Potential benefits of circumcision

Phimosis treatment

Phimosis is defined as a scarring and thickening of the foreskin that prevents retraction back over the glans.[7]Phimosis may occur secondary to recurrent infections, inflammation or lichen sclerosis. Phimosis needs to be differentiated from the normal nonretractile foreskin.
The foreskin can become inflamed or infected (posthitis), often in association with the glans (balanoposthitis) in 1% to 4% of uncircumcised boys.[8][9] The foreskin can also become entrapped behind the glans (paraphimosis) in 0.5% of cases. Both conditions usually resolve with medical therapy but, if recurrent, can cause phimosis.[7][10]An estimated 0.8% to 1.6% of boys will require circumcision before puberty, most commonly to treat phimosis.[7]The first-line medical treatment of phimosis involves applying a topical steroid twice a day to the foreskin, accompanied by gentle traction. This therapy serves to thin the tissue and release adhesions, allowing the foreskin to become retractable in 80% of treated cases, thus usually avoiding the need for circumcision.[11][12] Topical steroid treatment is also useful to hasten foreskin retraction in boys with nonretractile foreskins.[12] A number of steroid preparations have been used, including betamethasone 0.05% to 0.1%, triamcinolone 0.1% and mometasone furoate 0.1%.
Other dermatoses of the penis can occur in childhood and should be considered if the skin over the penile shaft, foreskin or glans is abnormal.[10][13] Such presentations may necessitate referral to a urologist or dermatologist for diagnosis and treatment, which may include circumcision.

UTI reduction

The preputial sac provides an environment for colonization of the urethra with uropathogenic organisms that can cause UTI in infant boys.[14] UTI occurs in approximately one in 100 boys in the first month of life. A meta-analysis that included one randomized trial and 11 observational studies found that UTI was decreased by 90% in circumcised infants, with a significant OR of 0.13 (95% CI 0.08 to 0.20).[15] In a more recent meta-analysis that included 14 studies, the pooled prevalence of UTI in febrile infants <3 months of age was 7.5% for females, 2.4% for circumcised males and 20.1% for uncircumcised males. The prevalence rate of UTI in febrile males (circumcised and uncircumcised) decreased to 1.7% by six to 12 months of age, but the 10-fold difference related to circumcision status was maintained.[16] Since the publication of this meta-analysis, a further prospective cohort study, in which a series of urine cultures were obtained in boys up to 15 months of age, also found a lower incidence of UTI in individuals who had undergone newborn circumcision (0% versus 2%, P<0.001).[17] The risk of UTI declines rapidly in males after the first few months of life to an incidence of one in 1000 by one year of age.[16] Using estimates of lifetime risk for male UTI, a recent meta-analysis calculated that, over a lifetime, the RR for UTI was 3.65 for uncircumcised versus circumcised males, with 23% of all UTIs attributed to lack of circumcision.[18] However, this conclusion should be questioned because the adult data were limited to a single study of only 78 men.
It has been estimated that 111 to 125 normal infant boys (for whom the risk of UTI is 1% to 2%) would need to be circumcised at birth to prevent one UTI.[15][16] In boys at higher risk for UTI, such as those with recurrent UTI or an underlying urinary tract anomaly (eg, high-grade vesico-ureteric reflux or obstructive uropathy), circumcision may be of greater benefit. In these cases, it is estimated that only four boys would need to be circumcised to prevent one UTI.[15] However, it should be noted that contaminated urines are more common in uncircumcised males, potentially leading to overdiagnosis of UTI; thus, the number needed to treat may be considerably higher than that found in these studies. Childhood UTI leads to dimercaptosuccinic acid (DMSA)-detectable renal scarring in 15% of cases.[19] Although these scars could theoretically have an impact on long-term renal function and hypertension, there is no evidence for this effect, and most experts believe that UTIs in children with normal kidneys do not result in long-term sequelae.

