Circumcision

Volume 1, Number 1
June, 1996

TABLE OF CONTENTS

EDITORIAL

A New Adventure

Circumcision is breaking new ground on a number of different levels both in content and vehicle of delivery. The concept for this journal arose out the inability of welliwritten credible studies relating to the prepuce to find a publishing home in mainstream American medical journals. While the reasons for this have never been clear, a pro-circumcision bias on the part of editors of these journals has been speculated. Most published studies that have been performed in North America that have not maligned the prepuce have been published in British and European journals. While there is an inborn bias against negative studies, this alone cannot explain why several excellent studies have gone unpublished.

For some inexplicable reason the prepuce has been shrouded with controversy that encompasses many disciplines. In addition to the obvious medical aspects, religion, aesthetics, sexuality, cultural sensitivity, social engineering, psychology, ethics, constitutional rights, and cosmology are all intertwined in different aspects of this relatively small part of the anatomy. Circumcision hopes to address all of these issues (but obviously not all at once).

The articles you read here have all been peer-reviewed. The agenda of Circumcision is to print good science and well-reasoned thinking. As with any human being I have biases, some of which I am aware, others which I am not aware of. My personal perspective is that the prepuce has a value and a function (if not just from an intuitive standpoint looking at the physiology of our species, but also from recently published scientific studies) and its routine removal requires that a certain threshold be cleared before it can be justified. This stance, which is the standard for every other medical practice and procedure, is not the current paradigm in the United States. It is important to treat the prepuce just like any other tissue in the human body. I do not want my perspective to discourage anyone from contributing, but I wish to make it clear.

Circumcision will include original studies which are peer reviewed, review articles, when appropriate, which are likewise reviewed, a review of the medical literature with abstracts and comments, letters to the editors, a forum for suggestions for future research, perhaps a nonimedical feature written by guest experts. Presentations from symposiums which are relevant may be a portion of Circumcision in the future, and reverting to my short-lived life as a disc-jockey in college an occasional golden-oldie may be available in its entirety if copyright laws allow.

The other ground-breaking event is a virtual journal. Think of the trees which will be spared. We will be taking electronic submission via e-mail. Those referees on line will be able to read the submissions and make comments without having to lick a stamp. The time delays avoided through bypassing USPS will be substantial. The other reason for doing this, honestly, is financial. Printing and paper costs are substantial. How many of the articles in the journals you get each month do you actually read? Not many. This medium allows the reader to browse before downloading, read before printing, responding directly to me or the authors when a bone needs to be picked or congratulations need to be spread around. Immediate feedback can bring life to this format that printed journals lack.

I am looking forward to this adventure.

Robert S. Van Howe, M.D. F.A.A.P.
Marshfield Clinic - Lakeland Center
Minocqua, Wisconsin 54548

[Table of Contents]

ORIGINAL ARTICLE

"Modern" Circumcision: The Escalation of a Ritual

George C. Denniston, M.D. M.P.H.

ABSTRACT:

The Biblical technique of circumcision designed to fulfill the Covenant with Abraham removed only preputial tissue that extended beyond the tip of the glans penis (Bris Milah). By first pulling up on the foreskin, then placing a glans shield, the operator preserved virtually all of the sensitive inner lining of the prepuce.

In 1934, the Gomco Clamp, and even more recently the Plastibell, were invented. Both are still widely used in foreskin removal in America. Both remove tissue at the base of the glans, resulting in a total loss of the sensitive inner lining of the prepuce. This tissue is an integral part of the structure of the penis and contains large numbers of specialized nerve endings involved in normal sexual response.

INTRODUCTION

Adult foreskins have been measured, and including both the inner and the outer surfaces, approximate the area of a 3 x 5 inch card. Infant circumcision, although removing only a small amount of newborn tissue, results in the loss of a large amount of adult tissue.

A distinctive band of mucosa that begins at the junction of the prepuce with the base of the glans penis, called the ridged band, is specialized sensory tissue. It is transversely ridged, highly vascular and contains specialized nerve endings, called Meissner's corpuscles. [1] These ridges converge ventrally at the frenulum. Every intact male recognizes the sensitivity of this mucosal band and of the frenulum. It is this sensitive tissue that was preserved during Biblical circumcision, but is almost always excised during "modern" circumcision with the Gomco Clamp or the Plastibell.

MATERIALS AND METHODS

Biblical circumcision, that type used during Biblical times (c. 1700 B.C. - 140 A.D.) [2] placed a metal shield with a slit in it near the tip of the foreskin, so only the tip was removed. Often the operator, or mohel, pulled up on the outside of the foreskin before placing the shield. The result was that virtually all of the inner lining of the prepuce was preserved. This was known as Bris Milah.

The wonderful statue of David by Michelangelo appears intact but is in fact correctly represented because the future King David has been circumcised by the accepted procedure of the Biblical era. Only the tip of his foreskin has been removed, fulfilling the Covenant with Abraham (Genesis 17).

The Gomco Clamp was invented in 1934 by Aaron Goldstein and Hiram Yellen M.D., and reported by Dr. Yellen in 1935 (Figure 1). [3]

gomco clamp
Figure 1. - Gomco Clamp (courtesy Am. J. Ob. Gyn. 1935)

The procedure for circumcision with a Gomco Clamp as described by Yellen is as follows:

"After properly cleansing the penis and pubis, the dorsal aspect of the prepuce is put on a stretch by grasping it on either side of the median line with a pair of hemostats. No anesthesia is used. A flat probe, anointed with vaseline, is then inserted between the prepuce and the glans to separate adherent mucous membrane. The prepuce is then gently drawn backwards exposing the entire glans penis... In cases where the prepuce is drawn tightly over the glans, a partial dorsal slit will facilitate applying the cone of draw stud [the bell] over the glans. After anointing the inside of the cone, it is placed over the glans penis allowing enough of the mucous membrane to fit below the cone so that too much is not removed [emphasis added]. The prepuce is then pulled through and above the bevel hole in the platform and clamped in place. In this way the prepuce is crushed against the cone causing hemostasis. We allow this pressure to remain five minutes, and in older children slightly longer. The excess of the prepuce is then cut with a sharp knife without any danger of cutting the glans, which is always protected by the cone portion of the instrument, leaving a very fine 1/32 of an inch ribbon-like membrane formed between the new union of the skin and mucous membrane. The pressure is then released."

