Male neonatal circumcision: indications, controversies and complications (original) (raw)

2004, Urologic Clinics of North America

Circumcision is one of the oldest surgical procedures performed today. The practice of circumcision in males and females arose in many ancient cultures. Conflicting theories have been proposed to account for this ritual, including a sacrifice or sign of submission to a deity, a fertility offering, a mark of tribal identification, a rite of passage to adulthood, and a means of humiliating and marking vanquished enemies [1]. Circumcision was performed in ancient Egypt and as a ritual by Jews and is described in Genesis [2]. Male circumcision became a common medical practice in the 19th century, with improved anesthetic, surgical, and antiseptic techniques. The prevention of masturbation was one of the primary indications for circumcision. With the ''medicalization'' of circumcision, such misconceptions about the role of circumcision persist [3]. Approximately one man in six is circumcised worldwide. Circumcision is the fifth most common procedure performed in the United States today [4]. In 1992, nearly 1.2 million circumcisions were performed, with 62% of newborn males undergoing the procedure [5]. The practice of circumcision the United States increased dramatically following World War II and peaked in the mid-1970s, when the American Association of Pediatrics (AAP) stated it was not a medically necessary procedure [2]. The AAP reversed its stance, however, after evidence documented an increased risk for urinary tract infections (UTIs) in uncircumcised male infants [6]. At present, routine neonatal circumcision is neither recommended nor condemned by the AAP [7]. It is left to the physician to discuss the pros and cons of circumcision, including the controversy, potential medical benefit, and complications involved with this procedure. Controversies Risk for urinary tract infection Uncircumcised infant males are at increased risk for UTI, especially during the first year of life [6,8-14]. The increase in risk is presumably secondary to increased periurethral bacterial colonization. The incidence of UTI in uncircumcised males is low and ranges between 1 in 100 and 1 in 140. UTI risk seems to be reduced in circumcised males by up to 10 fold. Many of the studies examining the role of circumcision in preventing UTI have not assessed and controlled systematically for other factors, including breastfeeding, that may decrease risk. A recent study has suggested that tight covering of the urethral meatus by the prepuce may increase the risk for UTI [15]. The low risk for UTI in uncircumcised males does not warrant mandatory circumcision. See later discussion for the role of circumcision in those at higher risk for UTI. Anesthesia/analgesia Neonatal circumcisions usually are performed within the first several days of life. Before the 1990s, anesthesia was not used routinely. In a recent survey of physicians stratified by specialty and geography, 35% of pediatricians, 60% of family practitioners, and 70% of obstetricians responding to a questionnaire performed at least one circumcision per month. Of these physicians, only 45%