Neonatal circumcision revisited
Canadian Medical Association Journal Vol. 154, no. 6 (March
15, 1996): pp. 769-780.
Reaffirmed February 2001.
Paper reprints of the full text may be obtained from: Fetus and Newborn
Committee, Canadian Paediatric Society,
401 Smyth Rd., Ottawa ON K1H 8L1; phone: (613) 526-9397; fax: (613) 526-3332.
Objective: To assist physicians in providing guidance to parents
regarding neonatal circumcision.
Options: Whether to recommend the routine circumcision of newborn
male infants.
Outcomes: Costs and complications of neonatal circumcision,
the incidence of urinary tract infections, sexually transmitted diseases
and cancer of the penis in circumcised and uncircumcised males, and
of cervical cancer in their partners, and the costs of treating these
diseases.
Evidence: The literature on circumcision was reviewed by the
Fetus and Newborn Committee of the Canadian Paediatric Society. During
extensive discussion at meetings of the committee over a 24-month period,
the strength of the evidence was carefully weighed and the perspective
of the committee developed.
Values: The literature was assessed to determine whether neonatal
circumcision improves the health of boys and men and is a cost-effective
approach to preventing penile problems and associated urinary tract
conditions. Religious and personal values were not included in the assessment.
Benefits, harms and costs: The effect of neonatal circumcision
on the incidence of urinary tract infection, sexually transmitted diseases,
cancer of the penis, cervical cancer and penile problems; the complications
of circumcision; and estimates of the costs of neonatal circumcision
and of the treatment of later penile conditions, urinary tract infections
and complications of circumcision.
Recommendation: Circumcision of newborns should not be routinely
performed.
Validation: This recommendation is in keeping with previous
statements on neonatal circumcision by the Canadian Paediatric Society
and the American Academy of Pediatrics. The statement was reviewed by
the Infectious Disease Committee of the Canadian Paediatric Society.
The Board of Directors of the Canadian Paediatric Society has reviewed
its content and approved it for publication.
Sponsor: This is an official statement of the Canadian Paediatric
Society. No external financial support has been received by the Canadian
Paediatric Society, or its members, for any portion of the statement's
preparation.
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Introduction
Circumcision is one of the procedures performed most often on males.
It was estimated in 1970 that 69% to 97% of all boys and men in the
United States had been circumcised, in comparison with 70% of those
in Australia, 48% of those in Canada and 24% of those in the United
Kingdom.1 The procedure is uncommon in
northern European countries, Central and South America and Asia.1
In 1971
and 1975
the American Academy of Pediatrics (AAP) took a stand against the routine
circumcision of newborns on the basis that there are no valid medical
indications for circumcision in the neonatal period.2,3
In 1975
the Fetus and Newborn Committee of the Canadian Paediatric Society (CPS)
reviewed the literature available at that time and reached the same
conclusion.4 In 1983 this position was
reiterated by the AAP and the American College of Obstetricians and
Gynecologists in their joint publication Guidelines for Perinatal
Care.5 The CPS Fetus and Newborn Committee
re-examined the issue in 1982,
in response to an article on the benefits and risks of circumcision,6
and saw no reason to modify its 1975 statement.7
In 1989
a multidisciplinary Task Force on Circumcision established by the AAP
summarized the evidence for and against the routine circumcision of
newborns but did not make a specific recommendation.8
The evidence the task force reviewed on the status of circumcision of
newborns and the question of routine neonatal circumcision was subsequently
discussed in commentaries by the chairman of the task force and by one
of its members.9,10 Considerable discussion
followed in the letters to the editor of the two journals in which these
appeared.11-17
There have continued to be articles published presenting arguments
supporting and opposing routine neonatal circumcision.18-26
Detailed estimates of the financial and medical advantages and disadvantages
have been made.27,28 Groups opposed to
neonatal circumcision have been formed and have become visible lobbyists
(for example, the National
Organization to Halt the Abuse and Routine Mutilation of Males,
San Francisco, and the National Organization
of Circumcision Information Resource Centers based in San Anselmo,
Calif., with branches across the United States and in Canada and other
countries).29 It therefore seemed appropriate
for the Fetus and Newborn Committee of the CPS to revisit the subject.
Articles on circumcision published between 1982 and 1992 were identified
from Index Medicus, and articles published from 1988 to 1994
were found through MEDLINE searches. Relevant articles were also identified
from the bibliographies of the AAP task force statement,8
the subsequent commentaries and other review articles. The reference
lists of identified articles were searched for additional publications.
