Circumcision 

Updated: Jun 12, 2018
Author: Carlos A Angel, MD; Chief Editor: Ted Rosenkrantz, MD 

Overview

Background

Circumcision of males involves removing the fold of skin that normally covers the glans penis.

Although no consensus exists among scholars regarding the origins of circumcision, some have suggested that this procedure likely originated in Egypt some 15,000 years ago and that its practice later spread throughout the world during prehistoric human migrations. Egyptian mummies and wall carvings discovered in the 19th century offer some of the earliest records of circumcision dating this procedure to at least 6000 years BC. However, other authors believe that circumcision developed independently in different cultures. For example, on his arrival to the New World, Columbus found that many of the natives were already circumcised.

Many cultures have historically used circumcision for hygienic reasons while others performed it as a rite of passage to manhood, as a mark of cultural identity (similar to a tattoo), or as a ceremonial offering to the gods. Ritual circumcisions in Middle Eastern cultures have been practiced for at least 3000 years. Late in the 19th century, this ancient ritual evolved into routine medical practice influenced by reports that associated it with miraculous cures for hernias, paralysis, epilepsy, insanity, masturbation, headache, strabismus, rectal prolapse, hydrocephalus, clubfoot, asthma, enuresis, and gout.

Routine neonatal circumcision has become a controversial issue in the past 2 decades as many of the previously accepted medical indications have come under considerable scrutiny. Because neonatal circumcision poses both potential benefits and risks and because the procedure is not necessary for a child's well-being, the American Academy of Pediatrics (AAP) Task Force on Circumcision in its latest policy statement in 2012 affirms that "existing scientific evidence demonstrates potential benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision."[1] As a consequence, parents should be appropriately counseled so that they can make an informed choice and decide whether a circumcision is in the best interest of their child.

Bossio et al conducted a review of peer-reviewed medical journal articles to assess the state of circumcision research, as that research applies to North American populations.[2] Their review uncovered considerable gaps within the current literature on circumcision, including a need for empirically based studies to address questions about circumcision and sexual function, penile sensitivity, the effect of circumcision on men's sexual partners, reasons for circumcision, the effects of age at circumcision (particularly with regard to neonatal circumcision), and the need for objective research outcomes. The investigators commented that such research is needed to inform policy makers, healthcare professionals, parents, and others with regard to the decision to perform routine circumcision on male neonates in North America.[2]

The penile skin is continuous with that of the lower abdominal wall. Distally, the penile skin is confluent with the smooth, hairless skin covering the glans. At the corona, it is folded on itself to form the prepuce (foreskin), which overlies the glans. The subcutaneous connective tissue of the penis and scrotum has abundant smooth muscle and is called the dartos fascia, which continues into the perineum and fuses with the superficial perineal (Colle) fascia. In the penis, the dartos fascia is loosely attached to the skin and deep penile (Buck) fascia and contains the superficial arteries, veins, and nerves of the penis. For more information about the relevant anatomy, see Penis Anatomy.

Pathophysiology

The prepuce, a fold of skin that covers the glans penis, is lined up by an external keratinized layer and an internal mucosal layer. The pouch thus created can collect desquamated epithelial cells forming the so-called keratin pearls in infants and toddlers (which are not infectious in nature). In adolescence, cellular debris and local secretions collect in the form of smegma if the penis is not cleaned regularly. The prepuce provides protection to the glans from dryness and keratinization. Innervation of the prepuce is complex, the dorsal nerve of the penis and branches of the perineal nerve provide somatosensory input, whereas autonomic innervation comes primarily from the pelvic plexus.

Infant penis. Infant penis.

Epidemiology

Frequency

United States

In the United States, accurate estimates of the rate of neonatal circumcisions are limited. The frequency of circumcision varies depending on geographic location, religious affiliation, and socioeconomic classification. One study showed differences in neonatal circumcision rates among racial and ethnic groups: 81% in whites, 65% in African-Americans, and 54% in Hispanics.

According to data from the National Hospital Discharge Survey, 1.2 million (65.3%) babies were circumcised in the United States in 1999, making this the highest rate of routine neonatal circumcision among developed nations. The national rate of newborn circumcision declined from 64.5% to 58.3% from 1979 through 2010.[3]  Healthcare coverage has and will continue to affect the rates of routine neonatal circumcision. As of 2004, 13 states had terminated Medicaid funding for neonatal circumcisions. At present, approximately 70% of obstetricians, 60% of family practitioners, and 35% of pediatricians practice newborn circumcision.

Sex

Circumcision applies only to male individuals.

 

Presentation

Physical

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]

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%).[6, 7]

  • 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.

  • 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.[8]

    • 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.[9]

  • 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.[10]

    • 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.[11] 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.[12] 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.[13] Recently, in a large population-based study, Schoen et al confirmed the protective effect of circumcision against penile cancer.[14] 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.

 

DDx

Differential Diagnoses

 

Treatment

Medical Care

Daily cleaning, without forceful retraction of the foreskin, is the only treatment necessary for phimosis in patients without urinary obstruction, hematuria, or preputial pain.

Treatment with topical corticosteroids is effective in separating the loose adhesions found between the glans and the foreskin.

