Male circumcision: time to re - examine the evidence

Stefan A Bailis and Daniel T Halperin argue that the benefits of circumcision exceed the risks

Male circumcision, probably the oldest surgery known, continues to be relevant, with ever increasing evidence of its benefits published regularly in leading, peer reviewed journals. Preventive circumcision in newborn baby boys has been generally shunned in the British isles since the 1949 publication of Fate of the Foreskin by the late British doctor Douglas Gairdner,^w1 who concluded from his review of the limited evidence at the time that there was no convincing reason for neonatal circumcision and therefore advocated a conservative approach. Medical students (among other professionals) and future parents should be aware of all the benefits and risks of circumcision—especially in the period up to about 3 months of age, which is simpler, safer, less painful, faster healing, and cheaper than at a later time.

Uncircumcised boys and men—especially infants—are at greater risk for urinary tract infections. These occur in about 2% of uncircumcised infant boys, who have 12 times the risk as their circumcised peers.^w2 Long term sequelae can include bacteraemia, pyelonephritis, renal scarring, and death. Balanoposthitis, a painful infection of the prepuce and glans penis, occurs in about 4% of all uncircumcised boys.^w3 It occurs in about 12% of uncircumcised men but in only 2% of circumcised men.^w4-w5 Inflammatory dermatoses are three times more common in uncircumcised men.w6 One such condition, penile lichen sclerosus et atrophicus, also known as balanitis xerotica obliterans, is implicated in certain cancers of the penis.w7 A recent study found 8.4% of men with genital lichen sclerosus et atrophicus showed premalignant or malignant histopathological features.w8 The condition is found almost exclusively in men not circumcised as newborns and is difficult to prevent (except through circumcision) or treat.^w9 Although it has been thought rare by some—Shankar estimated the prevalence through age 15 to be 0.6%^w10—a large study of adults identified lichen sclerosus et atrophicus in 4-19% of all prepuces, the severity varying greatly.

The prepuce is normally adherent to the glans penis and thus unretractable at birth (“physiological phimosis”).^w11 Phimosis has been defined in various ways, leading to much confusion. Difficulty in retracting the prepuce can be caused either by adherence between the glans and the prepuce or by a tight preputial opening. We define phimosis here simply as the inability (for whatever reason) fully to retract the prepuce easily at an age when 90% of the population can normally do so—typically by age 5.^w1 Some with a previously retractable prepuce acquire phimosis later. This may be due to a slower growth rate for the prepuce compared with the rest of the penis, posthitis (inflammation of the prepuce), or development of balanitis xerotica obliterans. Whether because of persistent physiological phimosis or acquired phimosis, cross sectional studies indicate retraction difficulty in older boys and men range from 9% to 14%.^w12-w13 Phimosis prevents adequate hygiene, which in turn increases the risk of balanoposthitis, penile cancer, and other conditions. A related condition, paraphimosis, exists when a tight prepuce is retracted but cannot be brought forward again, thus creating a dangerous tourniquet-like condition.^w3 It is impossible at birth to tell which boys will develop phimosis or paraphimosis. Circumcision eliminates the guesswork.

Penile cancer in uncircumcised men carries an approximate lifetime risk of one in 600.^w14 Men not circumcised at birth have 22 times the risk.^w15 The largest risk factor for invasive penile carcinoma is phimosis, which increases the risk 11-16 times.^w16-w17 Tobacco use, though not as great a risk as phimosis, is also a significant, independent factor.^w16

Human papillomavirus (HPV), especially HPV16, has been implicated in penile cancer. The rate of infection is lower in circumcised men (odds ratio 0.37).^w18 Circumcision protects not just men but also reduces the risk of cervical cancer (odds ratios 0.18 for women with high risks, 0.50 for women with intermediate risks),^w18 chlamydia (odds ratio 0.18),^w19 and herpes (odds ratio 0.45)^w20 in female partners through reduced sexual transmission of the applicable virus or bacterium. The lifetime risk of prostate cancer is one in six^w21; uncircumcised men have twice the risk as circumcised men.^w22-w23