A total of 671 published articles on circumcision were identified. Case
reports, case-control studies, cohort studies, randomized controlled
trials and two meta-analyses were identified and included. No randomized
controlled trials of circumcision per se were identified; the only randomized
controlled trials found involved the use of analgesia or anesthetic
agents during circumcision. Of the articles identified, 61 concerned
urinary tract infections (UTIs) and circumcision, 23 involved the relation
between male circumcision and HIV status and 25 discussed the pain caused
by circumcision and the use of analgesia. Articles reviewed were restricted
to those in English, except for one article in Spanish.
We asked the following questions. What is the effect of routine circumcision
of newborn male infants on the rate of UTI, sexually transmitted diseases,
cancer of the penis, cervical carcinoma and penile problems? What is
its effect on health care costs? Is the balance of evidence sufficient
to warrant a change in the position taken by the CPS in 1982?7
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What is the prepuce?
The prepuce is described anatomically as a simple fold of skin.30
Its function has been assumed to be protection of the glans. There are
unwritten assumptions in the literature discussing circumcision. However,
a recent
report has described numerous oval, rounded or elongated nerve corpuscles
in the inner mucosal surface of the prepuce.31
These are similar to nerve endings seen, although less frequently, in
the glans and the frenulum. Their function is unknown. The author of
the report speculated that this specialized sensory tissue may perform
different functions at different times of life and may be involved in
sexual responses in adults. The presence of these nerve endings also
emphasizes the need for pain control when circumcision is performed.
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Urinary tract infection
An association between an increased incidence of UTI and uncircumcised
status has been reported. In 1982 Ginsburg and McCracken32
reported a case series of 109 infants in whom UTI developed between
5 days and 8 months of age. Male infants predominated in their series;
of these, 95% were uncircumcised.
In 1985 Wiswell, Smith and Bass33 reviewed
a cohort of 5261 infants born at an army hospital and found a higher
incidence rate of UTI among the uncircumcised male infants (4.12%) than
among those who were circumcised (0.21%). A subsequent review of the
records of 427 698 infants (219 755 of whom were boys) born in US Armed
Forces hospitals from 1975 to 1979 supported these findings, showing
a 10-fold higher incidence rate of UTI among uncircumcised boys (1.03%)
than among circumcised boys (0.10%).34
By comparison, the incidence rate among the female infants was 0.52%.
In addition, the investigators reported a temporal association between
a decrease in the circumcision rate and an increase in the UTI rate
among boys in the early 1980s. There was no concurrent change in the
incidence among girls, and the ratio of the incidence of UTI among boys
to that among girls during early infancy shifted toward a predominance
among boys.34
A later review of UTI among 209 399 infants born between 1985 and 1990
in US Army hospitals worldwide found that 1046 infants, of which 496
were boys, had been admitted to hospital for UTI in the first year of
life.35 There was a 10-fold greater incidence
of infection among the uncircumcised than among the circumcised boys.
Among the uncircumcised boys younger than 3 months of age, the incidence
rate of concomitant bacteremia caused by the same organism that caused
the UTI was 23%. The diagnosis of UTI in all of these studies was made
on the basis of culture of urine samples obtained by bladder tap or
by catheter. These studies are retrospective, and therefore some caution
must be exercised in their interpretation. A potential bias in these
studies is that patients were admitted to hospital because of the infections;
since infections not requiring hospital treatment were excluded, the
true incidence may have been underreported.
Herzog,36 in an evaluation of febrile
infants seen in an outpatient clinic, also showed a higher incidence
of UTI among uncircumcised boys than among those circumcised. The authors
of two review articles each concluded that the circumcision of newborns
reduced the incidence of UTI.37,38 Despite
the impressive magnitude of the decrease in the incidence of UTI (10-fold
or more) associated with circumcision, when one recognizes the low overall
incidence rate of UTI among infant boys (1% to 2%), several questions
arise. Is universal circumcision warranted for the prevention of UTI?
What are the risks and the costs of this approach? Are there any alternative
strategies for the prevention of UTI that should be evaluated?
There is a plausible explanation for the association of UTI with uncircumcised
status. The explanation involves colonization of the prepuce with bacteria
in infancy and childhood. Several bacteria, including fimbriated strains
of Proteus mirabilis, nonfimbriated Pseudomonas, Klebsiella
and Serratia species39-41 and pyelonephritogenic
fimbriated Escherichia coli,39,41,42
have been shown to bind closely to the mucosal surface of the foreskin
within the first few days of life. It has been suggested that circumcision
protects male infants from UTI by preventing the bacterial colonization
of the prepuce and subsequent ascending infection.37
In natural settings, infants are often subject to colonization at
birth with the aerobic and anaerobic flora of their mothers; they also
receive specific immunoglobulin across the placenta before delivery
and, later, through ingestion of breast milk. In contrast, babies born
and cared for in hospital tend to be colonized by E. coli acquired
from the environment.43,44 The virulence
of E. coli strains isolated in cases of UTI is correlated with
the ability of the strain to adhere to uroepithelial cells.45
This ability has been shown to be associated with the presence on the
bacteria of proteinaceous, filamentous organelles called fimbria, which
appear to recognize and bind to specific receptors on the epithelial
cells.45 Kallenius and associates46
reported that 94% of the cases of infantile pyelonephritis they reviewed
were due specifically to P-fimbriated E. coli.