STI reduction

Observational studies performed in Africa and in developed countries since the emergence of HIV/AIDS have suggested that uncircumcised men are at higher risk for HIV infection.[20][21] The inner surface of the foreskin is rich in Langerhans and other HIV target cells that are exposed to infection during sexual intercourse, which is speculated to be one mechanism leading to HIV acquisition.[22] If true, then removing the foreskin could theoretically have a protective effect against HIV acquisition. Conclusive evidence that circumcision is partially effective in decreasing the risk for heterosexually-acquired HIV infection among men in sub-Saharan Africa has been provided by three large randomized controlled trials involving men and adolescent boys in Uganda,[23] South Africa[24] and Kenya.[25] Compared with uncircumcised controls, there was a decrease in new HIV infection by 50% to 60% in the circumcised male participants. In the Kenyan study, this protective effect was sustained for at least 42 months[25] (Level of Evidence 1). Observational studies undertaken in sub-Saharan Africa have also suggested that there is a similar degree of protection when circumcision is performed in the neonatal period[20][26](Level of Evidence 4).
It remains unclear, however, whether these conclusions can be applied to populations in developed countries, where the HIV seroprevalence rates are lower and common routes of HIV transmission include injection drug use (IDU) and men who have sex with men (MSM).[27]
The Centers for Disease Control and Prevention (CDC, Georgia, USA) recently published an analysis of the cost-effectiveness of newborn circumcision in reducing the lifetime risk of HIV acquisition in American males, assuming 60% efficacy over a lifetime and a risk of HIV acquisition varying from 0.94% for white males to 6.22% for black males.[28] The CDC estimated that the risk of lifetime acquisition through heterosexual transmission was reduced by 16% overall, ranging from 8% in white males to nearly 21% for black males. The analysis, based on a cost of USD$257 for the procedure, demonstrated cost savings in both Hispanic and black males. The number needed to treat to prevent one HIV infection varied from 1231 in white males to 65 in black males, with an average in all males of 298. The model did not account for the cost of complications of circumcision. In addition, there is a risk that men may overestimate the protective effect of being circumcised and be less likely to adopt safe sex practices.
In 2011, the Public Health Agency of Canada reported that 46.6% of new cases of HIV in Canada for which an exposure category was reported were attributed to MSM and 13.7% to IDU.[29] The proportion of new cases attributed to heterosexual transmission involving individuals not originally from a country where HIV is endemic was 20.3%, while 16.9% of new cases were in individuals originally from HIV-endemic countries. The report noted that the estimated rate of new infection in the latter group was nine times higher than in the general Canadian population. A disproportionate number of new cases occurred in Aboriginal people (12.2%), a rate estimated to be 3.5 times higher than in the non-Aboriginal population. IDU was the main reported source of exposure (58.1%), followed by heterosexual exposure (30.2%).[29]
It is presumed that male circumcision, by reducing the burden of HIV in men, will indirectly protect women. There does not appear to be a significant role in decreasing male-to-female transmission in HIV-discordant couples.[30][31]
Evidence obtained from observational studies that male circumcision can decrease the risk of other STIs has been conflicting. Analysis of data regarding subjects enrolled in the randomized sub-Saharan African studies revealed lower rates of herpes simplex virus-2 (HSV-2) seroconversion (adjusted HR = 0.72) and acquisition of high-risk human papillomavirus (HPV) genotypes (adjusted RR = 0.65) in circumcised men during the two-year follow-up postcircumcision.[32] The rate of HPV infection was also lower in circumcised men in many other countries (OR = 0.37)[32] (Level of Evidence 2). Circumcision was not found to be protective against gonorrhea or chlamydia.[33]No studies have examined the impact of routine neonatal circumcision on STIs other than HIV.
The female partners of men circumcised in the same African studies had a lower adjusted prevalence rate of 0.52 for Trichomonas vaginalis infection, 0.60 for bacterial vaginosis and 0.78 for genital ulcer disease.[34]
Although circumcision can decrease the risk of acquiring and transmitting STIs, it should be emphasized that other preventative measures, including abstinence, use of condoms and other safe sex practices, must continue to be taught and practiced.

Cancer reduction

Female partners of circumcised men have a reduced cervical cancer risk, with ORs ranging from 0.18 to 1.61 depending on the sexual-behavioural risk level of their partner[35] (Level of Evidence 3). The incidence of cervical cancer in Canada ranges from nine to 17/100,000.
Penile cancer is rare in developed countries (one in 100,000 men). Squamous cell carcinoma of the penis occurs almost exclusively in uncircumcised men, with phimosis being the strongest associated risk factor (OR 11.4 [95% CI 5.0 to 25.9]).[36] This finding underscores the importance of genital hygiene and of identifying and treating cases of phimosis and residual nonretractile foreskin in all males.
There is a strong association between HPV infection and penile cancer regardless of circumcision status, with 80% of tumour specimens being HPV DNA-positive.[37] It is expected that routine HPV vaccination for girls will dramatically decrease the incidence rate of cervical cancer. The benefit may also extend to penile cancer, especially as the program is broadened to include young men.

How is circumcision done?

During a circumcision, the foreskin is freed from the head of the penis, and the excess foreskin is clipped off. If done in the newborn period, the procedure takes about five to 10 minutes. Adult circumcision takes about one hour. The circumcision generally heals in five to seven days.

Is circumcision necessary?

The use of circumcision for medical or health reasons is an issue that continues to be debated. The American Academy of Pediatrics (AAP) found that the health benefits of newborn male circumcision outweigh the risks, but the benefits are not great enough to recommend universalnewborn circumcision. The procedure may be recommended in older boys and men to treat phimosis (the inability to retract the foreskin) or to treat an infection of the penis.
Parents should talk with their doctor about the benefits and risks of the procedure before making a decision regarding circumcision of a male child. Other factors, such as your culture, religion, and personal preference, will also be involved in your decision.

What are the benefits of circumcision?

There is some evidence that circumcision has health benefits, including:
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Circumcision also makes it easier to keep the end of the penis clean.
Note: Some studies show that good hygiene can help prevent certain problems with the penis, including infections and swelling, even if the penis is not circumcised. In addition, using a condom during sex will help prevent STDs and other infections.

What are the risks of circumcision?

Like any surgical procedure, there are risks associated with circumcision. However, this risk is low. Problems associated with circumcision include:
  • Pain
  • Risk of bleeding and infection at the site of the circumcision
  • Irritation of the glans
  • Increased risk of meatitis (inflammation of the opening of the penis)
  • Risk of injury to the penis




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