Circumcision

Article Author:
Warees Warees
Article Editor:
Alexander Rodriguez
Updated:
12/5/2018 8:57:42 PM
PubMed Link:
Circumcision

Introduction

Circumcision is the surgical removal of the prepuce (foreskin) covering the glans of the penis. The practice of circumcision has existed for thousands of years as part of cultural and religious teachings.[1] It was highly regarded as a rite of passage to adulthood and a hygienic process.  Over the past decades, cultural changes and new research have led to a closer examination of the circumcision practice. Recent knowledge of female circumcision has also fueled the discussions on the validity of male circumcision.[2][3][4][5]

Anatomy

The penis can be divided into the dorsal surface, ventral surface, base (proximal), shaft (middle) and glans (distal). The dorsal region contains the superficial dorsal vein, deep dorsal vein, dorsal artery, and dorsal nerve. This dorsal nerve is anesthetized during the dorsal nerve block to aid with pain control during circumcisions.

The major components of the penis include the urethra, corpora cavernosa, corpus spongiosum, glans, and the foreskin. The 2 corpora cavernosa lie ventral to the dorsal nerves and vasculature. They become engorged with blood to promote erection. The corpus spongiosum lies ventral to the corpora cavernosa. It houses the urethra.  The urethra starts at the bladder and runs through the length of the penis to end at the glans of the penis. The foreskin covers the entire penis and is trimmed distally during circumcision to expose the glans.

Indications

Medical indications for circumcision include but are not limited to phimosis, paraphimosis, and chronic urinary tract infections. Elective circumcision may be indicated in regions with increased HIV and human papillomavirus (HPV).

Contraindications

Contraindications to circumcisions include an unhealthy infant, anatomic pathology, and bleeding disorders. The general health of the infant should be assessed before the procedure. The procedure should be delayed if the infant is found to have electrolyte abnormalities (e.g., hypoglycemia), a bacterial infection, has yet to urinate, or to has a hypoxic cardiac disorder. In most cases, circumcision is an elective procedure and can be delayed. The penis should be evaluated for anatomical anomalies such as micropenis, concealed penis, swelling of the foreskin, and hypospadias. Any infant with a bleeding disorder or a strong family history of bleeding disorders should only undergo the circumcision at a healthcare facility with the proper subspecialist.[6][7]

Personnel

The practice of circumcision is not limited to medical professionals. As a result, standards of pain control, hygiene, technique, and outcomes cannot be guaranteed. The family of the patient must interview the personnel performing the circumcision. The person performing the procedure usually can provide the family with a portfolio of their outcomes.

Preparation

Proper pain control should be administered for the circumcision. It should be noted that a sugar-based oral solution alone is not an adequate pain control for infants. Effective analgesia is highly dependent on the person performing the procedure. Many infants are treated with a combination of oral sucrose solutions, topical analgesics like lidocaine cream 4% (LMX-4), lidocaine/prilocaine cream, and injected analgesics such as lidocaine without epinephrine or bupivacaine.[8][9][10]

Technique

There are various methods for circumcision. The goal of each method consists of removal both the inner and outer preputial skin while not injuring the underlying glans and urethra. The procedure should take minutes when performed on the newborn. However, it becomes more complicated when performed on adults. The healing phase and result depend on the procedure used. Below are common methods used for circumcision.[11][12][13][14]

Complications

Circumcision does not lower the risk of gonorrhea, chlamydia, or syphilis. However, circumcised heterosexual males have an averaged 40% to 60% reduction in acquiring HIV in regions with a high HIV heterosexual population, for example, areas in Africa. There is also a lower prevalence of human papillomavirus (HPV) infection and herpes simplex virus type 2 transmission.[15][16][17]

Risks

Surgical risks include, but are not limited to, infection, incision of the glans and urethra, necrosis of the glans, foreskin adhesions, phimosis, or penile loss.[15][17]

