Sexually transmitted diseases
Numerous studies, dating as far back as the 1940s, have focused on an association between circumcision and STD prevention. Approximately half of these studies showed a positive relationship between the two; however, the remainder of the studies showed virtually no relationship between the two.7 Those that indicated a positive relationship hypothesized that a general toughening of the glans skin in circumcised males and a relative ease in recognizing ulcerative disease of the penis accounted for the difference between the two populations. In 1999 the AAP issued a statement acknowledging that circumcision decreases the risk of acquiring syphilis, and the AMA followed with a statement suggesting that circumcised males were somewhat less susceptible to HIV infection and certain other STDs than were uncircumcised men.3,5
Support for the procedure was stated more strongly in 2000 by Schoen and colleagues.31 These researchers indicated that an analysis of data showed a strong association between uncircumcised status and the increased risk of genital ulcer disease, particularly chancroid and syphilis.31 Following this, a meta-analysis of 28 studies on HIV disease transmission concluded that the risk of acquiring heterosexually-transmitted HIV infection was 1.5 to 8.4 times greater in uncircumcised men than in circumcised men.32 In 2005, a 21-month study, which included approximately 3,000 South African heterosexual men, concluded that circumcision provided a 65% protective effect in female-to-male transmission of HIV disease during regular sexual intercourse.33 A 2006longitudinal study of over 500 New Zealand males revealed that neonatal circumcision has the potential to reduce the incidence of STDs by approximately 48% over a lifetime.34 The STDs considered in the New Zealand
study included genital warts, gonorrhea, chlamydia, and genital herpes. The reason for this protection is uncertain, although some have argued that the penile foreskin is particularly susceptible to penetration by genital bacteria and viruses.
Phimosis and paraphimosis
While circumcision completely prevents phimosis and paraphimosis, the likelihood of developing either condition remains relatively low in uncircumcised males. Moreover, both conditions can be easily prevented with adequate hygiene. For example, in a recently completed study involving approximately 2,000 Danish schoolboys, only 4% of the boys had problems with phimosis and tight prepuces and these were largely minimal.35 A few cases of paraphimosis have been reported, but STD-related balanitis or failure to maintain good hygiene was indicated as the cause. This suggests that effective patient education and early STD treatment are usually adequate preventive measures.36,37
Other issues
A reduced risk of cervical cancer in female partners of circumcised men has been documented by numerous studies,38-42 but other studies refute this, including the aforementioned New Zealand studies, which did not specifically indicate there was a decreased incidence of human papillomavirus infections in circumcised males.22,34,43 Masters and Johnson long ago disproved the claim that circumcised men experience less sexual pleasure than their uncircumcised counterparts in their extensive studies on male sexual arousal and pleasure.44
Conclusion
Circumcision, like any surgical procedure, has risks, and even though most are relatively minor, parents must be thoroughly educated about them. When parents do choose circumcision, newer forms of anesthesia effectively minimize infant discomfort during the procedure and should be used instead of or in addition to a sucrose nipple. Current evidence supports the practice of neonatal male circumcision based on the procedure's ability to prevent UTIs, phimosis, paraphimosis, STDs, and cancer. The risk of acquiring some of these conditions is extremely low at baseline to begin with, however, and for many parents, the benefits of circumcision will not outweigh the risks. JAAPA
Herb Ridings is Program Director of the Surgical PA Program, University of Alabama at Birmingham. Michelle Amaya is an Assistant Professor in the Department of Pediatrics at the University of Alabama at Birmingham. The authors have indicated no relationships to disclose relating to the content of this article.
REFERENCES
1. Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States. Prevalence, prophylactic effects, and sexual practice. JAMA. 1997;277(13):1052-1057.
2. Poland RL. The question of routine neonatal circumcision. N Engl J Med. 1990; 322(18):1312.
3. Circumcision Policy Statement. American Academy of Pediatrics. Task Force on Circumcision. Pediatrics. 1999;103(3):686-693.
4. American Academy of Pediatrics, Committee on Fetus and Newborns. Standards and Recommendations for Hospital Care of Newborn Infants. 5th ed. Evanston, Ill: American Academy of Pediatrics; 1971.
5. American Medical Association. Report 10 of the Council on Scientific Affairs: Neonatal Circumcision. Chicago, Ill: American Medical Association; 1999.
6. Anand KJ, Hickey PR. Pain and its effects in the human neonate and fetus. N Engl J Med. 1987;317(21):1321-1329.
7. Benetar D, Benetar M. A pain in the fetus: toward ending confusion about fetal pain. Bioethics. 2001;15(1):57-76.
8. Lander J, Brady-Fryer B, Metcalf JB, et al. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision: a randomized controlled trial. JAMA. 1997;278(24):2157-2162.
9. Benini F, Johnston CC, Faucher D, Aranda JV. Topical anesthesia during circumcision in newborn infants. JAMA. 1993;270(7):850-853.
10. Williamson PS, Williamson ML. Physiologic stress reduction by a local anesthetic during newborn circumcision. Pediatrics. 1983;71(1):36-40.
11. Stang HJ, Gunnar MR, Snellman L, et al. Local anesthesia for neonatal circumcision: Effects on distress and cortisol response. JAMA. 1988;259(10):1507-1511.
12. Holve RL, Bromberger PJ, Groveman HD, et al. Regional anesthesia during newborn circumcision. Effect on infant pain response. Clin Pediatrics. 1983;22(12):813-818.
