Okay, I don't care whether you circumcise or dont circumcise, but I want you to have as much REAL data on it to make a decision and not a bunch of opinions from the internet.
Circumcision: Risks and benefits
Author
Craig Shoemaker, MD
Section Editors
Charles J Lockwood, MD
Joseph A Garcia-Prats, MD
John G Bartlett, MD
Deputy Editor
Vanessa A Barss, MD
Last literature review version 17.1: January 2009 | This topic last updated: January 15, 2009 (More)
INTRODUCTION — Circumcision in the male refers to the surgical removal of the foreskin (ie, prepuce) of the penis. The procedure is centuries old and continues to be performed for a variety of religious, cultural, and medical reasons.
Parents of newborn males often have questions about circumcision: Is it necessary? What are its benefits? What are its risks? Nevertheless, major factors in parental decision-making are the father's circumcision status, opinions of family members and friends, a desire for conformity in their son's appearance, and the belief that the circumcised penis is easier to keep clean [1]. Maternal education is another important deciding factor. In the United States, there is a direct positive correlation between higher maternal education and elective circumcision in the Midwest and South, but an inverse correlation in the West [2-4].
The risks and benefits of circumcision will be reviewed here, with the focus on circumcision of neonates. Procedures for neonatal circumcision are discussed separately. (See "Procedures for neonatal circumcision").
HISTORICAL BACKGROUND — The practice of male circumcision dates as far back as ancient Egypt, several thousand years before the birth of Christ, when circumcision was performed to improve male hygiene and for purification. Routine circumcision of male infants was also part of the Abrahamic covenants with Jehovah; all males of that tribe were circumcised as a sign of the covenant, a tradition that continues today as a religious symbol for followers of Judaism. Circumcision is also practiced by the followers of Islam and certain aboriginal tribes in Africa and Australia as a rite of passage into manhood [5].
Although Christians initially did not espouse the practice, circumcision became popular in western cultures in the mid-19th century to prevent masturbation [6]. Circumcision was also proposed as a means of preventing or treating a variety of medical problems, such as epilepsy, polio, and diarrhea.
PREVALENCE — The United States is the only country in the developed world where the majority of male infants are circumcised for nonreligious reasons. Circumcision rates in the United States vary according to geographic area, socioeconomic status, religious affiliation, insurance coverage, hospital type, and racial and ethnic group. Rates based on hospital coding data (circumcision prevalence 55 to 65 percent) probably underestimate the true prevalence of circumcised males (80 to 85 percent) due to miscoding and because some circumcisions are performed after hospital discharge or later in life for religious, medical or personal reasons [2-7].
The overall prevalence of circumcision in healthy newborn male infants appears to have decreased from the 1970s, but the decrease has not been linear: from 1988 to 2000 the rate of circumcision of newborn infants prior to hospital discharge increased by 6.8 percent per year [2,3].
Circumcision rates in other nations tend to be lower, but vary from less than 20 percent to over 80 percent of males [8].
NORMAL PENILE DEVELOPMENT AND HYGIENE — The skin of the body of the penis starts to grow over the glans at approximately 8 weeks of gestation, eventually covering the entire organ. This skin is referred to as the foreskin or prepuce; its purpose is assumed to be protection of the glans. It is keratinized, except for the mucosal surface adjacent to the glans.
At birth, there is incomplete separation of the epithelial layers of the foreskin and glans, usually resulting in congenital or physiological phimosis (ie, inability to retract the distal prepuce over the glans penis). The separation process continues through childhood via desquamation and epidermal keratinization of the shaft. The foreskin becomes easily retracted from the glans over time (50 percent are easily retractable by three years of age; 95 percent by five years of age; 99 percent by adolescence). Retracting the foreskin while it is still firmly attached to the glans could cause injury [9,10].
The uncircumcised penis is generally easy to keep clean. Gentle washing of the genital area while bathing is sufficient in newborns and toddlers. Later, when the foreskin is fully retractable, boys should be taught the importance of washing beneath the foreskin on a regular basis.