Clinical Significance

Current Recommendations

AAP Statement

In an update to the 1999 recommendations, new evidence indicated that health benefits outweighed the complications for newborn male circumcisions. There was found to be a reduction in urinary tract infections, sexually transmitted infections, acquisition of HIV, and penile cancer. Circumcision was not associated with a decrease in sexual function and satisfaction. All families should be given the proper information regarding circumcision. These statements have also been endorsed by the American College of Obstetricians and Gynecologists.[15][18][19]

AAFP Statement

Family physicians should provide the family with information in an unbiased manner. Neonatal circumcision has potential health benefits in the reduction of urinary tract infection, sexually transmitted infections and penile cancer. However, circumcision is not without complications. Now the HPV vaccine alone may aid in the reduction of penile cancer.

American Urologic Association

The circumcised newborn infant will experience the risks and complications associated with the procedure. The circumcised adult will profit from reduced health illnesses. The benefits and risks should be discussed with the family.

Enhancing Healthcare Team Outcomes

This article is intended to be a short review of circumcision. As part of the education, the reader must be aware of the evolving view of circumcision. The AAP revised its 1999 policy on circumcision to be more pro-circumcision. This statement has reignited the debate.

The anti-circumcision papers site many reasons not to undergo the procedure. Bringing female circumcision to the mainstream has placed male circumcision under a similar spotlight. The procedure is described as a painful procedure that is needed to push the male into manhood. This trauma can then lead to sexual difficulties. It has been proposed that the procedure should be delayed until the male can decide for himself.

Healthcare professionals do not all agree with the disease prevention benefits. The HIV reduction is most prevalent in decreasing heterosexual transmission in regions with large HIV population, for example in parts of Africa). Thus, this fact needs to be included in the counseling conversation with families who are not from these regions.

HPV transmission can be reduced by circumcision. This point may become obsolete with the increased use of the HPV vaccine.

Providers must be educated about and understand religious doctrines, research findings, and cultural teachings surrounding circumcisions. The data must be provided to each family in an unbiased version. The provider must also be able to relate the data to the unique family situation.[20][21][22][23][24][25][26][27]


