Island Men's Journal Article

CIRCUMCISION

CMA Journal Article

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Canadian Medical Association Journal, vol 154, no. 6 (March 15, 1996: pp. 769-780

Clinical Practice Guidelines

NEONATAL CIRCUMCISION REVISITED

Fetus and Newborn Committee, Canadian Paediatric Society

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Objective: To assist physicians in providing guidance to parents regarding neonatal circumcision.

Options: Whether to recommend the routine circumcision of newborn male infants.

Outcomes: Costs and complications of neonatal circumcision, the incidence of urinary tract infections, sexually transmitted diseases and cancer of the penis in circumcised and uncircumcised males, and of cervical cancer in their partners and the costs of treating these diseases.

Evidence. The literature on circumcision was reviewed by the Fetus and Newborn Committee of the Canadian Paediatric Society. During extensive discussion at meetings of the committee over a 24-month period, the strength of the evidence was carefully weighed and the perspective of the committee developed.

Values: The literature was assessed to determine whether neonatal circumcision improves the health of boys and men and is a cost-effective approach to preventing penile problems and associated urinary tract conditions. Religious and personal values were not included in the assessment.

Benefits, harms and costs: The effect of neonatal circumcision on the incidence of urinary tract infection, sexually transmitted diseases, cancer of the penis, cervical cancer and penile problems; the complications of circumcision; and estimates of the costs of neonatal circumcision and of the treatment of later penile conditions, urinary tract infections and complications of circumcision.

Recommendation: Circumcision of newborns should not be routinely performed.

Validation: This recommendation is in keeping with previous statements on neonatal circumcision by the Canadian Paediatric Society and the American Academy of Pediatrics. The statement was reviewed by the Infectious Disease Committee of the Canadian Paediatric Society. The Board of Directors of the Canadian Paediatric Society has reviewed its content and approved it for publication.

Sponsor: This is an official statement of the Canadian Paediatric Society. No external financial support has been received by the Canadian Paediatric Society, or its members, for any portion of the statement's preparation.

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Circumcision is one of the procedures performed most often on males. It was estimated in 1970 that 69% to 97% of all boys and men in the United States had been circumcised, in comparison with 70% of those in Australia, 48% of those in Canada and 24% of those in the United Kingdom.[1] The procedure is uncommon in northern European countries, Central and South America and Asia.[1]

In 1971 and 1975 the American Academy of Pediatrics (AAP) took a stand against the routine circumcision of newborns on the basis that there are no valid medical indications for circumcision in the neonatal period.[2,3] In 1975 the Fetus and Newborn Committee of the Canadian Paediatric Society (CPS) reviewed the literature available at that time and reached the same conclusion.[4] In 1983 this position was reiterated by the AAP and the American College of Obstetricians and Gynecologists in their joint publication Guidelines for Perinatal Care.[5] The CPS Fetus and Newborn Committee re-examined the issue in 1982, in response to an article on the benefits and risks of circumcision,[6] and saw no reason to modify its 1975 statement.[7]

In 1989 a multidisciplinary Task Force on Circumcision established by the AAP summarized the evidence for and against the routine circumcision of newborns but did not make a specific recommendation.[8] The evidence the task force reviewed on the status of circumcision of newborns and the question of routine neonatal circumcision was subsequently discussed in commentaries by the chairman of the task force and by one of its members.[9,10] Considerable discussion followed in the letters to the editor of the two journals in which these appeared.[11-17]

There have continued to be articles published presenting arguments supporting and opposing routine neonatal circumcision.[18-26] Detailed estimates of the financial and medical advantages and disadvantages have been made.[27,28] Groups opposed to neonatal circumcision have been formed and have become visible lobbyists (for example, the National Organization to Halt the Abuse and Routine Mutilation of Males, San Francisco, and the National Organization of Circumcision Information Resource Centers based in San Anselmo, Calif., with branches across the United States and in Canada and other countries).[29] It therefore seemed appropriate for the Fetus and Newborn Committee of the CPS to revisit the subject.

Articles on circumcision published between 1982 and 1992 were identified from Index Medicus, and articles published from 1988 to 1994 were found through MEDLINE searches. Relevant articles were also identified from the bibliographies of the AAP task force statement,[8] the subsequent commentaries and other review articles. The reference lists of identified articles were searched for additional publications. A total of 671 published articles on circumcision were identified. Case reports, case-control studies, cohort studies, randomized controlled trials and two meta-analyses were identified and included. No randomized controlled trials of circumcision per se were identified; the only randomized controlled trials found involved the use of analgesia or anesthetic agents during circumcision. Of the articles identified, 61 concerned urinary tract infections (UTIs) and circumcision, 23 involved the relation between male circumcision and HIV status and 25 discussed the pain caused by circumcision and the use of analgesia. Articles reviewed were restricted to those in English, except for one article in Spanish.

We asked the following questions. What is the effect of routine circumcision of newborn male infants on the rate of UTI, sexually transmitted diseases, cancer of the penis, cervical carcinoma and penile problems? What is its effect on health care costs? Is the balance of evidence sufficient to warrant a change in the position taken by the CPS in 1982?[7]

WHAT IS THE PREPUCE?

