Continuing Education Activity

Male circumcision is the surgical removal of the prepuce, or foreskin, that covers the glans of the penis. Over the past decades, cultural changes and new research have led to a closer examination of the practice of circumcision. This activity reviews the indications, contraindications, and technique involved in performing circumcision and highlights the role of the interprofessional team in the care of patients undergoing this procedure.

Objectives:

• Identify the anatomical structures involved in routine circumcision.
• Describe the equipment required to perform a circumcision.
• Review the complications of circumcision.
• Explain a structured interprofessional team approach to provide effective care to and appropriate surveillance of patients undergoing circumcision.

Introduction

Circumcision is the surgical removal of the prepuce (foreskin) covering the glans of the penis. The practice of circumcision has existed for thousands of years as part of cultural and religious teachings.[1] It was highly regarded as a rite of passage to adulthood and a hygienic process. Over the past decades, cultural changes and new research have led to a closer examination of the circumcision practice. Recent knowledge of female circumcision has also fueled the discussions on the validity of male circumcision.[2][3][4][5]

Anatomy and Physiology

The penis can be divided into the dorsal surface, ventral surface, base (proximal), shaft (middle) and glans (distal). The dorsal region contains the superficial dorsal vein, deep dorsal vein, dorsal artery, and dorsal nerve. This dorsal nerve is anesthetized during the dorsal nerve block to aid with pain control during circumcisions.

The major components of the penis include the urethra, corpora cavernosa, corpus spongiosum, glans, and the foreskin. The 2 corpora cavernosa lie ventral to the dorsal nerves and vasculature. They become engorged with blood to promote erection. The corpus spongiosum lies ventral to the corpora cavernosa. It houses the urethra. The urethra starts at the bladder and runs through the length of the penis to end at the glans of the penis. The foreskin covers the entire penis and is trimmed distally during circumcision to expose the glans.

Indications

Medical indications for circumcision include but are not limited to phimosis, paraphimosis, and chronic urinary tract infections. Elective circumcision may be indicated in regions with increased HIV and human papillomavirus (HPV).

Contraindications

Contraindications to circumcisions include an unhealthy infant, anatomic pathology, and bleeding disorders. The general health of the infant should be assessed before the procedure. In most cases, circumcision is an elective procedure and can be delayed. The procedure should be postponed if the infant is found to have electrolyte or metabolic abnormalities (e.g., hypoglycemia), a bacterial infection, has yet to urinate, or to has a hypoxic cardiac disorder. The penis should be evaluated for anatomical anomalies such as micropenis, concealed penis, swelling of the foreskin, and hypospadias. Any infant with a bleeding disorder or a strong family history of bleeding disorders should only undergo the circumcision at a healthcare facility with the proper subspecialist.[6][7]

Personnel

The practice of circumcision is not limited to medical professionals. As a result, standards of pain control, hygiene, technique, and outcomes cannot be guaranteed. The family of the patient must interview the personnel performing the circumcision. The person performing the procedure usually can provide the family with a portfolio of their outcomes.

Preparation

Proper pain control should be administered for the circumcision. It should be noted that a sugar-based oral solution alone is not an adequate pain control for infants. Effective analgesia is highly dependent on the person performing the procedure. Many infants are treated with a combination of oral sucrose solutions, topical analgesics like lidocaine cream 4% (LMX-4), lidocaine/prilocaine cream, and injected analgesics such as lidocaine without epinephrine or bupivacaine.[8][9][10]

Technique

There are various methods for circumcision. The goal of each method consists of removal both the inner and outer preputial skin while not injuring the underlying glans and urethra. The procedure should take minutes when performed on the newborn. However, it becomes more complicated when performed on adults. The healing phase and result depend on the procedure used. Below are common methods used for circumcision.[11][12][13][14]

Complications

Circumcision does not lower the risk of gonorrhea, chlamydia, or syphilis. However, circumcised heterosexual males have an averaged 40% to 60% reduction in acquiring HIV in regions with a high HIV heterosexual population, for example, areas in Africa. There is also a lower prevalence of human papillomavirus (HPV) infection and herpes simplex virus type 2 transmission.[15][16][17]

Risks

Surgical risks include, but are not limited to, infection, incision of the glans and urethra, necrosis of the glans, foreskin adhesions, phimosis, or penile loss.[15][17]

Clinical Significance

Current Recommendations

AAP Statement

In an update to the 1999 recommendations, new evidence indicated that health benefits outweighed the complications for newborn male circumcisions. There was found to be a reduction in urinary tract infections, sexually transmitted infections, acquisition of HIV, and penile cancer. Circumcision was not associated with a decrease in sexual function and satisfaction. All families should be given the proper information regarding circumcision. These statements have also been endorsed by the American College of Obstetricians and Gynecologists.[15][18][19]

AAFP Statement

Family physicians should provide the family with information in an unbiased manner. Neonatal circumcision has potential health benefits in the reduction of urinary tract infection, sexually transmitted infections and penile cancer. However, circumcision is not without complications. Now the HPV vaccine alone may aid in the reduction of penile cancer.

American Urologic Association

The circumcised newborn infant will experience the risks and complications associated with the procedure. During the first three to six months of life, the incidence of urinary tract infections is significantly higher in uncircumcised boys. The circumcised adult will profit from reduced health illnesses. The benefits and risks should be discussed with the family.

Enhancing Healthcare Team Outcomes

This article is intended to be a short review of circumcision. As part of the education, the reader must be aware of the evolving view of circumcision. The AAP revised its 1999 policy on circumcision to be more pro-circumcision. This statement has reignited the debate.

The anti-circumcision papers cite many reasons not to undergo the procedure. Bringing female circumcision to the mainstream has placed male circumcision under a similar spotlight. The procedure is described as a painful procedure that is needed to push the male into manhood. This trauma can then lead to sexual difficulties. It has been proposed that the procedure should be delayed until the male can decide for himself.

Healthcare professionals do not all agree with disease prevention benefits. The HIV reduction is most prevalent in decreasing heterosexual transmission in regions with large HIV population, for example in parts of Africa). Thus, this fact needs to be included in the counseling conversation with families who are not from these regions.

HPV transmission can be reduced by circumcision. This point may become obsolete with the increased use of the HPV vaccine.

Providers must be educated about and understand religious doctrines, research findings, and cultural teachings surrounding circumcisions. The data must be provided to each family in an unbiased version. The provider must also be able to relate the data to the unique family situation.[20][21][22][23][24][25][26][27]

Nursing, Allied Health, and Interprofessional Team Interventions

Newborns babies cannot verbalize their pain. An interprofessional team approach is required to provide effective pain relief to newborns and infants after circumcision. Along with analgesics, swaddling is considered to be an effective pain relief intervention.