CircumcisionBy Taylor Morrison, CNM ~

Circumcision is one of the most controversial topics in newborn care. Parents of male newborns are tasked with making a decision about their baby’s foreskin – to leave it intact or to remove it by way of circumcision.

What is foreskin?

The foreskin (or prepuce) is a double layer of skin that folds in on itself, forming a covering for the glans (head) of the penis. The outer layer is a continuation of the skin of the shaft, while the inner layer is a unique type of mucous membrane. The foreskin serves several purposes: to protect the glans from feces and foreign bodies, to protect the glans from friction and abrasion, to moisturize and lubricate the glans, to provide sufficient skin to cover an erection by unfolding, to aid in masturbation, foreplay, and intercourse, and to serve as erogenous tissue due to its rich supply of erogenous receptors (Bullough & Bullough, 1994).

What does a circumcision involve?

Circumcision is the surgical removal of the foreskin. It involves estimating the amount of skin to be removed, dilating the preputial orifice (the opening at the tip of the foreskin), separating the inner layer of foreskin from the glans with surgical instruments (they are adhered in infancy), placing a device (devices reviewed later), leaving the device in place long enough to staunch bleeding (several minutes to several days), and surgically removing the foreskin (either by cutting it off with a scalpel or tying it so tightly that it necroses and falls off) (American Academy of Pediatrics (AAP), 2012).

The rate of circumcision of newborn males has been declining in the United States and vary widely by geographical region, race/ethnicity, and payment method (public vs. private). A current review estimates that an average of 55-59% of male babies born in the United States in 2010 were circumcised, with rates as high as 74% in Midwestern states and as low as 30% in Western states (AAP, 2012).

In 2012, the American Academy of Pediatrics revised their policy statement on newborn circumcision to state that the “preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure… Although health benefits are not great enough to recommend routine circumcision for all newborn males.” They go on to state that “parents ultimately should decide whether circumcision is in the best interests of their male child… in the context of their own religious, ethical, and cultural beliefs and practices” (AAP, 2012).

So what does the research show about the health benefits of circumcision?

HIV and STI Transmission
It must be noted that the majority of data comes from studies conducted on the circumcision of adult males in regions with high rates of heterosexual male HIV and STI transmission (mainly sub-Saharan Africa), thus there is debate on the applicability of this research to newborn males in the United States (Boyle & Hill, 2011; Earp, 2015).

Research on adult circumcision conducted in African countries shows a relative risk reduction of 40-60% for circumcised vs. uncircumcised heterosexual men (AAP, 2012). In these studies 1.18% of circumcised males contracted HIV, while 2.49% of uncircumcised males contracted the virus. This translates to an absolute risk reduction of 1.3% for circumcised males (Earp, 2015). The CDC attempted to extrapolate this data using a mathematical model to estimate the risk reduction for males born in the United States. When considering differences in overall HIV transmission rates, timing of circumcision, and differences in culture and hygiene, the CDC study estimated the relative risk reduction in U.S. to be 15.7% (AAP, 2012). This would translate to an absolute risk reduction of <1% for U.S. born male infants. It is also important to note that many studies show no difference in HIV transmission rates for circumcised vs. uncircumcised men, while a few actually show that circumcised males have an increased rate of HIV transmission (Boyle & Hill, 2011; Earp, 2015).

Similarly, studies of rates of syphilis, genital herpes, and HPV showed circumcision to have “some protective effect” in African studies (AAP, 2012). Again, the applicability of this data to male newborns in the U.S. is questionable (Earp, 2015). Circumcision has shown no effect on rates of chlamydia or gonorrhea transmission (AAP, 2012).

Essentially, research suggests that circumcision may be protective against transmission of HIV and some STIs; however, these “health benefits are not great enough to recommend routine circumcision for all newborn males” according to the American Academy of Pediatrics (2012).

Penile Cancer
Some studies have shown a reduced relative risk of penile cancer in circumcised men. Because penile cancer is a rare disease (estimated between 1/200,000 and 1/1,000,000), and because rates of penile cancer are declining worldwide (in countries with both low and high rates of newborn circumcision), it is difficult to determine the actual effect of circumcision on the development of penile cancer later in life (AAP, 2012; Earp, 2015). Some research estimates that 909 circumcisions would need to be performed to prevent one diagnosis of penile cancer, while other studies estimate that 322,000 circumcisions would be required to prevent one case (AAP, 2012). This is an incredibly wide range of very small numbers of actual reduction in penile cancer rates.

Urinary Tract Infections
Research has shown a reduction in the rates of UTIs in circumcised vs. uncircumcised infants under 2 years of age. Studies estimate that 1/100 uncircumcised infants will have a UTI before 2 years old, while 1/1000 circumcised infants will have a UTI (AAP, 2012). It is estimated that 100 circumcisions will prevent one urinary tract infection (AAP, 2012).

What are the risks of circumcision?