References

[1] Raveenthiran V, The evolutionary saga of circumcision from a religious perspective. Journal of pediatric surgery. 2018 Jul     [PubMed PMID: 29627177]
[2] Zurynski Y,Sureshkumar P,Phu A,Elliott E, Female genital mutilation and cutting: a systematic literature review of health professionals' knowledge, attitudes and clinical practice. BMC international health and human rights. 2015 Dec 10     [PubMed PMID: 26652275]
[3] Varol N,Fraser IS,Ng CH,Jaldesa G,Hall J, Female genital mutilation/cutting--towards abandonment of a harmful cultural practice. The Australian     [PubMed PMID: 24801568]
[4] Matar L,Zhu J,Chen RT,Gust DA, Medical risks and benefits of newborn male circumcision in the United States: physician perspectives. Journal of the International Association of Providers of AIDS Care. 2015 Jan-Feb     [PubMed PMID: 24899259]
[5] Foddy B, Medical, religious and social reasons for and against an ancient rite. Journal of medical ethics. 2013 Jul     [PubMed PMID: 23781076]
[6] Earp BD,Allareddy V,Allareddy V,Rotta AT, Factors Associated With Early Deaths Following Neonatal Male Circumcision in the United States, 2001 to 2010. Clinical pediatrics. 2018 Aug 1     [PubMed PMID: 30066572]
[7] Roth JD,Keenan AC,Carroll AE,Rink RC,Cain MP,Whittam BM,Bennett WE Jr, Readmission characteristics of elective pediatric circumcisions using large-scale administrative data. Journal of pediatric urology. 2016 Feb     [PubMed PMID: 26643790]
[8] Paix BR,Peterson SE, Circumcision of neonates and children without appropriate anaesthesia is unacceptable practice. Anaesthesia and intensive care. 2012 May     [PubMed PMID: 22577918]
[9] Al Qahtani R,Abu-Salem LY,Pal K, Effect of lidocaine-prilocaine eutectic mixture of local anaesthetic cream compared with oral sucrose or both in alleviating pain in neonatal circumcision procedure. African journal of paediatric surgery : AJPS. 2014 Jan-Mar     [PubMed PMID: 24647296]
[10] Fontaine P,Toffler WL, Dorsal penile nerve block for newborn circumcision. American family physician. 1991 Apr     [PubMed PMID: 2008820]
[11] Abdulwahab-Ahmed A,Mungadi IA, Techniques of male circumcision. Journal of surgical technique and case report. 2013 Jan     [PubMed PMID: 24470842]
[12] Alyami F,Ferandez N,Koyle MA,Salle JP, Keloid formation after pediatric male genital surgeries: an uncommon and difficult problem to manage. Journal of pediatric urology. 2018 Aug 8     [PubMed PMID: 30206024]
[13] Brook I, Infectious Complications of Circumcision and Their Prevention. European urology focus. 2016 Oct     [PubMed PMID: 28723479]
[14] Al Hussein Alawamlh O,Kim SJ,Li PS,Lee RK, Novel Devices for Adolescent and Adult Male Circumcision. European urology focus. 2018 Jul 11     [PubMed PMID: 30007543]
[15] Male circumcision. Pediatrics. 2012 Sep     [PubMed PMID: 22926175]
[16] Circumcision policy statement. Pediatrics. 2012 Sep     [PubMed PMID: 22926180]
[17] Friedman B,Khoury J,Petersiel N,Yahalomi T,Paul M,Neuberger A, Pros and cons of circumcision: an evidence-based overview. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases. 2016 Sep     [PubMed PMID: 27497811]
[18] Cultural bias and circumcision: the AAP Task Force on circumcision responds. Pediatrics. 2013 Apr     [PubMed PMID: 23509171]
[19] Lannon CM,Bailey A,Fleischman A,Shoemaker C,Swanson J, Circumcision debate. Task Force on Circumcision, 1999-2000. Pediatrics. 2000 Mar     [PubMed PMID: 10699124]
[20] Morris BJ,Bailis SA,Wiswell TE, In reply--Bias and male circumcision. Mayo Clinic proceedings. 2014 Nov     [PubMed PMID: 25444491]
[21] Morris BJ,Bailis SA,Wiswell TE, Circumcision rates in the United States: rising or falling? What effect might the new affirmative pediatric policy statement have? Mayo Clinic proceedings. 2014 May     [PubMed PMID: 24702735]
[22] Morris BJ,Tobian AA,Hankins CA,Klausner JD,Banerjee J,Bailis SA,Moses S,Wiswell TE, Veracity and rhetoric in paediatric medicine: a critique of Svoboda and Van Howe's response to the AAP policy on infant male circumcision. Journal of medical ethics. 2014 Jul     [PubMed PMID: 23955288]
[23] Di Pietro ML,Teleman AA,Di Pietro ML,Poscia A,González-Melado FJ,Panocchia N, Preventive Newborn Male Circumcision: What Is the Child's Best Interest? Cuadernos de bioetica : revista oficial de la Asociacion Espanola de Bioetica y Etica Medica. 2017 Sep-Dec     [PubMed PMID: 28963998]
[24] Reis-Dennis S,Reis E, Are Physicians Blameworthy for Iatrogenic Harm Resulting from Unnecessary Genital Surgeries? AMA journal of ethics. 2017 Aug 1     [PubMed PMID: 28846522]
[25] Svoboda JS, Nontherapeutic Circumcision of Minors as an Ethically Problematic Form of Iatrogenic Injury. AMA journal of ethics. 2017 Aug 1     [PubMed PMID: 28846521]
[26] Svoboda JS,Adler PW,Van Howe RS, Circumcision Is Unethical and Unlawful. The Journal of law, medicine     [PubMed PMID: 27338602]
[27] Merkel R,Putzke H, After Cologne: male circumcision and the law. Parental right, religious liberty or criminal assault? Journal of medical ethics. 2013 Jul     [PubMed PMID: 23698890]