COUNSELING — When counseling parents regarding infant male circumcision, it is important to consider the potential medical benefits and risks, as well as the social and religious aspects of this procedure. It is also important to consider that the magnitude of some benefits depends upon when the circumcision is performed; these benefits may not occur or may be less prominent if circumcision is postponed from infancy into late adulthood.
A 2001 survey in California reported that 40 percent of parents believed they had not been provided with enough information regarding circumcision for their son [11]. Parents of children who were not circumcised said that no medical provider discussed circumcision with them, whereas only 15 percent of parents of children who were circumcised stated they were not counseled. Parents of uncircumcised infants were more likely to be unhappy with their initial decision than parents of circumcised infants, 27 versus 14 percent. Another survey of 108 Utah mothers noted that six of the 15 mothers whose first born children were uncircumcised would choose to have their subsequent male children circumcised as a result of the stress of caring for their infants without adequate instruction [12].
There are no studies that give reliable data about the number of males who are circumcised after birth for elective or surgical indications. An Australian survey found that approximately 18 percent of males who were not circumcised as infants reported that they were circumcised subsequently [13,14].
BENEFITS — Circumcision has been associated with a number of medical benefits, including lower rates of urinary tract infection, penile cancer, penile inflammation, penile dermatoses, and sexually transmitted infections [15,16].
Reduction in urinary tract infection — Urinary tract infection (UTI) is uncommon in males at any age. The effect of circumcision on UTI has been studied primarily in infants because they have a higher prevalence of UTI than older males. UTIs in infants can have serious sequelae, such as lifelong renal dysfunction or, rarely, septicemia and death. The prevalence of UTIs in uncircumcised adult males increases with age and certain disease states, such as diabetes mellitus [17,18]. (See "Acute cystitis and asymptomatic bacteriuria in men" and see "Epidemiology and risk factors for urinary tract infections in children"). In a study of men with a mean age of 30 years, and matched for race, age and sexual activity, the circumcised had a lower rate of UTI [18].
All studies have demonstrated that circumcised male infants are at lower risk of UTIs than uncircumcised male infants [9,19-23]. The risk of UTI is, on average, 3 to 12-fold lower in circumcised infants. However, since the absolute risk of UTI is small (0.4 to 1 percent) in male infants, approximately 100 to 200 circumcisions would need to be performed to prevent one UTI.
Some representative examples of these studies are described below:
* A population-based cohort study of 58,000 Canadian infants reported hospital admission rates for UTI in circumcised and uncircumcised infant males under one year of age were 1.88 and 7.02 per 1000 person years, respectively [20]. It was estimated that approximately 195 circumcisions would be needed to prevent one hospital admission for UTI in the first year of life.
* A review of the medical records of 427,698 infants born in United States military hospitals found that the incidence of UTI in uncircumcised male infants, circumcised male infants, and female infants was 1.03, 0.10, and 0.52 percent per year, respectively [21].
* A literature review examining the rate of symptomatic UTI in male infants under age one year calculated a rate in circumcised and uncircumcised infants of 1 to 2 and 7 to 14 per 1000 infants, respectively [9]. In another study, the odds ratio for UTI in uncircumcised compared to circumcised males was 11.6 (95% CI 5.0-26.6) [22].
* A meta-analysis of nine studies published between 1984 and 1992 noted a 12-fold increased risk of UTI in uncircumcised males [24]. Most of the studies analyzed were case-control designs that analyzed the rate of UTI in the first year of life.
Uncircumcised male infants under six months of age have higher numbers of uropathogenic bacteria bound to the mucosal surface of the foreskin and at the urethral meatus than infants who have been circumcised [25]. This colonization probably plays a role in the pathogenesis of urinary infection. However, factors other than circumcision may affect the observed rate of UTI in these reports [9]. As an example, most hospitalized premature infants are not circumcised. Since premature infants have a higher rate of UTI than term infants, the inclusion of premature infants in a series may confound the data. Other factors that can affect UTI rates include the method of urine collection, type and timing of circumcision, and breastfeeding status (protective effect [26]).