On the basis of these observations, Winberg
and collaborators47 suggested two
alternative preventive strategies: deliberate colonization with nonpathogenic
bacterial flora during the newborn period or the promotion of rooming-in
to facilitate close contact between newborns and their mothers. The
first strategy is analogous to the active colonization of the umbilicus
and nasal mucosa undertaken in the past to arrest epidemics of infection
with Staphylococcus aureus.48
These two strategies need to be evaluated further. One would expect
both to have a low risk of complications. The second is in keeping with
recent trends in maternal and infant care and could also have a low
cost. If either strategy is successful, it may prove to be a more cost-effective
way to prevent UTI among male infants than circumcision. Such an approach
could also be applied to the prevention of UTI in female infants, since
adherence of bacteria to epithelial cells also plays a role in the development
of UTI in girls.45
There has been one report of a case-control
study of breast-feeding and UTI among infants.49
In the study, 47% of 62 infants presenting with a UTI had been breast-fed,
whereas 82% of 62 control infants seen at a well-baby clinic and 87%
of 62 control infants admitted to hospital because of fever had been
breast-fed, and none of the control infants had a UTI (p < 0.001).
No information was given about alterations in the bacterial flora of
the infants in the study.
A meta-analysis
has been made of six articles containing original patient data on circumcision
and UTI.50 In a sample of 221 799 patients
the odds ratio (OR) of UTI among uncircumcised male infants compared
with circumcised male infants was 13.1 (95% confidence interval [CI]
10.9 to 15.7). A second meta-analysis of nine studies of the circumcision
status of boys with UTI, which included the six articles covered by
the first meta-analysis, reported an OR of 12.0 (95% CI 10.6 to 13.6).35
However, the risk of UTI among the uncircumcised boys during the first
year of life was low enough that the first set of authors felt that
routine neonatal circumcision was not justified.50
The authors of the second analysis emphasized the importance of discussing
the association between UTI and uncircumcised status while counselling
parents about neonatal circumcision to obtain their informed consent.35
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Effect of timing of circumcision
An epidemiological study of UTI during the first year of life involving
169 children born in Israel found that 48% (27/56) of the male infants
presented with UTI within 12 days after ritual circumcision.51
The incidence of UTI among male infants was significantly higher just
after circumcision (from 9 to 20 days of life) than during the rest
of the first month of life and significantly higher in the first month
of life than during the rest of the year. After the immediate postcircumcision
period, the incidence rate of UTI dropped to a level comparable to that
reported among circumcised male infants in the United States. Among
the 113 female infants, the episodes of infection were evenly distributed
throughout the first year of life, except that the incidence was lower
during the first month. This study suggests that the method and the
timing of circumcision also may be important factors to consider.
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Circumcision and UTI among young adults
In a retrospective case-control study, 26 men with symptomatic UTI
confirmed by microbiological analysis were compared with 52 men who
had urinary symptoms but negative results of cultures from urine specimens.52
The groups were similar with respect to age, race and sexual activity.
Of the men with a UTI, 31% (8/26) were uncircumcised, whereas 12% (6/52)
of the men without a UTI were uncircumcised (p = 0.037,
OR 5.6, 95% CI 1.6 to 19.4).
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Identification of urinary tract abnormalities
In the case-control study by Herzog,36
in 8 of the 31 patients who underwent radiographic investigation, abnormalities
were found. Four of the patients had grade II reflux, two had grade
IV reflux, one had posterior urethral valves with hydronephrosis, and
one had ureteropelvic junction obstruction with hydronephrosis. Amir,
Varsano and Mimouni53 found anomalies
of the urinary tracts of three out of eight patients who had a UTI after
ritual circumcision. It has been suggested that not circumcising male
infants is, therefore, advantageous because it allows early identification
of infants who have structural abnormalities that require surgical intervention
or close medical follow-up.54,55 Whether
the reflux found in the patients in the case-control study was acquired
or was a result of a congenital lesion, as suggested by Rockney and
Caldamone,54 is unknown.
