumcision, and support the provision of accurate and unbiased information to parents to inform their choice. The recent policy revision by the American Academy of Pediatrics also states that analgesia (anesthesia) should be provided for the procedure.
Circumcision decreases the incidence of urinary tract infections in the first year of life, and also protects against the development of penile cancer later in life. The circumcised male also may be somewhat less susceptible to HIV infection and certain sexually transmissible diseases. The low incidence of urinary tract infections and penile cancer mitigates the potential medical benefits compared with the risks of circumcision. In the case of sexual transmission of HIV, behavioral factors are far more important in preventing these infections than the presence or absence of a foreskin.
A majority of boys born in the United States still undergo nonritual circumcisions. This occurs in large measure because parental decision-making is based on social or cultural expectations, rather than medical concerns.63-67 Studies from the 1980s suggested that the presentation of medical information on the potential advantages and disadvantages of circumcision had little influence on parents' decisions.64-66 This finding was recently confirmed.68 In another contemporary study, nearly half of those physicians performing circumcisions did not discuss the potential medical risks and benefits of elective circumcision prior to delivery of the infant son. Deferral of discussion until after birth, combined with the fact that many parents' decisions about circumcision are preconceived, contribute to the high rate of elective circumcision.67,68 Major factors in parental decision-making are the father's circumcision status, opinions of family members and friends, a desire for conformity in their son's appearance, and the belief that the circumcised penis is easier to care for with respect to local hygiene.
When the decision is made to proceed with circumcision, local anesthesia should be provided for the procedure. Ring block or dorsal penile blocks are most effective. EMLA cream has limited utility but has not been sufficiently investigated with regard to dose-response effects.
RECOMMENDATIONS
The following statements, recommended by the Council on Scientific Affairs, were adopted as AMA policy at the 1999 AMA Interim Meeting.
1. The AMA encourages training programs for pediatricians, obstetricians, and family physicians to incorporate information on the use of local pain control techniques for neonatal circumcision.
2. The AMA supports the general principles of the 1999 Circumcision Policy Statement of the American Academy of Pediatrics, which reads as follows: 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.
3. The AMA urges that as part of the informed consent discussion, the risks and benefits of pain control techniques for circumcision be thoroughly discussed to aid parents in making their decisions.
via
http://www.cirp.org/library/statements/ama2000/