Reduction of cancer — Compared to uncircumcised men, circumcised men appear to have a lower risk of penile cancer, and their sexual partners may have a lower risk of cervical cancer.
Penile cancer — Squamous cell cancer of the penis is a rare disease. The age-adjusted incidence in the United States is less than 1 per 100,000 males, comparable to that in other developed countries [27]. It has been estimated that the risk is increased three to six-fold in uncircumcised men. Much of the protective benefit of circumcision is lost if circumcision is not performed in early infancy. The data supporting these conclusions are presented separately. (See "Carcinoma of the penis: Epidemiology, risk factors, and clinical presentation", section on Circumcision).
Cervical cancer in partners — Cervical cancer is less common in the sexual partners of circumcised men. In one study, sex with either uncircumcised men or men circumcised after infancy increased a woman's risk of cervical cancer four-fold [28].
HPV infection is a necessary, but not sufficient, factor in development of virtually all cervical cancer. A partial explanation for the link between cervical cancer and lack of male circumcision is that uncircumcised men are more likely to acquire and transmit HPV to their partners [29] (see "Sexually transmitted infections (not including HIV)" below). (See "Invasive cervical cancer: Epidemiology, clinical features, and diagnosis", section on Role of human papillomavirus).
Other — Case-control studies have reported that circumcised men have a lower rate of prostate cancer than uncircumcised men [30,31]. This could be related to multiple confounders; further investigation is required.
Reduction in penile inflammation and retractile disorders — Penile inflammatory disorders, such as meatitis and balanitis (ie, inflammation of the glans), are less common in circumcised men, but can develop whether or not circumcision has been performed. Balanoposthitis, a suppurative inflammation of the glans and foreskin, usually requires surgical intervention [17]. Uncircumcised males who retract the foreskin while bathing are less likely to experience problems with inflammation [32]. (See "Balanoposthitis in children: clinical manifestations, diagnosis, and treatment").
Most studies suggest penile problems occur more often in uncircumcised men [33-35]:
* A longitudinal study of 500 New Zealand boys followed from birth to age 8 reported that circumcised infants had a higher rate of meatitis in infancy, but a lower rate of penile problems after infancy due to absence of foreskin-associated disorders (eg, balanitis and inflammation) [33]. By age 8, the rate of penile problems in circumcised and uncircumcised boys was 11.1 and 18.8 problems per 100 children, respectively. Most of these problems were minor and could be treated medically, but some required surgical intervention for phimosis or balanoposthitis.
* A retrospective survey of 272 uncircumcised boys and 273 controls who were circumcised at birth found that the total frequency of medical visits for penile problems (eg, balanitis, irritation, phimosis) was significantly lower in the circumcised group (5 versus 10 percent, respectively) [34]. Most of the problems were minor.
Chronic inflammation or repeated forceful retraction of a congenital phimosis may cause scarring and secondary phimosis, which sometimes requires surgical intervention [13,14,36]. Frequent catheterization without replacement of the foreskin, poor hygiene, and chronic balanoposthitis can lead to phimosis and eventual paraphimosis (ie, entrapment of a retracted foreskin behind the coronal sulcus). Urinary obstruction, hematuria, pain, and edema and necrosis of the glans may occur in severe cases. (See "Paraphimosis: Definition, pathophysiology, and clinical features").
Acute and recurrent problems of the foreskin can sometimes be managed medically with hyaluronidase or topical betamethasone cream [37,38], but mechanical or surgical intervention may be required.
Reduction in sexually transmitted infections — If only biological factors are considered, uncircumcised men may be at greater risk of acquiring sexually transmitted infections because the warm, moist environment provided by the prepuce may provide more favorable conditions for infection than the circumcised glans.