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Sexually transmitted diseases
A higher risk of nongonococcal urethritis among circumcised men than
among uncircumcised men has been described.56
A recent cross-sectional study of 300 consecutive heterosexual male
patients attending a sexually transmitted diseases (STD) clinic showed
that circumcision had no significant effect on the incidence of common
STDs.57 However, a significantly greater
incidence of STDs -- including genital herpes, candidiasis, gonorrhea
and syphilis -- among men who were not circumcised than among those
who were circumcised has been previously reported.58
Uncircumcised status and diseases causing genital ulceration have been
reported to be risk factors in the transmission of HIV to heterosexual
men.59,60 A recent review of the literature
on the association between circumcision status and the risk of HIV infection
included 30 epidemiological studies, of which 15 were published articles
and 15 were abstracts presented at conferences.61
Twenty-six of these studies were cross-sectional, two were prospective
and two ecological in design. One of the latter estimated the seroprevalence
of HIV in the general population of 37 African capital cities and correlated
these data with the estimated national proportions of uncircumcised
males. The other related data on HIV seroprevalence from 140 discrete
geographic locations in Africa to the usual male circumcision practices
in those areas. Both showed positive associations. Eighteen of the cross-sectional
studies reported a statistically significant association, determined
through univariate or multivariate analysis, between the presence of
the foreskin and the risk of HIV infection. Four other such studies
showed a trend toward an association, and four showed no association.
The two prospective studies showed positive associations. The ORs or
relative risks (RRs) calculated in the studies that showed statistically
significant associations ranged from 1.5 to 8.4. However, an editorial
review of 26 studies on this subject (including 23 of the previously
reviewed studies) commented on the lack of a distinction between susceptibility
and infectivity, the use of inadequate controls for confounding variables,
potential selection biases and misclassifications of exposure or inappropriate
choices of comparison groups, each of which may lead to an incorrect
estimation of the association.62 The authors
of this review also commented that the use of an OR rather than RR in
several of the studies may have led to an overestimation of the association,
which would incorrectly suggest a causal relation. They judged that
further studies were required to ascertain the RR associated with the
lack of circumcision before considering interventional studies.
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Cancer of the penis
The incidence rate of cancer of the penis is 0.3 to 1.1 per 100 000
men per year in developed countries and 3 to 6 per 100 000 men per year
in developing nations.63,64 In the United
States the incidence rate is less than 1 per 100 000 per year. This
is similar to the rates in Norway and Sweden, where circumcision is
rarely performed.64-67 Among uncircumcised
men in the United States, the incidence rate is 2.2 per 100 000 per
year.68 Only a few cases have been reported
among men who were circumcised as newborns.69-72
In two reported studies, human papillomavirus (HPV) types 16 and 18
were found in 58% (31/53) and 49% (33/67) of cases of penile cancer,
respectively, which suggests that this virus plays a causal role in
penile cancer.73,74
A recent population-based case-control study involved 110 men with
penile cancer who were available and consented to participate, from
a total of 219 men diagnosed with this condition, and 355 controls who
were successfully interviewed, from a total of 481 eligible men. The
controls were matched with the case subjects in a 2:1 ratio by 5-year
age groups and the year of diagnosis.74
The authors found that the RR of penile cancer was 3.2 for uncircumcised
men compared with circumcised men (95% CI 1.8 to 5.7). However, other
factors were also found to be associated with an increased risk of penile
cancer. The RR was 2.8 (95% CI 1.4 to 5.5) among men who currently smoked
compared with men who had never smoked. In addition, the RRs associated
with a history of genital warts, penile rash or penile tear were 5.9
(95% CI 2.1 to 17.6), 9.4 (95% CI 3.8 to 23.9) and 3.9 (95% CI 1.9 to
7.7), respectively. Furthermore, the men with penile cancer reported
more sexual partners than those without cancer, and the men with tumours
associated with HPV also reported more sexual partners than those whose
tumours had a negative result of a test for HPV. In a case-control study
conducted in Hunan province in China, where a high rate of death from
penile cancer has been documented and early circumcision is not practised,
the RR of penile cancer was 32.9 (95% CI 4.3 to 253.8) among subjects
who had been circumcised compared with those who had not.75
An elevated risk persisted when the analysis was restricted to men who
were circumcised more than 5 years before penile cancer was diagnosed
(RR 14.9, 95% CI 1.8 to 121). Among those who had never been circumcised,
those who failed to retract their foreskin while bathing were at elevated
risk (RR 1.49), although this risk was not statistically significant
(95% CI 0.8 to 2.8). Smoking was not identified as a risk factor. More
case than control subjects reported previous STDs. Reported premarital
or extramarital affairs were associated with an elevated risk. Although
the number of subjects was small, making it difficult to ascertain the
significance of this finding, the investigators found a greater number
of genital warts, many in the same area as the tumours, during physical
examination of the case subjects. The researchers did not test the subjects
for HPV. Although circumcision was not routinely practised in Hunan,
among the men who had been circumcised the most common reason for circumcision
was the presence of a redundant prepuce or phimosis; both of these conditions
were also identified as risk factors for penile cancer. These studies
support the need for further evaluation of the causal role of hygiene
and STDs in penile cancer.