Undoubtedly the most important finding in the past 20 years is the protective effect of circumcision against HIV/AIDS, particularly in heterosexual transmission from women to men. More than 40 epidemiological studies have found that circumcision reduces the risk of HIV by anywhere from twofold to eightfold, depending on the particular study..^w24-w26 A recent randomised clinical trial in South Africa had to be suspended early when an obvious protective effect—an approximate 60-75% HIV risk reduction—made continuing it unethical.^w27-w28 Two other randomised trials are currently under way in Uganda and Kenya.^w26 The main mechanism for the sexual transmission of HIV is immune system cells—especially Langerhans cells—which are highly concentrated in the inner preputial mucosa.^w25-w26 In addition to HIV/AIDS, circumcision is effective against some other sexually transmitted infections, especially ulcerative types such as syphilis and chancroid^w24-w26; and new data from Uganda show that circumcision may also reduce transmission of HIV (and some other infections) from infected men to their female partners.^w29

Current, well established techniques for newborns would include the use of one of several clamps—the Gomco, Plastibell, or Mogen—in the hands of a well trained operator. The clamps make sutures unnecessary and, although different in design, they help to maximise skin removal accuracy while minimising bleeding. Each clamp has its advantages and disadvantages. It is imperative to avoid electric cutting methods in conjunction with metal clamps as penile necrosis may result. Local anaesthetic methods such as the dorsal penile nerve block or ring block methods with lidocaine (lignocaine) provide good effect about 80% of the time.^w30 A very sweet, sucrose coated pacifier or gauze provides additional antinociception. Unlike Gairdner's time in the 1940s when general anaesthesia— then the norm—resulted in about 16 deaths annually,^w1 no deaths or serious complications have resulted from these local anaesthetic methods. Crucial to minimising complications is inspection for congenital anomalies such as hypospadias, which require postponement of the circumcision and referral to a paediatric urologist. Of equal importance is adequate aftercare instructions to the parents during the first week or so. Healing is rapid; seven to 10 days is typical.

The complication rate for neonatal circumcision using current technique sis 2-3%,^w31 nearly all of which are minor complications, most commonly excessive bleeding that can be staunched by pressure or other topical means, or local infection that can be treated easily.^w30 One in 500 cases may be expected to experience a more serious complication, such as bleeding requiring sutures, systemic infection, excess skin removal, etc. Most are successfully corrected.^w30 Deaths as a result of the surgery itself are extremely rare. From an economic standpoint, a large health maintenance organisation study found that it has neutral or even positive cost effectiveness.^w32

A common criticism by anti-circumcision activists is that circumcision is sexually harmful. Most evidence implies otherwise.^w33 Circumcised men seem to have fewer sexual problems overall. In addition, sexual functioning and sensitivity are generally similar in both circumcised and uncircumcised men. Only a few methodologically sound studies of female preferences have been conducted. In all of them to date, such as studies conducted in Botswana, Kenya, and the US, most women—including those who had an uncircumcised partner and were familiar with both types—preferred the circumcised penis.^{w26-w34 w36} Sexual hygiene was the most important factor cited. Some critics argue that circumcision is a form of mutilation that causes hidden trauma, which may in turn lead to a higher risk of post-traumatic stress disorder, rape, suicide, and even warfare, among other consequences.^w37 There are, however, no scientific studies to support such allegations.

Other critics argue that circumcision is done mainly for social, cultural and religious reasons.^w38 We believe that, although it is true that parents often choose circumcision for their infant son primarily on a social, cultural or religious basis, this in no way diminishes the value of circumcision as a preventive health measure. Moreover, some people are opposed to circumcision on a more philosophical basis—nature makes no mistakes—whereas others disagree, reasoning that the natural form is imperfect and that circumcision improves on nature. These philosophical arguments go back to the second century debate between the Roman governor of Palestine, Tinneius Rufus, and Rabbi Akiba ben Joseph.^w39 Notwithstanding the primacy of such non-medical, cultural, or philosophical reasons for their circumcision decision making, we believe that doctors should help parents familiarise themselves with the procedure, with the empirically demonstrated medical benefits and risks. This should be standard clinical practice.

References ^w1-w39 are on studentbmj.com

Circumcision will continue to be a controversial subject. However, our review of the evidence shows that the benefits exceed the risks. Circumcision, when performed in the newborn period by a skilled operator using current, well established techniques (including effective local anaesthesia), produces lifelong benefits with low risk and minimal pain. We implore full disclosure of such information to prospective parents, in an impartial manner, as well as discussion of alternative approaches.

