The prevalence of neonatal circumcision increased dramatically during the early part of the last century, from about 30% in the 1930s to around 80% by the 1970s.1 After the 1970s the prevalence of the procedure declined somewhat, but current statistics indicate that 61% to 65% of male infants still have it performed on them during the neonatal period.2,3 This decline can be attributed, in part, to a 1971 American Academy of Pediatrics (AAP) policy statement that scientific data did not support the need for routine circumcision. 4 But most often the decision to circumcise a male child is based on religious and cultural practices, not on scientific data, and confusion about the procedure's benefits and risks is a big part of the reason. Although numerous studies have been conducted on the procedure, major disagreements still exist on how to interpret the results. Even studies that purported to show the benefits of circumcision have been criticized for failing to control confounding variables.
In 1989, the AAP updated its position by stating that studies indicated that the procedure was at least partially effective in preventing urinary tract infections (UTIs) and some sexually transmitted diseases (STDs).3 However, the AAP continued to deemphasize the necessity of circumcision, stressing instead that a full review of the risks and benefits was necessary before making a decision to perform the procedure.3 Inherent in this statement is awareness that parents' cultural, religious, and ethnic traditions are important aspects of the decision and that these must be balanced against the medical risks and benefits3 (see Table 1). Some years later, the American Medical Association (AMA) issued a similar policy statement acknowledging the aforementioned benefits, while noting that the risk of UTI in boys was extremely low regardless of circumcision status and that behavioral factors were far and away the most important aspect of STD prevention.5
Today, the controversy surrounding neonatal circumcision has expanded to include surgical pain and postsurgical complications, as well as the procedure's preventive effects on penile cancer, UTIs, STDs, and phimosis and paraphimosis. The results of studies conducted over the past 5 years suggest that neonatal circumcision has distinct benefits and identify techniques that minimize discomfort and surgical risk. This article examines each of these issues and discusses the recent scientific studies.
Surgical pain and anesthetics
It is well known that an infant experiences pain during circumcision and that a sucrose nipple, the traditional anesthetic, does not provide adequate pain relief.6,7 Both the AAP and the AMA recommend using a eutectic mixture of local anesthetics (EMLA cream), dorsal penile nerve block (DPNB), or a subcutaneous penile ring block.3,5 The DPNB and the subcutaneous penile ring block may be used together. All three have been proven to reduce surgical pain by a significant degree, but subcutaneous anesthetics are more effective than EMLA cream.8,9 The subcutaneous anesthetics reduced pain 34% to 76%, as measured by duration of crying, infant heart rate, and facial grimacing. 10-14 EMLA cream reduced pain 20% to 55% in essentially the same parameters.8,9,15,16
Both the DPNB and the subcutaneous ring block use lidocaine without epinephrine, with local bruising being the most common complication.11,12,17,18 The literature describes an occasional hematoma resulting from use of these anesthetics, and one case of penile necrosis has been reported.19 EMLA cream is a lidocaine-prilocaine mixture applied topically to the penile shaft about 1 hour before the procedure. In addition to being less effective than the injectable anesthetic, it also has the potential to cause methemoglobinemia.8,15,16 Newborns and premature infants are somewhat more susceptible to this very rare but serious complication.20 Few studies on controlling postoperative pain exist, probably because clinicians generally believe that such pain is effectively controlled with topical petroleum or oral acetaminophen.21 This is not recommended because acetaminophen has the potential to mask temperature changes needed to assess for neonatal sepsis. Combining topical petroleum gel with either the DPNB or the subcutaneous ring block is the recommended method for controlling postoperative pain.
Surgical complications
The surgical complication rate for circumcision is 0.2% to 1.5%, with minor bleeding and infection accounting for the majority of cases.22-25 Higher rates were reported in a few studies, probably because insignificant oozing was included as a complication.26 Rare complications include denudation of the penile shaft, laceration and necrosis of the glans penis, meatal stenosis, urinary retention, urethral fistula formation, and death.5,7 Surgical instruments that allow complete visualization of the glans throughout the procedure, such as the Plastibell device and the Gomco clamp, have lower rates of complications than those that conceal the glans during the procedure27 (see Figures 1 and 2).
Penile cancer
Circumcision's preventive effect on penile cancer is an interesting issue because the risk of acquiring the disease is extremely low regardless of circumcision status. The incidence of penile cancer in the United States is 0.9 per 100,000 men, with the risk increasing to 2.2 per 100,000 for uncircumcised men. Critics of circumcision often cite penile cancer incidence rates in countries such as Denmark, where the large majority of men are uncircumcised yet the penile cancer incidence rate is only 0.8 per 100,000 men, to point out that frequency of sexual intercourse, cigarette smoking, and the presence of venereal warts and other STDs are more important factors in disease development.7 Both the AAP and the AMA note that the risk of acquiring penile cancer is greater among uncircumcised men than among circumcised men; however, they also say that the absolute risk of penile cancer is low enough that circumcision should not be recommended as a preventive measure.3,5
Urinary tract infections 
Circumcision provides some degree of protection against UTIs during the first year of life. But as with penile cancer, the significance of this is debatable. In l993, a metaanalysis showed a 12-fold increase in UTI risk among uncircumcised male infants, but another study concluded that there was only a 3.7-fold increased risk of acquiring UTIs among uncircumcised children to begin with.28,29
Additionally, the absolute risk of developing a UTI during infancy and early childhood remains very low—0.12% to 0.19% for circumcised boys and 0.7% to 1.4% for uncircumcised boys.3 For this reason, both the AAP and the AMA do not recommend circumcision to prevent UTIs.3,30