Circumcision

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.

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]

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]

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]

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.

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]

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.