13. Dixon S, Snyder J, Holve R, Bromberger P. Behavioral effects of circumcision with and without anesthesia. J Dev Behav Pediatr. 1984;5(5):246-250.
14. Maxwell LG, Yaster M, Wetzel RC, Niebyl JR. Penile nerve block for newborn circumcision. Obstet Gynecol.1987;70(3 Pt 1):415-419.
15. Taddio A, Ohlsson A, Einarson T, et al. A systematic review of lidocaine-prilocaine cream (EMLA) in the treatment of acute pain in neonates. Pediatrics. 1998;101(2):e1. Available at: http://www.pediatrics.org/cgi/content/full/101/2/e1. Accessed January 11, 2006.
16. Taddio A, Stevens B, Craig K, et al. Efficacy and safety of lidocaine-prilocaine cream for pain during circumcision. N Engl J Med. 1997;336(17):1197-1201.
17. Mintz MR, Grillo R. Dorsal penile nerve block for circumcision. Clin Pediatr. 1989; 28(12):590-591.
18. Fontaine P, Dittberner D, Scheltema KE. The safety of dorsal penile nerve block for neonatal circumcision. J Fam Pract. 1994;39(3):243-248.
19. Sara CA, Lowry CJ. A complication of circumcision and dorsal nerve block of the penis. Anaesth Intensive Care. 1985;13(1):79-82.
20. Kumar AR, Dunn N, Naqvi M. Methemoglobinemia associated with prilocaine-lidocaine cream. Clin Pediatr. (Phila.) 1997;36(4):239-240.
21. Stang HJ, Snellman LW, Condon LM, et al. Beyond dorsal penile nerve block: a more humane circumcision. Pediatrics. 1997;100(2):e3. Available at: http://www.pediatrics.org/cgi/content/full/100/2/e3. Accessed January 22, 2007.
22. Moses S, Bailey RC, Ronald AR. Male circumcision: assessment of health benefits and risks. Sex Transm Inf. 1998;74(5):368-373.
23. Gee WF, Ansell JS. Neonatal circumcision: a ten-year overview: with comparison of the Gomco clamp and the Plastibell device. Pediatrics. 1976;58(6):824-827.
24. Harkavy KL. The circumcision debate. Pediatrics. 1987;79(4):649-650.
25. Kaplan GW. Complications of circumcision. Urol Clin North Am. 1983;10(3):543-549.
26. Patel H. The problem of routine circumcision. Can Med Assoc J. 1966;95(11):576-581.
27. Hay WW, Levin MJ, Sondheimer JM, Deterding RR (eds). Current Pediatric Diagnosis & Treatment. 17th ed. New York, NY: McGraw Hill; 2005.
28. Wiswell TE, Hachey WE. Urinary tract infections and the uncircumcised state: an update. Clin Pediatrics. 1993;32(3):130-134.
29. To T, Agha M, Dick PT, Feldman W. Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection. Lancet. 1998;352(9143):1813-1816.
30. Craig JC, Knight JF, Sureshkumar P, et al. Effect of circumcision on incidence of urinary
tract infection in preschool boys. J Pediatr. 1996;128(1):23-27.
31. Schoen EJ, Wiswell TE, Moses S. New policy on circumcision—cause for concern. Pediatrics. 2000;105(3 Pt 1):620-623.
32. Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV infection in sub- Saharan Africa: a systematic review and meta-analysis. AIDS. 2000;14(15):2361-2370.
33. Harby K. Circumcision provided 65% protective effect against HIV in randomized trial. Medscape Medical News. 2005. Available at: http://www.medscape.com/viewarticle/509046. Accessed January 11, 2006.
34. Fergusson DM, Boden JM, Horwood LJ. Circumcision status and risk of sexually transmitted infection in young adult males: an analysis of a longitudinal birth cohort. Pediatrics. 2006;118(5):1971-1977.
35. Oster J. Further fate of foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child. 1968;43(228):200-203.
36. Kreuger H, Osborn L. Effects of hygiene among the uncircumcised. J Fam Pract. 1986;22(4):353-355.
37. Williams JC, Morrison PM, Richardson JR. Paraphimosis in elderly men. Am J Emerg Med. 1995;13(3):351-353.
38. Baldwin SB, Wallace DR, Papenfuss MR, et al. Condom use and other factors affecting penile human papillomavirus detection in men attending a sexually transmitted disease clinic. Sex Transm Dis. 2004;31(10):601-607.
39. Castellsague X, Bosch FX, Munoz N, et al. Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. N Engl J Med. 2002; 346(15):1105-1112.
40. Lajous M, Mueller N, Cruz-Valdez A, et al. Determinants of prevalence, acquisition, and persistence of human papillomavirus in healthy Mexican military men. Cancer Epidemiol Biomarkers Prev. 2005;14(7):1710-1716.
41. MacLean R. Odds of penile HPV are reduced in circumcised men and condom users. Int Fam Plan Perspect. 2005;31(1):42.
42. Svare EI, Kjaer SK, Worm AM, et al. Risk factors for genital HPV DNA in men resemble those found in women: a study of male attendees at a Danish STD clinic. Sex Transm Infect. 2002;78(3):215-218.
43. Niku SD, Stock JA, Kaplan GW. Neonatal circumcision. Urol Clin North Am. 1995; 22(1):57-65.
44. Masters WH, Johnson VE. Human Sexual Response. Boston, Mass: Little Brown & Company; 1966.