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Indications and contraindications

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Routine or elective

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Neonatal circumcision is often elected for non-medical reasons, such as for religious beliefs or for personal preferences possibly driven by societal norms.[1] Outside the parts of Africa with high prevalence of HIV/AIDS, the positions of the world's major medical organizations on non-therapeutic neonatal circumcision range from considering it as having a modest net health benefit that outweighs small risks to viewing it as having no benefit with significant risks for harm. No major medical organization recommends non-therapeutic neonatal circumcision, and no major medical organization calls for banning it either. The Royal Dutch Medical Association, which expresses the strongest opposition to routine neonatal circumcision, does not call for the practice to be made illegal out of their concern that parents who insist on the procedure would turn to poorly trained practitioners instead of medical professionals. This argument to keep the procedure within the purview of medical professionals is found across all major medical organizations. In addition, the organizations advise medical professionals to yield to some degree to parents' preferences, commonly based in cultural or religious views, in the decision to agree to circumcise.[2]

Owing to the HIV/AIDS epidemic there, sub-Saharan Africa is a special case. The finding that circumcision significantly reduces female-to-male HIV transmission has prompted medical organizations serving the affected communities to promote circumcision as an additional method of controlling the spread of HIV.[2] The World Health Organization (WHO) and UNAIDS (2007) recommend circumcision as part of a comprehensive program for prevention of HIV transmission in areas with high endemic rates of HIV.[3]

Medical indications

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Circumcision may be medically indicated in children for pathological phimosis, refractory balanoposthitis and chronic, recurrent urinary tract infections (UTIs) in males who are chronically susceptible to them.[4][1] The World Health Organization promotes circumcision as a preventive measure for sexually active men in populations at high risk for HIV.[3]

Contraindications

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Circumcision is contraindicated in infants with certain genital structure abnormalities, such as a misplaced urethral opening (as in hypospadias and epispadias), curvature of the head of the penis (chordee), or ambiguous genitalia, because the foreskin may be needed for reconstructive surgery. Circumcision is contraindicated in premature infants and those who are not clinically stable and in good health.[5][1][6] If an individual, child or adult, is known to have or has a family history of serious bleeding disorders (hemophilia), it is recommended that the blood be checked for normal coagulationproperties before the procedure is attempted.[1][6]

Technique

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Main article: Circumcision surgical procedure
Circumcision surgery with hemostats and scissors
Before (left) and after (right) an adult circumcision, undertaken to treat phimosis. The glans is exposed even when the penis is flaccid.

The foreskin extends out from the base of the glans and covers the glans when the penis is flaccid. Proposed theories for the purpose of the foreskin are that it serves to protect the penis as the fetus develops in the mother's womb, that it helps to preserve moisture in the glans, or that it improves sexual pleasure. The foreskin may also be a pathway of infection for certain diseases. Circumcision removes the foreskin at its attachment to the base of the glans.[7]

Removal of the foreskin

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For infant circumcision, devices such as the Gomco clamp,Plastibell and Mogen clamp are commonly used in the USA.[8] These follow the same basic procedure. First, the amount of foreskin to be removed is estimated. The practitioner opens the foreskin via the preputial orificeto reveal the glans underneath and ensures it is normal before bluntly separating the inner lining of the foreskin (preputial epithelium) from its attachment to the glans. The practitioner then places the circumcision device (this sometimes requires a dorsal slit), which remains until blood flow has stopped. Finally, the foreskin is amputated.[8] For adults, circumcision is often performed without clamps,[9] and non-surgical alternatives such as the elastic ring controlled radial compression device are available.[10]

Pain management

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The circumcision procedure causes pain, and for neonates this pain may interfere with mother-infant interaction or cause other behavioral changes,[11] so the use of analgesia is advocated.[8][12] Ordinary procedural pain may be managed in pharmacological and non-pharmacological ways. Pharmacological methods, such as localized or regional pain-blocking injections and topical analgesic creams, are safe and effective.[8][13][14] The ring block and dorsal penile nerve block (DPNB) are the most effective at reducing pain, and the ring block may be more effective than the DPNB. They are more effective thanEMLA (eutectic mixture of local anesthetics) cream, which is more effective than a placebo.[13][14] Topical creams have been found to irritate the skin of low birth weight infants, so penile nerve block techniques are recommended in this group.[8]