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Cervical carcinoma
HPV types 16 and 18 are the viruses most commonly associated with cancer
of the cervix.76-79 Herpes simplex virus
type 2 has also been shown to be a causal agent in cervical cancer.78,80
A higher-than-average risk of cervical cancer has been reported among
the wives of men who had been previously married to women with cervical
cancer.81 As well, epidemiological studies
have shown that starting sexual activity at an early age and having
multiple sexual partners predispose women to cervical cancer.82,83
Overall, no specific cause-and-effect relation between exposure to uncircumcised
sexual partners and cervical cancer has been established.80
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Complications of circumcision
Circumcision may lead to complications, which range from minor to severe.
They include easily controllable bleeding,84,85
amputation of the glans,84-86 acute renal
failure,87 life-threatening sepsis and,
rarely, death.84,85 The exact incidence
of postoperative complications is unknown.84
The rates of complications reported in several large case series are
low, from 0.2% to 0.6%.8 However, published
rates range as widely as 0.06%88 to 55%.89
Williams
and Kapila90 have suggested that a
realistic rate is between 2% and 10%.
Wiswell and Geschke,91 in a survey of
136 086 boys, reported a rate of complications of circumcision and other
genitourinary problems of 0.19% among circumcised infants during the
first month of life and a rate of genitourinary problems of 0.24% among
uncircumcised boys. Among the circumcised boys, hemorrhage, local infection,
surgical trauma, UTI and bacteremia were identified. Among those not
circumcised, the problems were all related to UTIs. Three of these children
also had meningitis, two had renal failure, and two died. The incidence
of urinary-tract abnormalities was not reported. The incidence of UTI
and bacteremia was lower among the circumcised boys, at a statistically
significant level, although the overall rates of complications and other
problems between the two groups were not significantly different.
Therefore, the incidence of complications of circumcision, according
to some reports, approaches or exceeds the incidence of UTI among uncircumcised
male infants. Although some of the complications are less severe than
a UTI, the incidence and cost of complications need to be included in
any assessment of the cost-effectiveness of routine circumcision.
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Penile problems during childhood
The incidence of bleeding, erosion of the glans and stenosis of the
ureteral meatus has been reported to be higher in male infants who have
been circumcised than in those who have not been circumcised.84
Meatitis and meatal ulcers occur almost exclusively in circumcised boys.84
However, a retrospective survey of boys 4 months to 12 years of age
showed a significantly greater frequency of penile problems (14% v.
6%, p = 0.001) and of medical visits for penile problems
(10% v. 5%, p = 0.05) among uncircumcised boys than
among those circumcised.92 Most of the
problems were minor. Another study of boys in their first 8 years of
life reported that the relation between the risk of penile problems
and circumcision status varied with the child's age.93
During infancy, the circumcised children had a statistically significantly
higher risk of problems than the uncircumcised boys, but among the older
children the uncircumcised boys had a significantly higher rate of penile
problems, which included penile inflammation and phimosis.
These studies did not assess the possible effect of the forcible retraction
of the prepuce, before it had separated naturally from the glans, on
the later incidence of phimosis, penile inflammation or UTI. Is this
an important factor? How common is this practice? There are articles
published describing this procedure.94,95
The development of adhesions, bleeding and phimosis are among its reported
complications.84,95 In general, there
is inadequate recognition of the long period before the natural separation
of the prepuce and glans is complete.96
Some authors still refer to the presence of "adhesions," when, in fact,
separation has not yet taken place; similarly, a nonretractile foreskin
is still sometimes incorrectly diagnosed as phimosis.97
In a study by Rickwood
and Walker98 involving 420 boys referred
to their unit for possible circumcision, only 116 (28%) required the
procedure. They found no true phimosis in boys younger than 5 years
of age. Most of the patients had developmental nonretractability of
the prepuce, and their preputial orifice, although somewhat narrow,
was supple and unscarred. The authors compared this finding with data
from the Mersey region of England, where phimosis was the most common
indication for circumcision, accounting for 87% of the procedures, and
where 390 of the 950 patients circumcised were younger than 5 years
of age. They estimated that approximately two thirds of these circumcisions
performed in the Mersey area were probably unnecessary.
