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Circumcision: "To cut or not to cut, that is the question The issue of whether babies should be routinely circumcised continues to be fiercely debated in the US. The controversy is peculiar only to the US; routine (non-religious) circumcision, which begun about a century ago, has been largely abandoned in other English-speaking countries. Of the 1.19 million boys born in the US in 1987, some 61% were circumcised at birth, whereas the rate in Australia and Canada is 25%(6% in Quebec) and negligible in New Zealand, England and the Northern European countries. When compared to a 90% incidence in the 1950s and 60s, circumcision seems to be growing less popular in recent years. There are three reasons for this declining use of a once universal procedure. First, over the past 20 years, many of the reasons once given for infant circumcision have been called into question. Second, the natural childbirth movements that begun in the late 70s fueled the development of a vigorous anti-circumcision movement, whose polemical tenets are passionately argued in Rosemary Romberg's book, "Circumcision, the Painful Dilemma". Third, and most recently, insurance companies and other third-party payers have begun questioning the utility of the procedure, using tangible cost-benefit analysis. Very recent evidence, however, that supports the case for circumcision may reverse this declining trend in the future. Circumcision is the surgical removal of the foreskin, or prepuce. The prepuce covers, like a monk's cowl, the head or glans of the penis. At birth, the prepuce is only retractable in 4% of infants, but by early adolescence all normal prepuces should be full retractable. The failure of an adult foreskin to retract is called phimosis, and is a medically accepted indication for circumcision. At the inner-most edge (see diagram) of the prepuce and glans, there are glands that produce a cheesy substance called smegma, on which numerous microbes grow. Many of the bad effects of being uncircumcised have been traditionally attributed to an accumulation of smegma and the attendant bacteria. The outer side of the foreskin is normal keratinized skin, but the inner side, as is the glans of the uncircumcised penis, is a soft, moist mucous tissue (stratified squamous), similar to the walls of the vagina. Circumcision removes the foreskin's moist tissue, and exposure of the glans converts, or hastens the conversion of, its moist tissue into normal skin. Most of the benefits being attributed to circumcision today rely on the removal of this moist tissue, which is thought to be a preferred portal for disease. BENEFITS Urinary Tract lnfections(\JT\s). Uncircumcised boys have a higher incidence of UTI than their circumcised counterparts. Ginsburg and McCraken2, in their study of UTI in infants under 8 months, note that 95% of such infections occur in uncircumcised boys. Wiswell's31987 study of over 400,000 infants notes a 10-fold high rate of UTI in uncircumcised boys. A meta-analysis of all such studies reveals a 5- to 89-fold higher rate of UTI in uncircumcised boys. UTI can have serious complications, and many cases are often not diagnosed. Circumcision is thought to protect against UTI by removing a source for bacterial colonization, the preputial sac. Colonization of the prepuce, with fecal bacterial setting up a local base using smegma for nutrition, would then be a prelude to more advanced incursions up the urethra, into the body. Sexually Transmitted Diseases(STD) and AIDS/HIV. There is a likely positive relation between an intact prepuce and STD. A higher rate of genital herpes, condyloma acuminatum, and chancroid has been reported in uncircumcised men4. Uncircumcised men also have a much higher chance of acquiring HIV from heterosexual intercourse; recent reports suggest that circumcision protects against HIV (which cannot penetrate intact skin) infection by reducing the virus's major route of entry into the body. Admittedly, the American Academy of Pediatrics' most recent task force(1989) on circumcision found the data inconclusive. I personally opine, in the light of very recent corroborating data from the mid 90s (reported in class - Sci Am), that circumcision greatly reduces the risk of HIV infection; indeed it is the strongest factor in explaining HIV infection rates in Africa. Cancer of the Penis. Routine circumcision almost totally eliminates the risk of development of penile cancer, which has an incidence of some 0.7 to 0.9 per 100,000 men in the US, and a mortality rate of 25%5. One study suggests the rate of penile cancer in uncircumcised males is 1 in 6006(167 in 100,000), whereas in Israel the rate is less than 0.1 in 100,000 men. Although circumcision at birth is invariably protective, later circumcision is less or not successful in preventing this cancer. Many penile cancers are related to human papillomavirus, a virus that causes malignant transformation, which may suggest that many cases are derived from sexually transmitted infections. Thus, circumcision may protect against cancer via the same mechanism it protects against STD. Cancer of the Cervix. This cancer is far less common in Jewish and Muslim women, than in communities that are uncircumcised7. Studies indicate a strong correlation between this cancer, multiple sexual partners, frequent sexual intercourse, and sexually transmitted disease. Further, the same viruses that cause cancer of the penis also are those most commonly associated with cervical cancer. Unfortunately, statistical data linking uncircumcised men to cervical cancer is currently inconclusive, and we await data from larger, more controlled studies. If the relationship is proved, a likely mechanism would be as for the case of penile cancer, with men acting as a reservoir for a cancer-causing virus. Methods. A review of various methods will be