A significant reduction in risk of acquiring sexually transmitted infections would be an important medical benefit of circumcision. However, behavioral factors, such as having a low number of sexual partners and consistent correct use of condoms, are probably more important than circumcision status for protection against sexually transmissible diseases. Unfortunately, there is no evidence that any public health or educational program has had an effect on the hygienic practices of adolescent or adult males, other than the increased use of condoms in a few HIV high risk populations in the western world [39-41]. (See "Prevention of sexually transmitted diseases").
HIV infection — Randomized trials in South Africa, Kenya, and Uganda have shown that circumcision protects against the acquisition of HIV [42-45]. As an example, a randomized trial in South Africa demonstrated that the risk of acquiring human immunodeficiency virus (HIV) infection was 50 to 60 percent lower in adult men who were offered circumcision at trial entry compared to those who were not offered circumcision [43]. It is presumed that neonatal circumcision would offer a similar benefit. (See "The stages and natural history of HIV infection", section on Lack of circumcision).
In Africa, the lack of circumcision appears to be one of several facilitating factors in HIV seroconversion. The World Health Organization has recommended that circumcision be considered as part of a comprehensive HIV prevention package that includes provision of voluntary HIV testing and counseling services, treatment for sexually transmitted infections, promotion of safer sex practices (delayed initiation of sexual activity, reduced numbers of sexual partners, avoidance of penetrative sex), and provision of male and female condoms and promotion of their correct and consistent use [46]. Additional research is required to develop male circumcision programs in resource poor settings, but there is increasing support for circumcision as a part of the preventative public health care plan for the prevention of HIV spread in Africa [47].
It is important to remember that circumcision does not provide complete protection against acquisition of HIV infection and that there is no strong evidence that circumcised HIV-infected men are less likely to transmit the infection to their female or male partners [46].
Circumcision may significantly reduce HIV infection because the inner aspect of the foreskin appears to be richer in cells with HIV-1 receptors than the glans [48-50]. Thus, removal of these target cells may reduce, but not eliminate, the risk of acquiring infection when the man is exposed to HIV.
Sexually transmitted infections (not including HIV) — An embedded study within the randomized South African trial discussed above [43] assessed the effect of circumcision on acquisition of high oncogenic risk HPV (HR-HPV), Neisseria gonorrhoeae, and Trichomonas vaginalis infections [51,75]. Urethral swabs and urine samples were analyzed using PCR.
* Male circumcision had a protective effect on HR-HPV prevalence (intention-to-treat analysis, HR-HPV prevalence in the circumcision group 14.8 percent (94/637) versus 22.3 percent (140/627) in the control group; RR 0.66, 95%CI 0.51-0.86) [75].
* Male circumcision had a borderline effect on prevalence of trichomonas infection (intention to treat analysis OR 0.54, 95% CI 0.29-1.03), but the reduction became statistically significant in the 'as treated' analysis (OR 0.49, 95% CI 0.25-0.93) [51].
* There was no evidence of a protective effect against Neisseria gonorrhoeae infection [51].
This study is the best evidence to date that circumcision reduces the risk of HR-HPV and trichomonas infections among heterosexual men and explains why women with circumcised partners are at a lower risk of cervical cancer than other women.
Females can benefit from male circumcision, as well. An analysis of the spouses of men enrolled in another randomized trial of adult male circumcision for HIV prevention [45] found partners of circumcised men had lower rates of genital ulceration (adjusted prevalence risk ratio [aPRR] 0.78, 95% CI 0.61-0.99), trichomonas infection (aPRR 0.55, 95%CI 0.34-0.89), and bacterial vaginosis (aPRR 0.82, 95% CI 0.74-0.91) than partners of uncircumcised men [52]. Possible explanations for these findings are that circumcised men may be less susceptible to infection/colonization with these organisms or the circumcised penis may be less likely to transmit these organisms than the uncircumcised penis.
