Circumcision

Circumcision
Andy Hsi, M.D. & Dan Stulberg, M.D.
August 14, 2013
Learning Objectives
1. The learner will have an understanding of the
medical benefits of circumcision
2. The learner will see and understand the
concepts of the Gomco and Mogan circumcision
techniques.
3. The learner will understand the indications,
risks and benefits of medications used in
circumcision.
Selected slides courtesy of
Ephraim Back, MD, MPH
Ellis Hospital
Schenectady, NY
World’s Oldest Account of
Circumcision – Egypt 2400 BC
Ephraim Back, MD, MPH
AAP and AAFP Recommendations
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AAP
AAFP
UTI
STD
AAP Circumcision Policy -- 1999
• “Existing scientific evidence demonstrates potential
medical benefits of newborn male circumcision;
however these data are not sufficient to recommend
routine neonatal circumcision.”
• To make an informed choice, parents of all male
infants should be given accurate and unbiased
information.”
• If a decision for circumcision is made, procedural
anesthesia should be provided”
Pediatrics.1999:103:686
Ephraim Back, MD, MPH
Circumcision and Prevention of Penile
Problems
• Longitudinal study in New Zealand followed a birth
cohort of 500 boys:
– Uncircumcised boys had higher rate of penile inflammation
(14.4% vs.7.6%) and phimosis (3.7%)
– During infancy, circumcised group had a higher rate of
meatitis. Older uncircumcised group had a higher rate of
penile problems
– Majority of problems were relatively minor
• Other problems include balanitis (esp. with diabetes),
paraphimosis, chronic scarring, secondary phimosis.
Fergusson et.al. Pediatrics. 1988.81:537
Ephraim Back, MD, MPH
Circumcision Status and UTI
• Relative risk of UTI in uncircumcised males
<1 year old compared with circumcised
males increased from 4 to 10 fold:
– Uncircumcised ~ 7-14 per 1,000 (0.7-1.4%)
– Circumcised ~ 1-2 per 1,000 (0.1-0.2%)
– NNT to prevent one UTI = 83-166
• Increased periurethral bacterial colonization.
• Uropathogenic bacteria adhere to mucosal
surface, but not to keratinized surface of
foreskin
Ephraim Back, MD, MPH
Implication of UTIs Referred To
• Wiswell 2000 AAP commentary
– Reason for UTI; microbial colonization and bacterial
adherence of pathogenic organisms
– Association of pyelo in ~90% with UTIs
– Long term; renal injury with scarring
• Caused by renal parenchymal infection and inflammation,
• Not as associated with vesicourethral reflux (VUR)
– Past articles reported about 10-20/10000
uncircumcised males with renal scarring
Circumcision and Cancer of Penis
• Risk of developing penile cancer in
uncircumcised man increased 3-fold
– Annual rate in U.S. 9-10 cases per 1 million
men
– Over past 20 years, of 750 to 1,000 cases of
penile cancer/year in U.S., only 3 cases in men
who had been circumcised as infants
– NNT ~ 50,000 to prevent 1 case of cancer
• May be related to HPV, hygiene, phimosis,
smegma
Ephraim Back, MD, MPH
Wiswell’s Observations Limited?
• Most studies retrospective or case series
• Before prenatal ultrasound screened for:
– Pyelactasis
– Dilated ureters
• Cochrane review of circumcision to prevent UTI
– Jagannath VA, et al. Cochrane Database of
Systematic Reviews 2012, Issue 11
– No research met randomization criteria
So What?
• Infant UTIs serious infection under 1 year
– Uncircumcised males > females > circumcised males
– Hospitalization costs
– Long term renal injury may occur
– No prospective circ vs no circ with prenatal US
findings
• What about all the females with renal scarring?
• Role of hygeine? No prospective randomize study
• Role of nappies, diapers, other cleaning stuff
Circumcision, Cervical Cancer and
STDs
• Cervical cancer -- controversial:
– NEJM study – circumcised men had a
decreased risk of HPV (OR = 0.37)
– Monogamous partners of circumcised men had
a decreased risk of cervical cancer (OR = 0.42)
• STDs:
– Uncircumcised men may be more susceptible
to STDs that disrupt epithelial surfaces, such as
herpes, syphilis, condyloma, and chancroid
– GC and Chlamydia conflicting data
Castellsagué et al. NEJM. 2002; 346:1105
Ephraim Back, MD, MPH
Prevention of Transmission
• CDC Information Sheet Updated March 2013
• Consistent and correct use of latex condoms reduces the
risk of other sexually transmitted diseases (STDs),
including diseases transmitted by genital secretions, and
to a lesser degree, genital ulcer diseases. Condom use
may reduce the risk for genital human papillomavirus
(HPV) infection and HPV-associated diseases, e.g., genital
warts and cervical cancer.