The prepuce is described anatomically as a simple fold of skin.[30] Its function has been assumed to be protection of the glans. There are unwritten assumptions in the literature discussing circumcision. However, a recent report has described numerous oval, rounded or elongated nerve corpuscles in the inner mucosal surface of the prepuce.[31] These are similar to nerve endings seen, although less frequently, in the glans and the frenulum. Their function is unknown. The author of the report speculated that this specialized sensory tissue may perform different functions at different times of life and may be involved in sexual responses in adults. The presence of these nerve endings also emphasizes the need for pain control when circumcision is performed.

URINARY TRACT INFECTION

An association between an increased incidence of UTI and uncircumcised status has been reported. In 1982 Ginsburg and McCracken[32] reported a case series of 109 infants in whom UTI developed between 5 days and 8 months of age. Male infants predominated in their series; of these, 95% were uncircumcised.

In 1985 Wiswell, Smith and Bass[33] reviewed a cohort of 5,261 infants born at an army hospital and found a higher incidence rate of UTI among the uncircumcised male infants (4.12%) than among those who were circumcised (0.21%). A subsequent review of the records of 427,698 infants (219,755 of whom were boys) born in US Armed Forces hospitals from 1975 to 1979 supported these findings, showing a 10-fold higher incidence rate of UTI among uncircumcised boys (1.03%) than among circumcised boys (0.10%).[34] By comparison the incidence rate among the female infants was 0.52%. In addition, the investigators reported a temporal association between a decrease in the circumcision rate and an increase in the UTI rate among boys in the early 1980s. There was no concurrent change in the incidence among girls, and the ratio of the incidence of UTI among boys to that among girls during early infancy shifted toward a predominance among boys.[34] A later review of UTI among 209,399 infants born between 1985 and 1990 in US Army hospitals world-wide found that 1,046 infants, of which 496 were boys, had been admitted to hospital for UTI in the first year of life.[35] There was a 10-fold greater incidence of infection among the uncircumcised than among the circumcised boys. Among the uncircumcised boys younger than 3 months of age, the incidence rate of concomitant bacteremia caused by the same organism that caused the UTI was 23%. The diagnosis of UTI in all of these studies was made on the basis of culture of urine samples obtained by bladder tap or by catheter. These studies are retrospective, and therefore some caution must be exercised in their interpretation. A potential bias in these studies is that patients were admitted to hospital because of the infections; since infections not requiring hospital treatment were excluded, the true incidence may have been underreported.

Herzog,[36] in an evaluation of febrile infants seen in an outpatient clinic, also showed a higher incidence of UTI among uncircumcised boys than among those circumcised. The authors of two review articles each concluded that the circumcision of newborns reduced the incidence of UTI.[37,38] Despite the impressive magnitude of the decrease in the incidence of UTI (10-fold or more) associated with circumcision, when one recognizes the low overall incidence rate of UTI among infant boys (1% to 2%), several questions arise. Is universal circumcision warranted for the prevention of UTI? What are the risks and the costs of this approach? Are there any alternative strategies for the prevention of UTI that should be evaluated?

There is a plausible explanation for the association of UTI with uncircumcised status. The explanation involves colonization of the prepuce with bacteria in infancy and childhood. Several bacteria, including fimbriated strains of Proteus mirabilis, non-fimbriated Pseudomonas, Klebsiella and Serratia species[39-41] and pyelonephritogenic fimbriated Escheriechia coli, [39,41,42] have been shown to bind closely to the mucosal surface of the foreskin within the first few days of life. It has been suggested that circumcision protects male infants from UTI by preventing the bacterial colonization, of the prepuce and subsequent ascending infection.[37]

In natural settings, infants are often subject to colonization at birth with the aerobic and anaerobic flora of their mothers; they also receive specific immunoglobulin across the placenta before delivery and, later, through ingestion of breast milk. In contrast, babies born and cared for in hospital tend to be colonized by E. coli acquired from the environment.[43,44] The virulence of E. coli strains isolated in cases of UTI is correlated with the ability of the strain to adhere to uroepithelial cells.[45] This ability has been shown to be associated with the presence on the bacteria of proteinaceous, filamentous organelles called fimbria, which appear to recognize and bind to specific receptors on the epithelial cells.[45] Kallenius and associates[46] reported that 94% of the cases of infantile pyelonephritis they reviewed were due specifically to P-fimbriated E. coli.

On the basis of these observations, Winberg and collaborators[47] suggested two alternative preventive strategies: deliberate colonization with nonpathogenic bacterial flora during the newborn period or the promotion of rooming-in to facilitate close contact between newborns and their mothers. The first strategy is analogous to the active colonization of the umbilicus and nasal mucosa undertaken in the past to arrest epidemics of infection with Staphylococcus aureus.[48] These two strategies need to be evaluated further. One would expect both to have a low risk of complications. The second is in keeping with recent trends in maternal and infant care and could also have a low cost. If either strategy is successful, it may prove to be a more cost-effective way to prevent UTI among male infants than circumcision. Such an approach could also be applied to the prevention of UTI in female infants, since adherence of bacteria to epithelial cells also plays a role in the development of UTI in girls.[45]

There has been one report of a case-control study of breast-feeding and UTI among infants.[49] In the study, 47% of 62 infants presenting with a UTI had been breast-fed, whereas 82% of 62 control infants seen at a well-baby clinic and 87% of 62 control infants admitted to hospital because of fever had been breast-fed, and none of the control infants had a UTI (p 0.001). No information was given about alterations in the bacterial flora of the infants in the study.