An evaluation of hygienic practices among uncircumcised patients showed
that those who retracted the foreskin while bathing were less likely
to have inflammation, phimosis or adhesions than those who did not.99
The authors of this evaluation stated that these findings supported
the 1975 recommendation of the AAP3 that
good hygiene can offer many of the advantages of circumcision. There
is an urgent need for appropriate studies of the effectiveness of simple
hygienic interventions among circumcised and uncircumcised boys and
men.
Pain control during circumcision
Newborn infants exhibit physiological, autonomic and behavioural responses
to noxious stimuli. These responses suggest that they experience pain,
and there is evidence that preventing pain in newborns can be important.100
Newborns who undergo circumcision without an anesthetic have greater
increases in heart rate, cry longer and have greater decreases in transcutaneous
oxygen tension than those who undergo the procedure after administration
of a dorsal penile nerve block with lidocaine.101
Behavioural differences have also been reported. Infants circumcised
without an anesthetic were reported to show decreases in reponsiveness
and in optimal motor performance in comparison with those who received
a dorsal penile nerve block.102 These
differences were still evident a day after the procedure. Furthermore,
a recent report
has described significantly longer crying bouts and pain scores among
circumcised boys than among uncircumcised boys during routine vaccination
at 4 to 6 months of age.103
Dorsal penile nerve block has been shown to reduce the behavioural
and physiological changes during circumcision104,105
but may have serious consequences, including skin sloughs.106,107
Topical anesthetic agents show promise108-110
but do not take effect until 45 to 60 minutes after application. Furthermore,
these agents may produce methemoglobinemia.111
A prospective, randomized, double-blind, placebo-controlled trial involving
47 patients showed that acetaminophen did not alleviate the intraoperative
or the immediate postoperative physiological and behavioural changes
indicating pain.112 However, it may have
provided some benefit after the immediate postcircumcision period.
The use of sucrose for pain relief has also been tested. In a controlled
trial, 30 normal term infants undergoing circumcision were randomly
assigned to receive no intervention, a nipple dipped in water or a nipple
dipped in a solution of 24% sucrose.113
The bottles of sterile water and of sucrose solution were prepared and
marked so as to ensure that neither the investigator nor the physician
knew their contents. The use of a pacifier dipped in sterile water reduced
the percentage of time spent crying after circumcision from 67% to 49%
(p < 0.01), and the use of sucrose on the pacifier
further reduced the percentage of time spent crying to a mean of 31%
(p < 0.05).
The evidence of the need for pain control is strong, and there is
evidence of the increasing use of agents to achieve this.114
However, the most effective and least risky type of anesthesia or analgesia
remains to be determined.115 Further
studies are required to determine the most appropriate agents and the
timing of their use.
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Cost-benefit analyses
Prevention of UTI
Chessare116 developed a model for decisions
concerning circumcision of newborn male infants to prevent UTIs. In
the model, the probability of having a UTI in the first year of life
was considered to be 4.1% for an uncircumcised boy and 0.2% for a circumcised
boy,33 and the likelihood of renal scarring
as a result of a UTI was considered to be 7.5%.47
The probability of minor complications was set at 21.8%, which is a
much higher incidence rate than the rate of 0.19% reported by Wiswell
and Geschke91 or of 2% to 10% estimated
by the authors of a recent review.90 Chessare
stated that the rate of minor complications has no effect on the preferred
choice. Major complications were not included because they are relatively
rare. All possible outcomes were ranked from worst (e.g., circumcision
followed by renal disease) to best (e.g., no circumcision and no later
UTI) on a scale of 0 to 1. For the set of values assigned to the possible
outcomes, the highest expected benefit was obtained from the choice
not to circumcise. The choice would remain not to circumcise even if
none of the infants circumcised had complications as a result of the
procedure and would change only if the probability of a UTI in the first
year of life was 29% or greater. The possible reductions in the risk
of penile carcinoma and of HIV infection were not considered in this
model.
Thompson21
interpreted the published data by considering a hypothetical cohort
of 2000 newborn male infants, half of whom were circumcised and half
of whom were not. Given an incidence of UTI of 0.1% in the circumcised
boys and of 1.0% in the uncircumcised ones during the first year of
life, he calculated that there would be nine more UTIs for every 1000
newborns who were not circumcised. Thus, 99.9% of the circumcised infants
would not experience a UTI, whereas 99.0% of the uncircumcised group
would not have a UTI. Given a complication rate of 0.2%,91
Thompson estimated that, whereas 9 boys out of 1000 circumcised would
benefit from circumcision, 12 would have moderately severe complications.
