Circumcision Clinical Presentation

Medical indications

Groups that oppose neonatal circumcision contend that the foreskin has specialized nerve endings that enhance sexual pleasure and important functions, including natural protection of the glans penis. They argue that permanent externalization of the glans penis results in desensitization due to keratinization of the glans that buries nerve endings deep into this structure. However, no solid scientific evidence supports this assumption.

A study by Bossio et al assessed penile sensitivity in 62 adult men (30 circumcised, 32 intact, 18 to 37 years in age) by comparing peripheral nerve function of the penis across circumcision status. The study’s findings suggested that minimal long-term implications for penile sensitivity exist as a result of neonatal circumcision. ^{[4, 5]}  Similarly, a systematic review by Morris et al found no reduction in sexual arousal, touch, pain, or warmth thresholds, as measured by quantitative sensory testing, in men who had undergone neonatal circumcision. ^[6]

Although many families choose to have their male infants circumcised for cultural, religious, or hygienic reasons, only a few accepted medical indications are recognized: phimosis, paraphimosis, balanitis and posthitis. Circumcision is also recommended in male infants and toddlers who develop UTIs and children who require clean, intermittent catheterization to facilitate this procedure.

• Phimosis

  • Phimosis is a condition in which the distal prepuce cannot be retracted over the glans penis. In infants, toddlers and preschool children, the foreskin may appear tight and nonretractable with thin adhesions to the glans. This situation persists until progressive keratinization of the epithelial layers occurs between the glans and the inner prepuce dislodges the foreskin from the glans. This is known as physiologic phimosis, which is not considered a pathologic condition.

  • Severe phimosis in the young age groups is rare and can be demonstrated by bulging of the foreskin during micturition. At 3 years of age only 10% of boys are unable to fully retract the foreskin. By adolescence, 98-99% can fully retract their foreskin to expose the glans. Acquired phimosis occurs as a result of poor hygiene, chronic balanitis, or repetitive forceful retraction of the foreskin, which eventually leads to the formation of a fibrotic ring of tissue close to the opening of the prepuce which prevents retraction to expose the glans. Phimosis does not cause obstruction to the urinary stream. However, without proper hygiene, the individual is at risk for chronic skin irritations, yeast infections, balanitis, posthitis, and the forceful retraction of the foreskin may result in paraphimosis. A person with true phimosis may have pain during sexual activity.

  • A study by Sneppen et al evaluated the incidence and morbidity of foreskin surgery due to medical indications in 181 boys from Denmark in 2014 and found that phimosis was the most frequently reported indication (95.0%). ^{[7, 8]}

• Paraphimosis

  • Paraphimosis is the inability to reduce a retracted foreskin over the glans penis to its naturally occurring position. This condition is a true urologic emergency. If not treated promptly, it can result in venous engorgement and edema of the glans and foreskin which, over time, progresses to arterial occlusion with its ensuing risk of ischemic loss of portions or of the entire glans. Paraphimosis can result when parents or caregivers forcibly retract the foreskin to clean the penis or attempt catheterization and do not return the foreskin to its original position. Edema, tenderness, and erythema of the glans are seen, along with edema of the distal foreskin and flaccidity of the penile shaft proximal to the areas of paraphimosis.

  • Paraphimosis is a urologic emergency and should be treated as soon as possible. Manual reduction of the prepuce over the glans can usually be achieved. Manual reduction is accomplished by placing pressure, by using the index and middle fingers, around the prepuce to reduce edema while simultaneously applying pressure to the glans with both thumbs to push the glans through the tight prepuce and in this manner allow the foreskin to lie in its naturally occurring position. If this manipulation is ineffective, a dorsal incision at the level of the constricting band releases the foreskin. Circumcision should later be performed electively.

• Balanitis or posthitis

  • Posthitis is an infection of the prepuce, whereas balanitis is an infection of the glans penis. Both of these infections respond to oral and topical antibiotics and warm baths. In posthitis, signs and symptoms include erythema, swelling, warmth, and tenderness of the foreskin. In balanitis, erythema, swelling, warmth, and tenderness are noted in the glans penis. A foul-smelling, thin, seropurulent exudate may be evident. Balanitis, posthitis, or both may be the result of poor hygiene.

  • In young children, mixed flora usually causes this infection, whereas trichomonal balanitis and candidal infections may be seen in sexually active teenagers. A white, cheeselike substance (smegma) is a normal finding that is not indicative of infection. Smegma is formed by desquamated epithelial cells trapped between the glans and foreskin through a natural process that aids in the normal separation of the glans from the foreskin.

  • Balanitis, posthitis, or both are typically treated with oral antibiotics and antibiotic ointments that cover skin flora. Warm soaks or baths are recommended to relieve the discomfort and maintain the area clean. Pain control with oral acetaminophen or ibuprofen is usually adequate.

