Circumcision

Circumcision and UTIs:
It has been suggested that circumcision protects male infants from UTI by preventing the bacterial colonization of the prepuce and subsequent ascending infection.

A meta-analysis of nine studies of the circumcision status of boys with UTI reported an odds ratio of 12.0 (95% CI 10.6 to 13.6).

Circumcision and STIs:
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. 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.

Circumcision and 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. In a recent population-based case-control study, the RR of penile cancer was 3.2 for uncircumcised men compared with circumcised men (95% CI 1.8 to 5.7). But there are many other risk factors like smoking, genital rash, penile tear, number of sexual partners…

Circumcision and cervical cancer:
Overall, no specific cause-and-effect relation between exposure to uncircumcised sexual partners and cervical cancer has been established.

Circumcision complications:
They include easily controllable bleeding, amputation of the glans, acute renal failure, life-threatening sepsis and, rarely, death. The evidence of postoperative complications is unknown. The rates of complications reported in several large case series are low, from 0.2% to 0.6%. However, published rates range as widely as 0.06% to 55%. Williams and Kapila have suggested that a realistic rate is between 2% and 10%.

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.

Conclusions:

  • 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.

Benefits:

  • Decreased:
    • UTI
    • Penile cancer
    • STD
    • Balanitis
    • Prepuce problems

Indications:

  • Phymosis
  • Paraphymosis
  • Balanitis
  • Cultural
  • Cosmetic

Risks:

  • Bleed
  • Infection
  • Scar
  • Necrosis
  • Death
  • Anesthetic reaction

Contraindications:

  • Bleeding disorders
  • Hypo/Epispadias
  • Penile abnormalities
  • Comorbid disease

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