provided in class, but is largely omitted here in the interest of
brevity. The very distinguished mohel I spoke with, Mr. Joel Shoulson8,
uses the Mogen clamp, which was developed by his father, together
with topical anesthetics. Interestingly, the use of such anesthetic
creams was pioneered by younger Mr. Shoulson. Mr. Shoulson exclusively
performs circumcisions, though not only on Jews, and his tens of
thousands of patients have never reported any problems. In contrast,
doctors report a complication rate of 1% - 5%, depending on the
patient and the expertise of the doctor. Mr. Shoulson's expertise
in the field is so well-known that urologists often request his
help during circumcisions of atypical foreskins. The Mogen clamp,
as shown in the accompanying illustration, helps meet all four requirements
for a successful circumcision: COMPLICATIONS AND RISKS Meatitis, meatal ulcers, and meatal stenosis10. The meatus is the interface between the urethra and the external surface of the penis, where urine exits. The foreskin in the normal (incontinent) infant protects the delicate meatus from inflammation (meatitis) following exposure to urine in soiled diapers. Worsening inflammation, combined with abrasion against wet diapers, results in ulceration at the meatus. If ulcer is missed, or healing is prolonged, granulation(like scar) tissue forms at the meatus, occluding it and resulting in meatal stenosis, or narrowing of the meatus. Meatal ulcers almost never occur in uncircumcised boys, but occur in 8% to 30% of circumcised boys, usually when the child is still in diapers. Thus, meatal ulcers are the commonest complication peculiar to circumcision. The entire problem with the meatus and circumcision can usually be prevented by careful post-circumcision care by the baby's parents. Rare problems with circumcision. As a procedure requested by most Americans parents primarily for cosmetic reasons, the most frequent complaint after circumcision is that of asymmetric or insufficient skin removal, typically due to the circumcisor leaving too much inner preputial skin and too little outer preputial penile skin. This results in a two-tone penis, which while fully functional, is often unpopular with parents. Post-circumcision phimosis occurs in about 2% of circumcisions, when excessive inner preputial skin is left; it is easily corrected with an minor touch-up operation. Skin bridges occur when the healing edges of the circumcision wound attaches the glans to the penile skin over the corona; this is also easily treated with an quick outpatient procedure. Partial amputation of the penis or the tip of the glans has been reported in medical literature, especially when the Mogen clamp is used, but Mr. Shoulson emphatically denies that this problem ever occurs when a skilled operator is using the clamp. Any severed parts can usually be reattached, though. Penile necrosis, causing the sloughing off and loss of the entire penis, is a complication of hurried hospital circumcisions, when electrocauterization is used with the metal Gomco clamp. Unfortunately, the best approach to this complication is to raise the child as a female! Pain. Circumcision is a painful procedure11, even in newborns. Although many infants sleep through or after the procedure, neonates respond to pain with sweating, increased pulse and blood pressure and increased plasma cortisol (stress hormone) levels. Behavioral changes include changes in cry pattern, irritability and altered sleep patterns. These responses are always of short duration, from minutes to hours, and there is no evidence of any long-term changes. Surgeons typically inject local anesthetics at the base of the penis("dorsal nerve block") which relieves pain for 6 hours. This, as does Mr. Shoulson's topical application of an eutectic mix of local anesthetics (EMLA), significantly diminishes pain response in babies. The use of local anesthesia, especially when injected, carries the rare risks of allergy, anaphylaxis (severe allergic-type shock), cardiac rhythm disturbances and sudden collapse and death. CONCLUSION 1 With my profound apologies to William Shakespeare. References: Duckett, JW. The neonatal circumcision debate: In Urologic Surgery in neonates and young infants, (ed.: King, LR) Saunders: Philadelphia, PA (1988) Niku SD, Stock JA, Kaplan GW: Neonatal Circumcision. [Review] Urol Clin North Am 22(1):57-65, 1995 Feb Gairdner D: The Fate of the Foreskin: A Study of Circumcision. Brit Med J, Vol. 2,1433 (1949) Glenn, JF(ed): Urologic Surgery. Lippincott: Philadelphia, PA (1991) Holman JR, Lewis EL, Ringler RL: Neonatal Circumcision Techniques. Am Family Phys, 52:511-527 (Aug 1995) Kaplan GW: Complications of Circumcision. Urol Clin North Am 10:543,1983 Kirkemo, A: Complications of Penile Surgery: In Complications of Urologic Surgery: prevention and management [Smith, RB, ed.] Saunders: Philadelphia, PA (1990) Polland RL: The question of routine neonatal circumcision. N Engl J med 322:1312, 1990 Schoen EJ, the Task Force on Circumcision: Report of the Task Force on Circumcision. Pediatrics 84:388, 1989
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