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5. Fakjian N, Hunter S, Cole GW, Miller J. An argument for circumcision. Prevention of balanitis in the adult. Arch Dermatol 1990; 126: 1046-1047.
6. Mallon E, Hawkins D, Dinneen M, Francis N, Fearfield L, Newson R, Bunker C. Circumcision and genital dermatoses. Arch Dermatol 2000;136:350-4.
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8. Barbagli G, Palminteri E, Mirri F, Guazzoni G, Turini D, Lazzeri M. Penile carcinoma in patients with genital lichen sclerosus: a multicenter survey. J Urol. 2006;175:1359-63.
9. Rickwood AMK, Kenny SE, Donnell SC. Towards evidence based circumcision of English boys: survey of trends in practice. Brit Med J. 2000; 321: 792-793.
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11. Aynaud O, Piron D, Casanova J-M. Incidence of preputial lichen sclerosis in adults: Histologic study of circumcision specimens. J Am Acad Dermatol 1999; 41: 923-926.
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16. Daling JR, Madeleine MM, Johnson LG, Schwartz SM, Shera KA, Wurscher MA, Carter JJ, Porter PL, Galloway DA, McDougall JK, Krieger JN. Penile cancer: importance of circumcision, human papillomavirus and smoking in in situ and invasive disease. Int J Cancer. 2005;116:606-616.
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18. Castellsague X, Bosch FX, Munoz N, Meijer CJLM, Shah KV, de Sanjose S, Eluf-Neto J, Ngelangel CA, Chichareon S, Smith JS, Herrero R, Franceschi S. Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. N Engl J Med 2002;346:1105-1112.
19. Castellsague X, Peeling RW, Franceschi S, de Sanjose S, Smith JS, Albero G, Diaz M, Herrero R, Munoz N, Bosch FX. Chlamydia trachomatis infection in female partners of circumcised and uncircumcised adult men. Am J Epidemiol 2005;162:907-916.
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	SECTION Male circumcision: time to re - examine the evidence       Stefan A Bailis,Daniel T Halperin (May 2006)
	Samuel Yates (May 26th, 2006)       2nd-year GEP medical student, St. George's, University of London m0402220@sgul.ac.uk
	As a recently circumcised adult male of 24, I read with great interest the article by Bailis and Halperin. My circumcision (or bris) was performed as a necessary part of religious conversion to Judaism and would therefore have taken place regardless of the state of the medical evidence. Nevertheless, having surveyed the medical literature extensively before going ahead with the procedure, I had come to the interim conclusion that, overall, the risk-benefit equation yielded an answer not significantly different from zero! It is interesting and pleasing to read a well-researched paper (not accessed via google!) suggesting that the evidence may in fact point definitely towards circumcision. My question for the authors is whether they know of any studies looking at whether the benefits of neonatal circumcision discussed in their article apply also to males circumcised as adults. This would be of relevance to me personally, but also more generally to the extensive population of men either already circumcised as adults or making decisions about whether to be circumcised. I look forward to finding out more. With appreciation from a new 'roundhead', Samuel Yates.

	EDITORIALS Male circumcision: time to re - examine the evidence       Stefan A Bailis,Daniel T Halperin (may 2006)
	Siddhartha Sahu (May 13th, 2006)       final year M.B.B.B.S, batch of 2002, Bangalore Medical College, Bangalore, India sidsahu85@rediffmail.com
	The authors have done an excellent job of listing the benefits of circumcision. However they have not done justice to the serious adverse effects that may result from the procedure.Circumcision subjects infants to trauma and pain.Any anaesthetic used can cause complications including death although rare.While a major justification for this procedure is to reduce the risk of genitourinary infection ,such infections are not common in children and are manageable .Does it outweigh the risk of serious infection caused by the procedure itself? Furthermore while serious renal complications are far rarer ,meatal stenosis due to circumcision can be damaging to the kidneys as well. Circumcision in unrecognised hypospadias renders later correction challenging. The promotion of circumcision for it's protective value against AIDS and STDS will in fact encourage risky sexual behaviour reducing any protective value it may have.