• Should anyone have sex without a condom?
• Relevance of circumcision vs condom use?
AAP Recommendations
• Evaluation of current evidence indicates that…
• the health benefits of newborn male
circumcision outweigh the risks
• and that the procedure’s benefits justify
access to this procedure for families who
choose it.
• http://pediatrics.aappublications.org/content/
early/2012/08/22/peds.2012-1989
AAFP Recommendations
• The American Academy of Family Physicians recommends…
• physicians discuss the potential harms and benefits of
circumcision with all parents or legal guardians considering
this procedure for their newborn son.
• Evidence from the literature is often conflicting or
inconclusive.
• Most parents base their decision whether or not to have
their newborn son circumcised on nonmedical preferences
(i.e. religious, ethnic, cultural, cosmetic).
• http://www.aafp.org/patient-care/clinicalrecommendations/all/circumcision.html
Factors Affecting Circumcision Decision
Parents who circumcised Parents who Refused
• Easier to keep clean
• Not necessary
• Easier to do now
• Painful
• Medically, its better
• Baby’s father not
circumcised
• Same as baby’s father
• My doc recommended • Hospital failed to do it
• Not sure
• Same as other sons
• Religious
• Cosmetic
Tiemstra JD. JABFP.1999.12:16
Ephraim Back, MD, MPH
A Boy Should Look Like His Father
• Brown & Brown 1987
– Survey of new mothers
after hospital discharge
– Major reasons for
procedure non-medical
• Cleanliness
• As a custom, preference
• Same appearance as
father or sibling
• Not being different from
friends
Ephraim Back, MD, MPH
Ephraim Back, MD, MPH
Techniques
• Gomco
• Mogen
• Plastibell
Contraindications
• Recognized hypospadias – Yes
• Unrecognized hypospadias/Megameatus with
intact prepuce MIP - No
• Flap not needed for current repair methods
• Short phallus with large fat pad
• Chordee
• Ambiguous genitalia
• Bleeding/clotting problems – “still bleeding from
the heel stick”
Chordee
Photo Courtesy Daniel Stulberg, MD
Incomplete Foreskin
Photo Courtesy Daniel Stulberg, MD
Managing Pain
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Suckling
Sugar water
Acetaminophen
Dorsal penile block
Catecholamine levels
Facial expression score
Consensus Statement for the Prevention and
Management of Pain in the Newborn
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Circumcision
If deemed necessary:
Use an appropriate clamp (Mogen clamp preferred
over Gomco).
Apply EMLA to the proposed site.
Place a dorsal penile nerve block, ring block, or
caudal block, using plain or buffered lidocaine.
Use a pacifier* with sucrose.
Consider acetaminophen for postoperative pain.
Ephraim Back, MD, MPH
The four A's of the humane approach
to circumcision
• Anesthesia: Ring Block, DPNB, EMLA
• Ancillary measures: Positioning, pacifier use,
sugar administration, human contact
• Appropriate technique: Minimal
instrumentation and traction on tissue, for
whatever tools are used
• Analgesia: Postoperative acetaminophen
Veltman L. A humane approach to neonatal
circumcision. Contemporary OB Gyn. June 1988
Ephraim Back, MD, MPH
Sucrose
Herschel et.al. Arch Pediatr Adolesc Med. 1998;152:279
Ephraim Back, MD, MPH
Comparison of Ring Block, DPNB,
and Topical Anesthesia
• 54 infants randomized to 4
groups – Gomco method
• Injections completed 8
minutes before circ
• EMLA cream applied 90
minutes before circ
• Ring block equally effective
through all stages. DPNB
and EMLA not effective
during foreskin separation
and incision
Lander et. Al. JAMA. 1997.278:2157
Ephraim Back, MD, MPH
Video Presentations
Video Presentations
Defective Mogen
Clamp
Opens wider
than 2-3 mm
Photo Courtesy Daniel Stulberg, MD
Defective Mogen
Clamp
Edges not flush
Photo Courtesy Daniel Stulberg, MD
Postoperative Care
• Petrolatum
• Signs of infection
Circumcision Complications
• Complication rate 0.2-0.6%
– Bleeding ~0.1% (rarely needing transfusion)
– Infection, usually manifest by local reaction
– Isolated case reports of recurrent phimosis,
wound separation, concealed penis, skin
bridges, urinary retention, meatal stenosis,
inclusion cysts
– Case reports of more serious complications,
including scalded skin syndrome, necrotizing
fasciitis, sepsis, urethral fistula, partial
amputation, and penile necrosis
Ephraim Back, MD, MPH
Adverse Outcomes (cont)
and ? Side Effects
• Cosmetic
• Sexual dysfunction
• Male genital mutilation