A meta-analysis has been made of six articles containing original patient data on circumcision and UTI.[30] In a sample of 221 799 patients the odds ratio (OR) of UTI among uncircumcised male infants compared with circumcised male infants was 13.1 (95% confidence interval [CI] 10.9 to 15.7). A second meta-analysis of nine studies of the circumcision status of boys with UTI, which included the six articles covered by the first meta-analysis, reported an OR of 12.0 (95% CI 10.6 to 13.6).[35]

However, the risk of UTI among the uncircumcised boys during the first year of life was low enough that the first set of authors felt that routine neonatal circumcision was not justified. [50] The authors of the second analysis emphasized the importance of discussing the association between UTI and uncircumcised status while counselling parents about neonatal circumcision to obtain their informed consent.[35]

EFFECT OF TIMING OF CIRCUMCISION

An epidemiological study of UTI during the first year of life involving 169 children born in Israel found that 48% (27/56) of the male infants presented with UTI within 12 days after ritual circumcision.[51] The incidence of UTI among male infants was significantly higher just after circumcision (from 9 to 20 days of life) than during the rest of the first month of life and significantly higher in the first month of life than during the rest of the year. After the immediate postcircumcision period, the incidence rate of UTI dropped to a level comparable to that reported among circumcised male infants in the United States. Among the 113 female infants, the episodes of infection were evenly distributed throughout the first year of life, except that the incidence was lower during the first month. This study suggests that the method and the timing of circumcision also may be important factors to consider.

CIRCUMCISION AND UTI AMONG YOUNG ADULTS

In a retrospective case-control study, 26 men with symptomatic UTI confirmed by microbiological analysis were compared with 52 men who had urinary symptoms but negative results of cultures from urine specimens.[52] The groups were similar with respect to age, race and sexual activity. Of the men with a UTI, 31% (8/26) were uncircumcised, whereas 12% (6/52) of the men without a UTI were uncircumcised (p = 0.037, OR 5.6 95% CI 1.6 to 19.4).

IDENTIFICATION OF URINARY TRACT ABNORMALITIES

In the case-control study by Herzog,[36] in 8 of the 31 patients who underwent radiographic investigation abnormalities were found. Four of the patients had grade II reflux, two had grade IV reflux one had posterior urethral valves with hydronephrosis, and one had ureteropelvic junction obstruction with hydronephrosis. Amir Varsano and Mimouni[53] found anomalies of the urinary tracts of three out of eight patients who had a UTI after ritual circumcision. It has been suggested that not circumcising male infants is, therefore, advantageous because it allows early identification of infants who have structural abnormalities that require surgical intervention or close medical follow-up.[54,55] Whether the reflux found in the patients in the case-control study was acquired or was a result of a congenital lesion, as suggested by Rockney and Caldamone,[54] is unknown.

SEXUALLY TRANSMITTED DISEASES

A higher risk of nongonococcal urethritis among circumcised men than among uncircumcised men has been described.[56] A recent cross-sectional study of 300 consecutive heterosexual male patients attending a sexually transmitted diseases (STD) clinic showed that circumcision had no significant effect on the incidence of common STDs.[57] However, a significantly greater incidence of STDs - including genital herpes, candidiasis, gonorrhea and syphilis - among men who were not circumcised than among those who were circumcised has been previously reported.[58] Uncircumcised status and diseases causing genital ulceration have been reported to be risk factors in the transmission of HIV to heterosexual men.[59,60] A recent review of the literature on the association between circumcision status and the risk of HIV infection included 30 epidemiological studies, of which 15 were published articles and 15 were abstracts presented at conferences.[61] Twenty-six of these studies were cross-sec tional, two were prospective and two ecological in design. One of the latter estimated the seroprevalence of HIV in the general population of 37 African capital cities and correlated these data with the estimated national proportions of uncircumcised males. The other related data on HIV seroprevalence from 140 discrete geographic locations in Africa to the usual male circumcision practices in those areas. Both showed positive associations. Eighteen of the cross-sectional studies reported a statistically significant association, determined through univariate or multivariate analysis, between the presence of the foreskin and the risk of HIV infection. Four other such studies showed a trend toward an association and four showed no association. The two prospective studies showed positive associations. The ORs or relative risks (RRs) calculated in the studies that showed statistically significant associations ranged from 1.5 to 8.4. However, an editorial review of 26 studies on this subject (including 23 of the previously reviewed studies) commented on the lack of a distinction between susceptibility and infectivity, the use of inadequate controls for confounding variables, potential selection biases and misclassifications of exposure or inappropriate choices of comparison groups, each of which may lead to an incorrect estimation of the association.[62] The authors of