In 2001, French researchers Berdeu, et al, used data from published reports and from claims by private hospitals for children younger than 13 years. They found that topical application of clobetasol or 0.05% betamethasone cream 2 times/day to the foreskin and glans for 4-8 weeks was effective in allowing full retraction of the foreskin in 85% (range, 70-100%) of the patients who had a mean age of 5 years at inclusion. The 15% failure rate was attributed to verifiable cases of lichen scleroticas et atrophicus or nonspecific chronic inflammatory processes. Success was achieved at approximately 10% of the cost of operative circumcision; this result showed a considerable cost-effectiveness with this approach.[15]

Surgical Care

Although several techniques are used in neonatal circumcision, all of the methods involve the following common elements:

  • Estimation of the amount of foreskin to be removed

  • Dilation of the preputial orifice to determine the presence of a normal glans and penis without any evidence of hypospadias, epispadias, chordee, or other anomalies

  • Blunt separation of the inner preputial epithelium from the glans

  • Placement of a device designed to ensure hemostasis

  • Removal of the foreskin

The 3 most common devices used to date are the Gomco clamp (67%), the Plastibell device (19%), and the Mogen clamp (10%). Both the Gomco clamp and the Mogen clamp are excellent instruments for infants but should not be used in toddlers who weigh more than 5 kg because of an increased risk of bleeding. Cosmetic results are excellent with any of these devices if they are used correctly.

In the authors' experience, the Plastibell technique can be used safely for office circumcisions in children up to 10 kg under local anesthesia because this technique induces tissue necrosis by means of suture compression of the foreskin over a plastic ring that protects the glans. Thus, adequate hemostasis is ensured in the older child. The skin sloughs off in 5-7 days, and the ring separates.

 

Follow-up

Further Outpatient Care

Newborn infants should only have sponge baths until the circumcision site is well healed.  Older patients should begin to take baths after 24 hours of the procedure.

Regular application of triple antibiotic ointment (4-6 times/d or after each diaper change) is important to prevent infections, adhesions and the formation of crusts on the denuded glans in older children.

Patients should return for a follow-up visit within 1 week after circumcision.

Further Inpatient Care

Neonates who have excessive and poorly controlled pain during infancy may have pain intolerance and hyperalgesia later in life.

Sympathetic arousal due to pain is regularly seen in neonates and is manifested as tachycardia, increased blood pressure, sweating, elevated serum catecholamine and cortisol levels, and decreased oxygen saturation.

Behavioral responses include crying, flailing, and grimacing.

The AAP Task Force on Circumcision recommends the use of environmental, nonpharmacologic, and pharmacologic interventions to reduce pain and distress during neonatal circumcision. These interventions include the use of a sucrose pacifier, local application of a eutectic mixture of local anesthetic agents (prilocaine and lidocaine) (EMLA) cream, dorsal penile blocks, and ring blocks.

  • Although some physicians are averse to the use of EMLA cream in the neonatal period because of concern of causing methemoglobinemia, its use has been proven to be safe for circumcisions in this age group.  It should be noted that in a Cochrane Review as well as other studies, the dorsal penile nerve block is more effective in eliminating pain than EMLA cream.[16]

  • A ring block that consists of the circumferential subcutaneous injection of local anesthesia (eg, 1% lidocaine without epinephrine) at the base of the penis is highly effective as is a dorsal penile nerve block.

  • Dorsal penile nerve block involves injection of 1% lidocaine without epinephrine with a 27 gauge needle at the base of the penis at the 2 and 10 o'clock positions.  The needle is advanced until it enters Buck's fascia.  After aspiration, 0.5 cc are injected in each site.

  • Oral acetaminophen provides adequate pain control after neonatal circumcision.

  • In patients who undergo formal circumcisions in the operating room, caudal blocks and dorsal penile blocks decrease the amount of pain medication required after the procedure.

Complications

Several complications are associated with neonatal circumcision.

  • Complications can be minimized if an experienced practitioner performs the circumcision.

  • Bleeding is the most common early complication and usually is adequately controlled with local hemostatic measures, such as pressure dressings. On occasion, the patient must be taken back to the operating room for surgical hemostasis and hematoma evacuation.

  • Infection is the second most common early postoperative complication, but usually is minor and easily managed with oral and topical antibiotics.

  • The most common long-term complication seen after circumcision is meatal stenosis.

Other complications described in isolated case reports include the following:

  • Recurrent phimosis

  • Wound separation

  • Penile torsion

  • Concealed penis

  • Unsatisfactory cosmesis

  • Skin bridges

  • Urinary retention

  • Meatitis

  • Skin chordee (due to removal of excessive skin)

  • Inclusion cysts

  • Retained Plastibell devices

Other case reports have mentioned rare events such as scalded skin syndrome, necrotizing fasciitis, sepsis, meningitis, urethral fistula, penile necrosis, and amputation of a portion of the glans penis.

Prognosis

Complete resolution is expected with appropriate treatments.

Patient Education

See the list below:

  • Instruct parents concerning the occurrence of physiologic childhood phimosis, which can last into the school-age years. Stress the danger of forcibly retracting the foreskin for hygienic purposes. Let them know that, after time, the adhesions found between the inner prepuce and the glans naturally lyse.

  • Instruct patients and parents of children with acquired phimosis regarding the importance of proper genital hygiene.

  • In addition, make them aware of the problems that may result from an acquired phimosis (eg, balanitis, paraphimosis, preputial pain).

  • Make all health care providers aware of the risk of paraphimosis associated with catheterization, and remind them to always reduce the foreskin after penile cleaning and catheterization.

  • Inform parents fully regarding the potential benefits and risks associated with neonatal circumcision so that they can determine whether circumcision is in the best interests of their child.

  • The AAP does not recommend routine neonatal circumcision; however, if circumcision is performed, the AAP recommends the use of procedural analgesia.

  • For excellent patient education resources, see eMedicineHealth's patient education articles Foreskin Problems and Circumcision.