The true incidence of complications due to newborn circumcisions is unknown due to a lack of data and varying definitions of complications and adverse events. It is estimated that “significant acute complications” (occurring during or immediately after circumcision) occur in about 1/500 circumcisions (AAP, 2012). Hemorrhage from excessive bleeding occurs in about 1% of circumcisions, infections occur in 0.06-0.4%, and penile injury occurs in about 0.04% (AAP, 2012). Late complications of circumcision include incomplete circumcision, excessive skin removal, adhesions, meatal stenosis, urethral damage, phimosis, and epithelial inclusion cysts. The prevalence of these complications is unknown due to inadequate data. Severe complications of circumcision are rare and difficult to quantify. These include amputation of glans or penis, herpes transmission after mouth-to-penis contact by a mohel, MRSA infection, urethral fistula, glans ischemia, and infant death (AAP, 2012). One study suggests that the rate of infant death attributable to complications from circumcision is 1/50,000 (Earp et al., 2018). Other possible complications that have been inadequately studied include impacts on sexual function and emotional trauma.

Important Considerations for Circumcision

Techniques
There are three methods of circumcision that are commonly used in United States: the Gomco, the Mogen, and the Plastibell.

The Gomco clamp is used by many practitioners. A slit is cut in the foreskin to allow space for the device, the bell of the device is placed over the glans of the penis to protect it, the foreskin is pulled over the bell, and the arm of the clamp is fitted and tightened. The device remains in place for 3-5 minutes to staunch blood flow before the clinician cuts the foreskin off with a scalpel. The device is then removed. The Gomco method protects the glans of the penis and produces good cosmetic results. The overall complication rate (including bleeding, infection, redundant prepuce, and phimosis) is 1.9-2.9%. However, some studies suggest that there is an increased risk of bleeding and removing too much skin compared to other methods (AAP, 2012; Bullough & Bullough, 1994).

The Mogen clamp is the oldest technique still commonly used. It consists of two flat blades with a small slit. The foreskin is drawn into the slit, the blades are locked together to crush the skin and staunch blood flow, and the foreskin is removed with a scalpel. The device is then removed. Studies suggest that the Mogen method is the quickest method and causes the least bleeding and pain. However, the Mogen is the only method that does not protect the glans of the penis, allowing the possibility of partial or total amputation (AAP, 2012; Bullough & Bullough, 1994).

The Plastibell device places a plastic ring under the foreskin and a tie around the outside of the foreskin to staunch blood flow. The device remains in place for 7-10 days until the foreskin dies from lack of blood flow, necroses, and falls off. The overall complication rate for this method is 2.4-5% and includes bleeding (0.8-3%), infection (2.1%), urinary retention, and “issues with the Plastibell ring” that may lead to swelling and compression of the penis (3.6%) (AAP, 2012; Bullough & Bullough, 1994).

Pain Control
According to the AAP Task Force on Circumcision, “adequate analgesia should be provided whenever newborn circumcision is performed” and “nonpharmacological techniques… are insufficient to prevent procedural and post-procedural pain and are not recommended as the sole method” (AAP, 2012). There are three commonly used analgesic options for circumcision: topical lidocaine, dorsal penile nerve block, and subcutaneous ring block.

Topical lidocaine prevents pain better than a placebo but is less effective than injectable analgesic options. Topical lidocaine needs to be applied 60-90 minutes before procedure. Complications occur in 8-14% of cases and include redness, swelling, and blistering. These complications are more common in premature or low birth weight infants. For these infants, topical analgesia is not recommended (AAP, 2012; Lemer, 2018).

The dorsal penile nerve block involves two injections of lidocaine to the base of the penis. It has been shown to be more effective than topical analgesia in reducing pain. Complications include bruising (11% of cases) and hematoma (0.2%). This method only takes 5 minutes to be effective (AAP, 2012; Lemer, 2018).

Subcutaneous ring block involves a series of injections around the base or mid-shaft of the penis. Studies show that it is more effective than topical analgesia and dorsal penile nerve block. However, there is up to a 5% failure rate. No complications have been reported from this method (AAP, 2012; Lemer, 2018).

Who Can be Circumcised?

According to the Task Force on Circumcision, “elective circumcision should be performed only if the infant’s condition is stable and healthy” (AAP, 2012). Contraindications to circumcision include significant prematurity, blood dyscrasias, a family history of bleeding disorders, and congenital abnormalities of the penis. Circumcision should be delayed for any premature, low birth weight, or ill infant. Additionally, babies should receive vitamin K supplementation before being circumcised to help prevent excessive bleeding (AAP, 2012).

The decision of whether or not to circumcise is complex and personal. Parents of male newborns should exam all the evidence and have a discussion about the importance of culture, religion, and ethics before making such a decision. The AAP states, “parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.”

References
American Academy of Pediatrics (AAP). (2012). Technical report: Male circumcision. Pediatrics. (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Boyle, G. J. and Hill, G. (2011). Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. Journal of Law and Medicine, 19, 316-344.

Bullough, V.L. & Bullough, B. (1994). Circumcision: Male – Effects upon human sexuality. Human Sexuality: An Encyclopedia. Garland Publishing: New York, NY, 119-122.

Earp, B.D. (2015). Do the benefits of male circumcision outweigh the risks? A critique of the proposed CDC guidelines. Frontiers in Pediatrics, 3 (18). doi: 10.3389/fped.2015.00018.

Earp, B.D., Allareddy, V., Allareddy, V., & Rotta, A.T. (2018). Factors associated with early deaths following neonatal male circumcision in the United States, 2001 to 2010. Clinical Pediatrics, 1:9922818790060. [Epub ahead of print].

Lemer, H.M. (2018). Eight common questions about newborn circumcision. MD Edge: ObGyn. https://www.mdedge.com/sites/default/files/document/january-2018/obgm0300127_lerner.pdf.