For infants, non-pharmacological methods such as the use of a comfortable, padded chair and a sucrose or non-sucrose pacifier are more effective at reducing pain than a placebo,[14] but the American Academy of Pediatrics (AAP) states that such methods are insufficient alone and should be used to supplement more effective techniques.[8] A quicker procedure reduces duration of pain; use of the Mogen clamp was found to result in a shorter procedure time and less pain-induced stress than the use of the Gomco clamp or the Plastibell.[14] The available evidence does not indicate that post-procedure pain management is needed.[8] For adults, general anesthesia is an option,[15]and the procedure requires four to six weeks of abstinence from masturbation or intercourse to allow the wound to heal.[6]

Effects

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Sexually transmitted diseases

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Human immunodeficiency virus

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Main article: Circumcision and HIV

There is strong evidence that circumcision reduces the risk of HIV infection in heterosexual men in high-risk populations.[16][17] Evidence among heterosexual men in sub-Saharan Africa shows a decreased risk of between 38 percent and 66 percent over two years,[16] and in this population studies rate it cost effective.[18] Whether it is of benefit in developed countriesis undetermined.[19]

There are plausible explanations based on human biology for how circumcision can decrease the likelihood of female-to-male HIV transmission. The superficial skin layers of the penis contain Langerhans cells, which are targeted by HIV; removing the foreskin reduces the number of these cells. When an uncircumcised penis is erect during intercourse, any small tears on the inner surface of the foreskin come into direct contact with the vaginal walls, providing a pathway for transmission. When an uncircumcised penis is flaccid, the pocket between the inside of the foreskin and the head of the penis provides an environment conducive to pathogen survival; circumcision eliminates this pocket. Some experimental evidence has been provided to support these theories.[20]

The WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) state that male circumcision is an efficacious intervention for HIV prevention, but should be carried out by well trained medical professionals and under conditions of informed consent.[7][3][21] The WHO has judged circumcision to be a cost-effective public health intervention against the spread of HIV in Africa, although not necessarily more cost-effective than condoms.[7] The Centers for Disease Control and Prevention (CDC) has calculated that newborn circumcision is cost-effective against HIV in the US.[22] The joint WHO/UNAIDS recommendation also notes that circumcision only provides partial protection from HIV and should not replace known methods of HIV prevention.[3]

The available evidence does not indicate that circumcision provides HIV protection for heterosexual women.[8][23] Data is lacking regarding the effect circumcision may have on the transmission rate of men who engage in anal sex with a female partner.[21][24] It is undetermined whether circumcision benefits men who have sex with men.[25][26]

Human papillomavirus

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Human papillomavirus (HPV) is the most commonly transmitted sexually transmitted disease, affecting both men and women. While most infections are asymptomatic and are cleared by the immune system, some types of the virus cause genital warts, and other types, if untreated, cause various forms of cancer, including cervical cancer and penile cancer. Genital warts and cervical cancer are the two most common problems resulting from HPV.[27]

Circumcision is associated with a reduced prevalence of oncogenictypes of HPV infection, meaning that a randomly selected circumcised man is less likely to be found infected with cancer-causing types of HPV than an uncircumcised man.[28] It also decreases the likelihood of multiple infections.[29] No strong evidence indicates that it reduces the rate of new HPV infection,[29][30][31] but the procedure is associated with increased clearance of the virus by the body,[29][30] which can account for the finding of reduced prevalence.[29]

Although genital warts are caused by a type of HPV, there is no statistically significant relationship between being circumcised and the presence of genital warts.[30][31]

Other infections

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Studies evaluating the effect of circumcision on the incidence of other sexually transmitted infections have reached conflicting conclusions. A 2006 meta-analysis found that circumcision was associated with lower rates of syphilis, chancroid and possibly genital herpes.[32] A 2010 review of clinical trial data found that circumcision reduced the incidence of HSV-2 (herpes simplex virus, type 2) infections by 28%. The researchers found mixed results for protection against trichomonas vaginalis and chlamydia trachomatis and no evidence of protection against gonorrhea or syphilis.[33] Among men who have sex with men, reviews have found poor evidence for protection against sexually transmitted infections other than HIV,[25][34]with the possible exception of syphilis.[25]

Phimosis, balanitis and balanoposthitis

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Phimosis is the inability to retract the foreskin over the glans penis. At birth, the foreskin cannot be retracted due to adhesions between the foreskin and glans, and this is considered normal (physiological phimosis). Over time, the foreskin naturally separates from the glans, and a majority of boys are able to retract the foreskin by age four. If the inability to do so becomes problematic (pathological phimosis), which is commonly due to the skin disease balanitis xerotica obliterans(BXO), circumcision is the preferred treatment option.[4][35] The procedure may also be used prophylactically to prevent the development of phimosis.[1]