At a complication rate of 4.0%, 41 boys would have moderately severe
or worse complications. He concluded that the potential benefit to 9
in 1000 boys would be more than offset by the rate of moderately severe
or worse complications, even if this rate was as low as 0.2%.
Prevention of penile cancer
There have been two assessments of the cost-benefit ratio of routine
neonatal circumcision to prevent penile cancer.6,117
However, neither assessment included the incidence and cost of the complications
of circumcision, and both assumed that neonatal circumcision was completely
protective. Since circumcision does not provide complete protection
from penile cancer, and other factors appear to be involved in the causation
of penile cancer, this assumption is an oversimplification. Cadman,
Gafni and McNamee,117 on the basis of
an incidence rate of penile carcinoma of two cases per 100 000 men annually
and of the fact that the condition almost never presents before 50 years
of age, calculated that the cost of circumcising 100 000 male infants
is $3.8 million and that this manoeuvre would prevent only two cases
of cancer of the penis. Cadman and colleagues then compared their estimate
with Hartunian, Smart and Thompson's118
estimate of $103 000 as the cost of treatment and the lost earnings
of a man 50 years of age with cancer. They conceptualized the cost of
circumcision as a long-term investment, which, invested at 4% for 50
years, would have a value of $27.2 million. Hence, they estimated that
the cost of prevention would be 100 times the cost of treatment.117
Not all factors concerning neonatal circumcision were considered, and
the restriction of the analysis to purely economic factors is a significant
limitation.
Overall assessments
Lawler, Bisonni and Holtgrave27 used
a decision tree to illustrate the consequences of the choice to circumcise
or not to circumcise male infants. With the use of the Markov process,119
they simulated the natural history of uncircumcised patients in whom
penile cancer develops later in life. They assumed there was no risk
of penile cancer after circumcision.
They included in the analysis the risks of death from the surgical
procedure, of surgical complications, of UTI, of death from UTI and
of penile problems. For the uncircumcised patients, the analysis included
the risks of penile problems (e.g., balanitis, phimosis and paraphimosis),
of death from the surgical procedure when performed at a later age,
of surgical complications, of UTI, of death from UTI and of penile cancer.
The incidence of these events was taken from the literature. However,
this incidence information varies widely, and reliable data on the incidence
of phimosis and the need for circumcision later in life are lacking
as a result of differences in diagnostic criteria.97
Given an 85-year life expectancy, these investigators calculated that
the expected lifetime cost of routine neonatal circumcision was $164.61
per patient, and the quality-adjusted survival was 84.999 years. For
those not circumcised, the expected mean lifetime cost was $139.26 per
patient and the quality-adjusted survival was 84.71 years. The investigators
therefore concluded there was no medical indication for circumcision
or contraindication against it. According to their sensitivity analyses,
if the rate of surgical complications of neonatal circumcision fell
below the threshold value of 0.6%, then circumcision would be preferred,
both in terms of its cost and its favourable effect on lifespan. Similarly,
if the risk of penile problems among uncircumcised males rose to 17%
from the baseline value of 14%, then circumcision would be preferred
from a cost perspective. The authors recognized and emphasized the need
for epidemiologically sound data on the surgical complications of circumcision
and on the incidence and outcome of therapy for balanitis, phimosis
and other penile problems, in order to better assess the risks and benefits.
Ganiats and
coworkers28 performed a cost-utility
analysis of two hypothetical groups of 1000 neonates, one circumcised
and the other uncircumcised. Their analysis included the reported differences
in incidence of UTIs and of penile cancer, the estimated costs of treating
these diseases, the incidence and cost of later therapeutic circumcision
and the costs of neonatal circumcision and its complications. The net
discounted lifetime cost of routine circumcision was $102 per man, and
the net discounted lifetime cost to health of no circumcision was 14
hours per man. The results suggested that the financial and medical
advantages and disadvantages of routine neonatal circumcision cancel
each other out, and that personal cultural or religious views, rather
than cost or health outcomes, should be the basis for decision making.
Poland10
commented that relatively few medical procedures are routinely recommended
for the care of infants and children, and that a good general principle
is to withhold the routine application of procedures to large groups
unless the benefits clearly far outweigh the risks and costs. Our review
of the literature leads us to conclude that, for routine neonatal circumcision,
the benefits have not been shown to clearly outweigh the risks and costs.
When information on the medical advantages and disadvantages of neonatal
circumcision is presented to parents before they make a decision concerning
neonatal circumcision, it results in little change in their decisions.120,121
There is evidence that parents' decision making is based mainly on social,
rather than medical, concerns.122 The
strongest factor associated with the decision about whether to circumcise
a male infant is whether his father was circumcised, and concerns about
the attitude of peers and the boy's self-concept are also prominent
influencing factors.122 These concerns
also need to be discussed during physician counselling of parents. Further
information that addresses these concerns is required.
