5/29/2015

Circumcision:LearntheProsandConsofThisCommonSurgery

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Circumcision:MedicalProsandCons
MedicalAuthor:
DavidPerlstein,MD,MBA,FAAP

DavidPerlstein,MD,MBA,FAAP
Dr.PerlsteinreceivedhisMedicalDegreefromtheUniversityofCincinnatiandthencompletedhis
internshipandresidencyinpediatricsatTheNewYorkHospital,CornellmedicalCenterinNewYorkCity.
AfterservinganadditionalyearasChiefPediatricResident,heworkedasaprivatepractitionerandthen
wasappointedDirectorofAmbulatoryPediatricsatSt.BarnabasHospitalintheBronx.

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MedicalEditor:
MelissaConradStppler,MD

MelissaConradStppler,MD
MelissaConradStppler,MD,isaU.S.boardcertifiedAnatomicPathologistwithsubspecialtytrainingin
thefieldsofExperimentalandMolecularPathology.Dr.Stppler'seducationalbackgroundincludesaBA
withHighestDistinctionfromtheUniversityofVirginiaandanMDfromtheUniversityofNorthCarolina.She
completedresidencytraininginAnatomicPathologyatGeorgetownUniversityfollowedbysubspecialty
fellowshiptraininginmoleculardiagnosticsandexperimentalpathology.

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Circumcision:medicalprosandconsfacts
Whathasbeenthemedicalviewofcircumcision?
Whatistheanatomyofthepenis?
Whatisaretractableforeskin?
Whatisnewborncircumcision?
Whatisphimosis?
Whatisparaphimosis?
Whatisbalanoposthitis?
Whatismeatitis?
Isiteasiertocareforthecircumcisedpenisoruncircumcisedpenis?
Whatistherelationshipbetweencircumcisionandurinarytractinfections?
Whatistherelationshipbetweencircumcisionandsexuallytransmitteddiseases?
Whatisthecorrelationbetweensexuallytransmitteddiseasesandcancerofthecervix?
Whatistherelationshipbetweencircumcisionandcancerofthepenis?

Circumcision:medicalprosandconsfacts
Inabilitytoretracttheforeskinfullyatbirthisnotamedicalreasonforacircumcision.
Circumcisionpreventsphimosis(theinabilitytoretracttheforeskinatanagewhenitshould
normallyberetractable),paraphimosis(thepainfulinabilitytoreturntheforeskintoitsoriginal
location),andbalanoposthitis(inflammationoftheglansandforeskin).
Circumcisionincreasesthechanceofmeatitis(inflammationoftheopeningofthepenis).
Circumcisionmayresultinadecreasedincidenceofurinarytractinfections.
Circumcisionmayresultinalowerincidenceofsexuallytransmitteddiseasesandmay
reduceHIVtransmission.
Circumcisionmaylowertheriskforcancerofthecervixinsexualpartners.
Circumcisionmaydecreasetheriskforcancerofthepenis.
Thereisstillnoabsolutemedicalindicationforroutinecircumcisionofthenewborn.
Theissueofcircumcisionisascontroversialasiteverhasbeen.Therearewellknownreligious,social,
andmedicalreasonstorecommendcircumcisionhowever,mostmajormedicalsocietieshavetakenan
"impartial"viewoftheprocedure,neitherrecommendingnorrenouncingthepractice.

Whathasbeenthemedicalviewofcircumcision?
In1975,theAmericanAcademyofPediatrics(AAP)statedinnouncertaintermsthat"thereisnoabsolute
medicalindicationforroutinecircumcisionofthenewborn."In1983,theAAPandtheAmericanCollegeof
ObstetriciansandGynecologists(ACOG)restatedthisposition.In1999andagainin2005,theAAPagain
restatedthispositionofequivocation.
Currently,thepracticeofnewborncircumcisionisverycommon.Ithasbeenestimatedthatamajorityof
malesintheUnitedStatesarecircumcised.Thisnumbervariesdependinguponethnicityandreligious
affiliation.
Regardingnewborncircumcision,mostphysicianstodayagreewiththepracticeofinformingparentsofthe
risksandbenefitsoftheprocedureinanunbiasedmanner.Recently,however,severallargestudies
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revealedalargedecreaseinHIVtransmissionincircumcisedmalescomparedtouncircumcisedmales.
Thismayultimatelyinfluencesomechangesinrecommendationsinthenearfuture,andthereissignificant
pressurefortheAAPandACOGtoreconsidertheirpositions.

Whatistheanatomyofthepenis?
Thepenisisacylindricalshaftwitharoundedtip.Theroundedtipiscalledtheglans.Thereisagroove
(termedthecoronalsulcus)betweentheshaftandtheglansofthepenis.Thefoldofskinthatcoversthe
glansistheforeskin(theprepuce).