Easier hygiene — Genital hygiene is easier in the absence of a foreskin. Good hygiene may prevent many problems associated with the foreskin [32], but can be difficult to maintain in uncircumcised boys, even in developed countries. Studies of middle class British and Scandinavian schoolboys concluded that penile hygiene is usually not well-maintained [10,53].
RISKS — The rate of procedure-related complications during and after circumcision is approximately 2 to 5 per 1000 cases [54-56], with most of these problems readily treatable and causing no long-term effects. Unsatisfactory cosmetic results (too little or too much skin removed) are also reported. The most common, significant medical complications of male circumcision are bleeding and local infection [19,57]. Most bleeding can be controlled simply by applying pressure to the bleeding site. Silver nitrate can also be used to control bleeding, but the use of topical epinephrine should be avoided because of possible compromise to circulation of the penile shaft.
Uncommon, but significant complications include life-threatening sepsis or death, buried penis, urethrocutaneous fistula, meatitis and meatal stenosis, and amputation of the glans [57]. Additional rare, but serious, complications have been described in case reports.
One of the largest studies on complications after circumcision included approximately 136,000 boys [54]. The frequency of complications and genitourinary problems among circumcised neonates was 0.19 percent, a figure comparable to the 0.24 percent rate of urinary tract infections in uncircumcised neonates. The complications of circumcision included 83 hemorrhages (31 required ligature, three required transfusion), 62 local infections, eight cases of bacteremia, 25 instances of surgical trauma, and 20 urinary tract infections. Parents should weigh the severity and incidence of these complications against the morbidity of the diagnosis, treatment, and complications of UTI in uncircumcised boys, as well as the other medical issues discussed above.
Cosmesis — If insufficient foreskin is removed, the penis may not appear to be circumcised, and phimosis and urinary obstruction may develop. Treatment consists of reoperation to remove additional foreskin. Although occurring infrequently, the foreskin may grow in the months after the procedure and circumcision may need to be repeated for satisfactory cosmesis.
If too much skin is pulled over the glans or ventral adhesions are not broken down well prior to the incision, then the shaft may be denuded after excision of the foreskin. Most cosmetic problems can be managed conservatively with a satisfactory and functional outcome, but split-thickness skin grafting may be required if more than 50 percent of the shaft is denuded. Surgical techniques to minimize the occurrence of cosmetic problems are described in detail separately. (See "Procedures for neonatal circumcision").
Buried penis — Buried penis (ie, concealed penis, trapped penis, hidden penis) refers to a penis that is buried under cicatricial scar tissue that develops at the incision site [58]. It may occur if either too much or too little skin is removed. Treatment is usually surgical, but a medical approach using topical betamethasone and manual retraction has shown some success in a pilot trial [59].
Bleeding — The risk of severe bleeding is higher if there is an underlying coagulopathy; therefore, a family history of bleeding diathesis or neonatal petechiae should prompt further evaluation before the procedure is undertaken. The presence of anatomic abnormalities, including anomalous vessels, also increases the risk of an adverse outcome. (See "Treatment of hemophilia").
Infection — Wound infection infrequently occurs after circumcision [57]. It is usually mild and manifested by local inflammatory changes, which resolve with local treatment. However, ulceration, suppuration, or sepsis may occur and require systemic antibiotics and surgical debridement.
Meatal ulceration — Irritation of the external urethral meatus by wet diapers may cause meatal ulceration in the first few weeks after circumcision. Ulceration can lead to meatal stenosis. Meatotomy is indicated if meatal stenosis results in obstructive uropathy or recurrent pyelonephritis.
Sexual dissatisfaction — The prepuce contains specialized sensory mucosa that is removed during circumcision [60]. Some studies suggest that the end of the penis becomes less sensitive when the foreskin is removed and sexual sensation may be decreased [61]. However, most circumcised males do not describe psychological trauma or decreased sexual function or desire as a result of the procedure [4,13,14,62-66].