An inflammation of the glans penis and foreskin is called balanoposthitis; that affecting the glans alone is called balanitis.[36][37] Most cases of these conditions occur in uncircumcised males,[38] affecting 4–11% of that group.[39] The moist, warm space underneath the foreskin is thought to facilitate the growth of pathogens, particularly when hygiene is poor. Yeasts, especially Candida albicans, are the most common penile infection and are rarely identified in samples taken from circumcised males.[38] Both conditions are usually treated with topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams.[36][37] Circumcision is a treatment option for refractory or recurrent balanoposthitis, but in recent years the availability of these other treatments have made it less necessary.[36][37]

Urinary tract infections

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A UTI affects parts of the urinary system including the urethra, bladder, and kidneys. There is about a 1% risk of UTIs in boys under two years of age, and the majority of incidents occur in the first year of life. There is good but not ideal evidence that circumcision reduces the incidence of UTIs in boys under two years of age, and there is fair evidence that the reduction in incidence is by a factor of 3–10 times,[8][40] but prevention of UTIs does not justify routine use of the procedure.[4] Circumcision is most likely to benefit boys who have a high risk of UTIs due to anatomical defects,[8][40] and may be used to treat recurrent UTIs.[4]

There is a plausible biological explanation for the reduction in UTI risk after circumcision. The orifice through which urine passes at the tip of the penis (theurinary meatus) hosts more urinary system disease-causing bacteria in uncircumcised boys than in circumcised boys, especially in those under six months of age. As these bacteria are a risk factor for UTIs, circumcision may reduce the risk of UTIs through a decrease in the bacteria population.[8][41]

Cancers

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Circumcision has a protective effect against the risks of penile cancer in men, and cervical cancer in the female sexual partners of heterosexual men. Penile cancer is rare, with about 1 new case per 100,000 people per year in developed countries, and higher incidence rates per 100,000 in sub-Saharan Africa (for example, 1.6 in Zimbabwe, 2.7 in Uganda and 3.2 in Swaziland).[42] Penile cancer development can be detected in the carcinoma in situ (CIS) cancerous precursor stage and at the more advanced invasive squamous cell carcinoma stage.[8] Childhood or adolescent circumcision is associated with a reduced risk of invasive squamous cell carcinoma in particular.[8][42] There is an association between adult circumcision and an increased risk of invasive penile cancer; this is believed to be from men being circumcised as a treatment for penile cancer or a condition that is a precursor to cancer rather than a consequence of circumcision itself.[42] Penile cancer has been observed to be nearly eliminated in populations of males circumcised neonatally.[39]

Important risk factors for penile cancer include phimosis and HPV infection, both of which are mitigated by circumcision.[42] The mitigating effect circumcision has on the risk factor introduced by the possibility of phimosis is secondary, in that the removal of the foreskin eliminates the possibility of phimosis. This can be inferred from study results that show uncircumcised men with no history of phimosis are equally likely to have penile cancer as circumcised men.[8][42] Circumcision is also associated with a reduced prevalence of cancer-causing types of HPV in men[29] and a reduced risk of cervical cancer (which is caused by a type of HPV) in female partners of men.[1] Because penile cancer is rare (and may get more rare with increasing HPV vaccination rates), and circumcision has risks, the practice is not considered to be valuable solely as a prophylactic measure against penile cancer in the United States.[8][43][39]

Adverse effects

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Neonatal circumcision is generally safe when done by an experienced practitioner.[44] The most common acute complications are bleeding, infection and the removal of either too much or too little foreskin.[8][45] These complications occur in less than 1% of procedures, and constitute the vast majority of all acute circumcision complications in the United States.[45] Minor complications are reported to occur in 3% of procedures.[44] A specific complication rate is difficult to determine due to scant data on complications and inconsistencies in their classification.[8] Complication rates are greater when the procedure is performed by an inexperienced operator, in unsterile conditions, or when the child is at an older age.[46]

Significant acute complications happen rarely,[8][46] occurring in about 1 in 500 newborn procedures in the United States.[8] Severe to catastrophic complications are sufficiently rare that they are reported only as individual case reports.[8] The mortality risk is estimated at 1 in every 500,000 neonatal procedures conducted within the United States.[45]

Circumcision does not appear to decrease the sensitivity of the penis, harm sexual function or reduce sexual satisfaction.[47][48] The Royal Dutch Medical Association's 2010 Viewpoint mentions that "complications in the area of sexuality" have been reported.[49]Additionally, the procedure may carry the risks of heightened pain response for newborns,castration anxiety for boys in the phallic stage, and dissatisfaction with the result.[11]