Whatisaretractableforeskin?
Aretractableforeskinisonethatcanbepulledbackbehindthegrooveofthecoronalsulcustoexposethe
glans.

Whatisnewborncircumcision?
Newborncircumcisionconsistsofremovaloftheforeskintheforeskinisresectedtonearthecoronal
sulcusinthenewbornperiod(beforetheageof2months).
Incidentally,theLatincircummeansaround(orabout).Circumcisionisacuttingaround.

Whatisthestatusoftheforeskinatbirth?
Fewboysarebornwitharetractableforeskin.Thisreflectsthefactthatthetissuedevelopmentofthe
foreskinisusuallynotcompleteatbirth.
Theforeskinisthusnotfullyseparablefromtheglansinmostnewbornboys.By1yearofage,theforeskin
canberetractedinabouthalfofboysandby3years,theforeskincanberetractedinamajorityof
uncircumcisedboys.

Whatdoesthishavetodowithcircumcision?
Itmeansthattheinabilitytoretracttheforeskinatbirthandininfancyisnormalanddoesnotconstitutea
medicalreasonforacircumcision.

Whatisphimosis?
Phimosisisamedicalindicationforcircumcision.Itisdefinedas"stenosisofthepreputialringwith
resultantinabilitytoretractafullydifferentiatedforeskin."Inotherwords,phimosisispresentiftheforeskin
cannotberetractedatanagewhenitshouldnormallyberetractable.

Howisphimosistreated?
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Phimosiscanbetreatedbycircumcisionorbysurgicalenlargementofthephimoticring,theringoftissue
causingthephimosis.

Whatisparaphimosis?
Paraphimosisoccurswhentheforeskin,onceretracted,cannotreturntoitsoriginallocation.Theforeskinis
trappedbehindthegrooveofthecoronalsulcus.Paraphimosiscausesbloodtopoolintheveinsbehind
theentrapment,whichinducesswelling.Theswellingleadstoseverepaininthepenisandmakesit
impossibletoreturntheforeskinmanuallytoitsoriginallocation.

Howisparaphimosistreated?
Theforeskin,afterlubrication,cansometimesbereduced.However,thisworksonlyiftheparaphimosisis
discoveredveryearly.Becauseofthepain,thechildhastohaveashortactinggeneralanestheticorheavy
sedationforthetreatment.Paraphimosismaybetreatedbycircumcision.

Whatisbalanoposthitis?
Balanitisisinflammationoftheglans,whileposthitisisinflammationoftheforeskin.Balanitisandposthitis
generallyoccurtogetherasbalanoposthitis:inflammationofboththeglansandforeskinofthepenis.

Whatifanuncircumcisedboyhasphimosis,paraphimosis,or
balanoposthitis?
Boyswhoarenotcircumcisedasnewbornsmaylaterhavecircumcisionforthetreatmentofphimosis,
paraphimosis,orbalanoposthitis.Whendoneafterthenewbornperiod,circumcisionisconsiderablymore
complicated.

Whatismeatitis?
Meatitisisinflammationoftheopening(themeatus)ofthepenis.Thisopeningisformallycalledthe
externalurethralmeatus.

Whatistherelationshipbetweencircumcisionandmeatitis?
Meatitisismorecommoninboyswhohavebeencircumcised.Thisstandstoreasonsince,incircumcised
boystheurethralmeatusismoreexposedandlikelytobechafedorirritatedthaninboyswhowerenot
circumcised.Thereisnoevidencethatmeatitisleadstonarrowing(stenosis)oftheurethralmeatusorto
otherseriousproblems.

Isiteasiertocareforthecircumcisedpenisoruncircumcisedpenis?
Thecircumcisedpenisisgenerallyeasiertokeepclean.Anuncircumcisedboyshouldbetaughttoclean
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hispeniswithcare.Cleaningofthepenisisdonebygently,notforcibly,retractingtheforeskin.Theforeskin
shouldberetractedonlytothepointwhereresistanceismet.Fullretractionoftheforeskinmaynotbe
possibleuntiltheboyis3yearsoldorolder.

Whatistherelationshipbetweencircumcisionandurinarytract
infections?
Theincidenceofurinarytractinfectionsinmaleinfantsappearstobelowerwhencircumcisionisdonein
thenewbornperiod.Itwasfirstreportedin1982thaturinarytractinfections(UTIs)aremorecommon
amonginfantmalesthantheyareininfantfemales(thisswitcheslateroninlife).Inthisstudy,itwas
revealedthatabout95%oftheinfectedinfantboyshadnotbeencircumcised.Thisriskisespecially
significantininfantslessthan1yearofage.Manystudieshaveshownthatuncircumcisedinfantshavea
tenfoldincreasedriskofdevelopingaUTIwhencomparedtocircumcisedinfants.