Suggested benefits and medical indications

Curing masturbation was historically the most common indication for circumcision. For many years, both lay people and medical practitioners have speculated that circumcision reduces the risk of sexually transmitted diseases (STDs), particularly ulcerative diseases of the penis (eg, syphilis). Recent reports in the medical literature support a protective effect of circumcision (at various levels) against urinary tract infections (UTIs), some STDs (including HIV infection), cervical cancer, and penile cancer. A study by Mishra et al showed a significant decrease in bacteria and fungi after circumcision, especially anaerobic bacteria. ^[9]

• Management of urinary tract infections

  • UTIs are more common in male neonates than in their female counterparts. Studies addressing the association between circumcision status and UTIs demonstrated an increased rate of UTIs in uncircumcised males, especially in infants younger than 1 year.

  • Wiswell and Hachey (1993) studied 209,399 infants born in US Army hospitals worldwide in 1985-1990. During the first year of life, 1046 infants (0.5%, 550 girls and 496 boys) were hospitalized for UTIs. Noncircumcised male infants had a 10-fold increased incidence of infection compared with that of circumcised male infants. ^[10]

  • A meta-analysis of data of 9 studies as of 1993 revealed a 12-fold increase in the risk of UTIs among uncircumcised male infants. A study of infants with UTIs showed that 75% of those younger than 3 months were males and, of those, 95% were uncircumcised. The UTI risk is also increased in premature infants, and circumcision had a protective effect against recurrent UTIs in this group of patients.

  • Although the relative risk of uncircumcised male infants developing a UTI is estimated to be 4-20 times greater than in circumcised neonates, the absolute risk of UTIs in uncircumcised male infants remains low at approximately 1%. Because the absolute risk is low, recommending routine circumcision in all newborn males is controversial both medically and ethically. Some children are at increased risk for UTIs, such as children with neurogenic bladders who require clean, intermittent catheterization or children with poorly emptying urinary tracts.

  • A study by Ellison et al reported that circumcision was associated with a decreased risk of UTI in infant boys with hydronephrosis.  ^[11]

• Management of sexually transmitted diseases

  • Mechanisms proposed to explain the increased risk for STDs in uncircumcised males include a relatively nonkeratinized inner layer of the prepuce which increases its susceptibility to minor trauma during intercourse, allowing pathogens to penetrate through microscopic abrasions. The warm microclimate created by the preputial pouch permits the microorganisms to thrive in the smegma that collects in this area.

  • The most consistent evidence that supports the association of circumcision with reduction of the risk of STDs refers to transmission of genital ulcerative disease and HIV. Eight studies (of variable design) report a significant 2- to 7-fold increased risk of genital ulcerative disease (mainly syphilis and chancroid) in uncircumcised male patients. ^[12]

  • In the only true meta-analysis to date, Weiss et al reviewed data from 27 studies and concluded that circumcision substantially reduces the risk of HIV infection across all populations evaluated. ^[13]  A study of 187 HIV-discordant couples in Uganda showed no infections occurring in 50 circumcised HIV-1-negative male subjects compared with 40 infections among 137 HIV-1-negative uncircumcised male subjects. ^[14]  Circumcision also decreases the likelihood of one's acquiring genital ulcerative diseases known to be independent risk factors for the transmission of HIV.

• Management of human papillomavirus and cervical cancer: Human papilloma virus (HPV) can be oncogenic or nononcogenic. Nononcogenic HPV (genotypes 6 and 11) causes genital warts in men and women. Oncogenic HPV (genotypes 16,18, 31, and 33) are responsible for the great majority of cervical, vulvar, vaginal, anal, and penile cancers. Circumcision significantly reduces the risk of penile HPV infection in men and of cervical cancer in the female partners of male individuals who practice high-risk behaviors such as engaging in sexual activity with multiple partners.  However, the most effective means of eliminating genital HPV is through vaccinations as currently recommended by the AAP.

• Management of penile cancer: The most important factor associated with the development of penile cancer is an intact foreskin. Wolbars, who was the first to point out that Jewish men (the great majority of them circumcised) rarely develop penile cancer, initially brought this association to the attention of the scientific community 70 years ago. ^[15]  Recently, in a large population-based study, Schoen et al confirmed the protective effect of circumcision against penile cancer. ^[16]  Of interest, the other known major risk factor associated with penile cancer is phimosis, which circumcision completely eliminates.

Contraindications

Contraindications for circumcision include prematurity, anomalies of the penis (eg, chordee, or curvature of the penis), hypospadias, epispadias, concealed or buried penis, micropenis, webbed penis, and ambiguous genitalia. Bleeding diatheses are not absolute contraindications for circumcision, but circumcisions should be discouraged in these cases. If, after being fully informed of the increased risks of complications, the family insists on circumcision then careful evaluation, clearance, and patient preparation and treatment both before and after the procedure by a pediatric hematologist may optimize the likelihood of a successful outcome.