Other — Surgical excision of the foreskin is painful. Although pain control was not provided in the past, safe and effective methods of pain control exist and should be provided to all infants undergoing the procedure [18,67]. Interestingly, in 1860 when circumcision began to gain in popularity in the English speaking world, pain during circumcision was desirable. An article in Lancet stated "the operation, too, should not be performed under chloroform, so that the pain experienced may be associated with the habit [masturbation] we wish to eradicate" [68]. (See "Procedures for neonatal circumcision", section on Pain control).
OPINIONS OF ORGANIZATIONS AND GROUPS — Every segment of society has an opinion regarding circumcision. Several pediatric and urologic experts feel that circumcision should be advocated as a prophylactic public health measure [5,6,11,67,69-71], and there is increasing commentary from the pediatric literature suggesting that male circumcision may be an effective prophylactic intervention for disease prevention in the United States and other countries [72,73]. Small, but vocal, groups have proposed the theory that all men who are circumcised may be emotionally harmed, but are unable to recognize their feelings. Other groups oppose circumcision on a human rights basis, saying the infant is not allowed to decide whether or not he wants to be circumcised and the procedure constitutes genital mutilation [69]. Still others believe the procedure decreases sexual pleasure [61].
The international medical community has published several opinions about male circumcision in neonates:
* The Canadian Paediatric Society issued a clinical practice guideline which stated "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" [19].
* The American Academy of Pediatrics (AAP) established a task force to evaluate the medical research, ethics, and other issues related to circumcision of the male infant and concluded that "existing scientific evidence demonstrates potential medical benefits of newborn male circumcision, but the data was not sufficient to recommend routine neonatal circumcision. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision" [9]. Pain control should be provided. Although this statement was reaffirmed in 2005, the AAP is reviewing this position, given recent evidence of the protective effect of circumcision against HIV and other sexually transmitted infections.
* The American College of Obstetricians and Gynecologists supported the conclusions of the AAP discussed above [74].
In addition, as discussed above (see "HIV infection" above), the World Health Organization has recommended that male circumcision be considered as part of a comprehensive HIV prevention package in Africa and other countries with high HIV prevalence and low rates of male circumcision [46]. They stated that a human rights-based approach to promotion of male circumcision requires measures that ensure that the procedure be carried out safely, with informed consent, and without coercion or discrimination.
INFORMATION FOR PATIENTS — Educational materials on this topic are available for patients. (See "Patient information: Circumcision in male infants"). We encourage you to print or e-mail this topic review, or to refer parents to our public web site,
UpToDate Inc., which includes this and other topics.
SUMMARY AND RECOMMENDATIONS
* Circumcision (removal of the male foreskin) is performed for religious, cultural, or medical reasons. The prevalence varies across the world. (See "Historical background" above and see "Prevalence" above).
* We recommend that all parents of newborn males be provided accurate, unbiased written information about circumcision (Grade 1C). This information should be in a language that they understand and they should have the opportunity to discuss this information with the operating practitioner prior to deciding whether or not to have their infant son circumcised. (See "Counseling" above).
* Benefits of circumcision include reduction in the rates of urinary tract infection, penile cancer, cervical cancer in partners, some sexually transmitted infections, penile dermatoses, and penile inflammation (meatitis, balanitis, phimosis, balanoposthitis), as well as easier hygiene. These benefits, which extend over a lifetime, need to be weighed against the potential risks of the circumcision procedure, which are often short-term, and in the context of the low incidence of urinary tract infections and penile cancer in uncircumcised men. (See "Benefits" above).
* In Africa, circumcision of adult men reduced the risk of acquiring HIV infection by 50 to 60 percent. (See "HIV infection" above).
* One of the more common complications of circumcision is an unsatisfactory cosmetic result (too little or too much skin removed). Other complications and side effects, which are uncommon, include procedure related bleeding or infection, and meatal ulceration. (See "Risks" above).
* Virtually all current policy statements from specialty societies and medical organizations recommend not performing neonatal circumcision as a routine procedure. (See "Opinions of organizations and groups" above).
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