Top of document
Conclusions
We undertook this literature review to consider whether the CPS should
change its position on routine neonatal circumcision from that stated
in 1982. The review led us to conclude the following.
- There is evidence that circumcision results in an approximately
12-fold reduction in the incidence of UTI during infancy. The overall
incidence of UTI in male infants appears to be 1% to 2%.
- The incidence rate of the complications of circumcision reported
in published articles varies, but it is generally in the order of
0.2% to 2%. Most complications are minor, but occasionally serious
complications occur. There is a need for good epidemiological data
on the incidence of the surgical complications of circumcision, of
the later complications of circumcision and of problems associated
with lack of circumcision.
- Evaluation of alternative methods of preventing UTI in infancy is
required.
- More information on the effect of simple hygienic interventions
is needed.
- Information is required on the incidence of circumcision that is
truly needed in later childhood.
- There is evidence that circumcision results in a reduction in the
incidence of penile cancer and of HIV transmission. However, there
is inadequate information to recommend circumcision as a public health
measure to prevent these diseases.
- When circumcision is performed, appropriate attention needs to be
paid to pain relief.
- The overall evidence of the benefits and harms of circumcision is
so evenly balanced that it does not support recommending circumcision
as a routine procedure for newborns. There is therefore no indication
that the position taken by the CPS in 1982 should be changed.
- When parents are making a decision about circumcision, they should
be advised of the present state of medical knowledge about its benefits
and harms. Their decision may ultimately be based on personal, religious
or cultural factors.
Top of document
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Top of page
Fetus and Newborn Committee, Canadian Paediatric Society
Members: Drs. Wayne Andrews, Department of Pediatrics,
Charles Janeway Hospital, St. John's, Nfld.; Douglas McMillan (chairman),
Department of Pediatrics, Foothills Hospital, Calgary, Alta.; Arne Ohlsson,
Department of Newborn and Developmental Pediatrics, Women's College
Hospital, Toronto, Ont.; Thérèse Perreault, Department
of Pediatrics, Montreal Children's Hospital, Montreal, Que.; Michael
Vincer, Department of Neonatal Pediatrics, Grace Maternity Hospital,
Halifax, NS; C. Robin Walker, Department of Pediatrics, Children's Hospital
of Eastern Ontario, Ottawa, Ont.; and John Watts, Department of Pediatrics,
Chedoke-McMaster Hospitals, Hamilton, Ont. Consultants: Drs. Alexander
Allen (former chairman), Department of Neonatal Pediatrics, Grace Maternity
Hospital, Halifax, NS; Eugene Outerbridge (principal author), Department
of Pediatrics, Montreal Children's Hospital, Montreal, Que.; and Saroj
Saigal, director, Growth and Development Clinic, Neonatal Follow-Up,
Chedoke-McMaster Hospitals, Hamilton, Ont. Liaisons: Ms. Debbie Fraser
Askin, Neonatal Nursing Consultant, Clinical Nurse Specialist, St. Boniface
Hospital, Winnipeg, Man.; Drs. Robert Liston, Maternal-Fetal Medicine
Committee, Society of Obstetricians and Gynaecologists of Canada, Grace
Hospital, Halifax, NS; Gerald Merenstein, Committee on Fetus and Newborn,
American Academy of Pediatrics, Department of Pediatrics, University
of Colorado, Children's Hospital, Denver, Colo.; Renato Natale, Maternal-Fetal
Medicine Committee, Society of Obstetricians and Gynaecologists of Canada,
chairman, Department of Obstetrics and Gynecology, St. Joseph's Health
Centre, London, Ont.; William Oh, Committee on Fetus and Newborn, American
Academy of Pediatrics, Department of Pediatrics, Women and Infants Hospital
of Rhode Island, Providence, RI; Apostolos Papageorgiou, Neonatal-Perinatal
Medicine Section, Canadian Paediatric Society, Department of Pediatrics,
Sir Mortimer B. Davis-Jewish General Hospital, Montreal, Que.; and Ms.
Janet Pinelli, Neonatal Nursing Consultant, School of Nursing, McMaster
University and Chedoke-McMaster Hospitals, Hamilton, Ont.
Disclaimer
This guideline is for reference and education only and
is not intended to be a substitute for the advice of an appropriate
health care professional or for independent research and judgement.
The CMA relies on the source of the CPG to provide updates and to notify
us if the guideline becomes outdated. The CMA assumes no responsibility
or liability arising from any outdated information or from any error
in or omission from the guideline or from the use of any information
contained in it.