Whatmightthisrelationshipbetweencircumcisionandurinarytract
infectionsmean?
Circumcisionpreventsthegrowthofbacteriaundertheforeskinandthis,inturn,protectsmaleinfants
againsturinarytractinfection.Thehighincidenceofurinarytractinfectionsinuncircumcisedboyshasalso
beenfoundtobeaccompaniedbyanincreasedincidenceofothersignificantinfectionssuchas
bacteremia(bacterialinfectionofthebloodstream)andmeningitis(infectionofthecoveringofthebrain).
Theprotectiveeffectofcircumcisionmaythusextendtoanumberofinfectiousdiseases.

Whatistherelationshipbetweencircumcisionandsexually
transmitteddiseases?
Thereisahigherriskofgonorrheaandinflammationoftheurethra(thetubethatcarriestheurinefromthe
bladderoutside)inuncircumcisedmen.Ithasalsobeenreportedthatothersexuallytransmitteddiseases
(suchaschancroid,syphilis,humanpapillomavirus,andherpessimplexvirustype2infection)aremore
frequentinuncircumcisedmen.Asmentionedabove,mostrecentlythreelargestudiesperformedinAfrica
documentedthatcircumcisionwasprotectivewithrespecttotheacquisitionofHIVinfectionascomparedto
thoseuncircumcisedsubjects.

Whatmightthisconnectionbetweencircumcisionandsexually
transmitteddiseasesmean?
Circumcisionpreventsthegrowthundertheforeskinoftheagentsthatcausesexuallytransmitteddiseases.
Removaloftheforeskinmayprovidesomemeasureofprotectionfromthesediseasestomalesandtheir
mates.

Whatisthecorrelationbetweensexuallytransmitteddiseasesand
cancerofthecervix?
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Thereisastrongconnectionbetweensexuallytransmitteddiseasesandcancerofthecervix.Human
papillomavirustypes16and18(aswellasotherlesscommonHPVtypes)arecausesofprecancerous
changesinthecervixandcervicalcancer.
Thestrongestpredisposingfactorsincervicalcancerareahistoryofintercourseatanearlyageand
multiplesexualpartners.AnHPVvaccineisnowavailableandrecommendedforallgirlsandboys,and
whengivenbeforethefirstsexualencounter,ithasbeenshowntobeprotectiveagainstthemostcommon
HPVtypesassociatedwithmalignancy.Thevaccinepresumablypreventscervicalcancerassociatedwith
thesespecificinfectionsbutisunabletopreventcancersarisingfrominfectionswithlesscommonHPV
typesnotcontainedinthevaccine.Therefore,routinescreeningforprecancerouschangesinthecervixis
stillrecommended.

Whatmightthisrelationshipbetweenlackofcircumcisionandcervical
cancermean?
Circumcisionmaypartiallyprotectthematefromcancerofthecervixbyremovingtheforeskinwhich
harborssexuallytransmittedviruses(HPVs)thatpromotethiscommonformoffemalecancer.

Whatistherelationshipbetweencircumcisionandcancerofthe
penis?
Thepredictedlifetimeriskofcancerofthepenisinanuncircumcisedmanisonein600intheU.S.Cancer
ofthepeniscarriesamortalityrateashighas25%.Thiscanceroccursalmostexclusivelyinuncircumcised
men.Infivemajorresearchstudies,nomanwhohadbeencircumcisedasanewborndevelopedcancerof
thepenis.Humanpapillomavirustypes16and18,whicharesexuallytransmitted,areinvolvedincancerof
thepenis.ThatiswhyroutinevaccinationagainstHPVisrecommendedforbothboysandgirls.

MedicallyreviewedbyMargaretWalsh,MDAmericanBoardofPediatrics
REFERENCES:
Morris,B.J.,etal."A'snip'intime:whatisthebestagetocircumcise?"BMC
Pediatrics12(2012):20.<http://www.biomedcentral.com/14712431/12/20>.
Tobian,A.R.,etal."MaleCircumcisionforthePreventionofAcquisitionand
Transmissionofsexuallytransmittedinfections:ThecaseforNeonatal
Circumcision."ArchivesofPediatricsandAdolescentMedicine.164.1(2010):78
84.
Wang,M.L.,etal."Updatedparentalviewpointsonmaleneonatalcircumcisionin
theU.S."ClinicalPediatrics49.2Feb.2010:130136.
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MedicallyReviewedbyaDoctoron10/8/2014

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