Prevalence

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Main article: Prevalence of circumcision
Prevalence of circumcision by country

Circumcision is probably the world's most widely performed procedure.[50] Approximately one-third of males worldwide are circumcised, most often for reasons other than medical indication.[7][46] It is commonly practiced between infancy and the early twenties.[7] The WHO estimated in 2007 that 664,500,000 males aged 15 and over were circumcised (30% global prevalence), almost 70% of whom wereMuslim.[7] Circumcision is most prevalent in the Muslim world, Israel, South Korea, the United States and parts of Southeast Asia and Africa. It is relatively rare in Europe, Latin America, parts of Southern Africa andOceania and most of Asia. Prevalence is near-universal in the Middle East and Central Asia.[7][51] Non-religious circumcision in Asia, outside of the Republic of Korea and the Philippines, is rare,[7] and prevalence is generally low (less than 20%) across Europe.[7][52] Estimates for individual countries include Taiwan at 9%[53] and Australia 58.7%.[54] Prevalence in the United States and Canada is estimated at 75% and 30% respectively.[7] Prevalence in Africa varies from less than 20% in some southern African countries to near universal in North and West Africa.[51]

The rates of routine neonatal circumcision over time have varied significantly by country. In the United States, hospital discharge surveys estimated rates at 48.3% around the year 1990,[55] 61% in 2000,[7] and around 56.6% in 2008. These estimates are lower than the actual rates, as they do not account for non-hospital circumcisions,[55] or for procedures performed for medical need;[7] community surveys have reported higher neonatal prevalence.[7] Canada has seen a slow decline since the early 1970s, possibly influenced by statements from the AAP and the Canadian Pediatric Society issued in the 1970s saying that the procedure was not medically indicated.[7] In Australia, the rate declined in the 1970s and 80s, but has been increasing slowly as of 2004.[7] In the United Kingdom, prevalence was roughly 25% in the 1940s, but declined dramatically after the National Health Service (NHS) did not cover the costs of the procedure.[7] The prevalence in South Korea has increased markedly in the second half of the 20th century, rising from near zero around 1950 to about 60% in 2000, with the most significant jumps in the last two decades of that time period.[7] This is probably due to the influence of the United States, which established a trusteeship for the country following World War II.[7]

Medical organizations can affect the neonatal circumcision rate of a country by influencing whether the costs of the procedure are borne by the parents or are covered by insurance or a national health care system. Policies that require the costs to be paid by the parents yield lower neonatal circumcision rates. The decline in the rates in the UK is one example; another is that in the United States, the individual states where insurance or Medicaid covers the costs have higher rates. Changes to policy are driven by the results of new research, and moderated by the politics, demographics, and culture of the communities.[2]

  1. ^ a b c d e f Cite error: The named reference hay_2012 was invoked but never defined (see the help page).
  2. ^ a b c Cite error: The named reference Bolnick_2012_ch1 was invoked but never defined (see the help page).
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  8. ^ a b c d e f g h i j k l m n o p q r s t Cite error: The named reference AAP_2012 was invoked but never defined (see the help page).
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  20. ^ Cite error: The named reference weiss_2010_HIV was invoked but never defined (see the help page).
  21. ^ a b Cite error: The named reference WHO_CandR_2007 was invoked but never defined (see the help page).
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  29. ^ a b c d e Cite error: The named reference rehmeyer_2011 was invoked but never defined (see the help page).
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  31. ^ a b Cite error: The named reference albero_2012 was invoked but never defined (see the help page).
  32. ^ Cite error: The named reference weiss_2006_syphilis was invoked but never defined (see the help page).
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  40. ^ a b Cite error: The named reference jagannath_2012 was invoked but never defined (see the help page).
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  42. ^ a b c d e Cite error: The named reference larke_penile_cancer_2011 was invoked but never defined (see the help page).
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  44. ^ a b Cite error: The named reference AUA_2007 was invoked but never defined (see the help page).
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  46. ^ a b c Cite error: The named reference weiss_2010_complications was invoked but never defined (see the help page).
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  48. ^ Morris BJ, Waskett JH, Banerjee J, Wamai RG, Tobian AA, Gray RH, Bailis SA, Bailey RC, Klausner JD, Willcourt RJ, Halperin DT, Wiswell TE, Mindel A (2012). "A 'snip' in time: what is the best age to circumcise?". BMC Pediatr. 12: 20. doi:10.1186/1471-2431-12-20. PMC 3359221. PMID 22373281. Circumcision in adolescence or adulthood may evoke a fear of pain, penile damage or reduced sexual pleasure, even though unfounded.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)
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