A Plastibell circumcision is carried out in a similar manner. After the prepuce is brought up over the plastic bell, a string is placed around the prepuce. A groove around the base of the bell is designed to facilitate keeping the string at the base. If tied tightly, the prepuce will slough after several days.

RESULTS

The two "modern" methods (Gomco Clamp and Plastibell) remove much more of the sensitive inner mucous membrane lining of the prepuce than was required by the Bible. The result of using different techniques may be seen in the following diagrams.

The intact newborn penis (Figure 2) is shown with a normal prepuce. The dotted line represents the inner layer of the prepuce, a mucous membrane which contains the frenulum, frenar bands and specialized Meissner's corpuscles. The solid line represents the outer layer of the prepuce, which is similar to and joins with the skin covering the penile shaft (broken line).

newborn penis
Figure 2. - Normal Newborn Penis

In Biblical circumcision, the foreskin was grasped with the fingers, which pulled the skin of the shaft upwards. The shield was then slid into place, and the tissue above the slit quickly sliced off.(Figure 3)

ritual shield
Figure 3. - Ritual Shield Method showing preservation of inner mucous membrane.

It can be seen that most of the tissue removed represented the outer layer of the prepuce. The inner layer was preserved. This inner layer everted, and became the covering for the distal portion of the penile shaft (Figure 4). A scar indicating the junction between foreskin and shaft skin lay some distance down the penile shaft from the base of the glans penis.

inner prepuce
Figure 4. - Shield Result with sensitive inner prepuce now covering shaft.

Usually the Biblical method removed even less tissue. During the two thousand years of Biblical time, the practice was to remove only the tip of the prepuce. (Figures 5 and 6). Men in Biblical times fulfilled the Covenant, appeared intact, and still had much of their sexual sensitivity preserved.

Biblical method
Figure 5. - Biblical Method - only the tip of the prepuce is removed.

result
Figure 6. - Biblical Result with glans still partially covered.

When the "modern" Gomco Clamp or the Plastibell are used, the foreskin is generally severed from the penis at a different spot - at the base of the glans penis (Figure 7). The inner layer of foreskin is not preserved. The scar that indicates the junction between the mucous membrane and the shaft skin, lies close to the base of the glans penis (Figure 8).

Gomco clamp method
Figure 7. - Gomco Clamp Method with removal of prepuce at base of glans.

Gomco result
Figure 8. - Gomco Result with little or no inner prepuce left.

The so-called "modern" methods remove frenulum, frenar ridges, large numbers of Meissner's corpuscles, and all the sexual sensitivity that goes with them. The older Biblical method still preserved much of that sensitivity.

The Biblical technique was completed much more quickly. Part of the foreskin is slid into the slit on the shield, and a knife slices off the portion above the shield in less than one second. Gomco Clamp circumcisions have been known to take up to 20 minutes.

The slit used in the Biblical method squeezes tissue as it slides in, but quickly releases it with the slice of the knife. The pain lasts but an instant. The Gomco Clamp applies a crushing force over a relatively large surface area with the turn of a screw, lasting several minutes.

DISCUSSION

Two techniques of circumcision, the Gomco Clamp and the Plastibell, invented some 60 years ago, remove much more normal foreskin than the Biblical method. Those men circumcised with the Gomco Clamp or the Plastibell are more likely to have little or none of their sensitive foreskin remaining. The author has seen this radical excision in many of the 4000 American men on whom he has performed vasectomy.

Why have modern techniques departed so radically from the much more conservative Biblical approach? To the best of our knowledge, at the end of Biblical times, some rabbis agreed to try to stop Jews who, by stretching their remaining prepuce forward, tried to pass for Gentiles. Bris Milah gave way to Bris Periah, a more radical procedure where the inner lining is stripped away. Many Jewish men are unaware of this tragic escalation in the technique, which has nothing to do with the Covenant.

The Gomco Clamp, invented recently, emulates Bris Periah, an unnecessarily radical procedure. It is also an attempt to reduce bleeding through crushing, but in the process, it causes severe pain.

The use of a probe to separate the prepuce from the glans penis before applying the bell is not simply "breaking adhesions." This probe is tearing the skin off the glans penis, causing bleeding and scarring. In infancy, the prepuce is the skin of the glans. If this skin is left alone, a fascinating natural process takes place. At approximately 17 weeks' gestation, the process of creating the preputial space begins. Cells in the area of separation between the future foreskin and the glans begin to form microscopic balls comprising multiple layers of cells. As these whorls of cells enlarge, cells at the center are cut off from nutrients; these die and create a space. These minute spaces coalesce, eventually becoming the preputial space. [4] At birth, the preputial space has just begun to form. This process continues and is complete in 90% of three year olds. However, it is still normal even if the process is not completed when the boy is 17 years old. [5] An inserted probe, or any type of forcible retraction, violently disrupts a process that would otherwise take place naturally.

The application of two hemostats to the edges of the sensitive, unanesthetized prepuce, the application of a third crushing hemostat to the prepuce before cutting the dorsal slit, and the crushing of the entire circumference of the prepuce by turning a screw on the Gomco Clamp produces excruciating pain. [6] Since Anand and Hickey's article in the New England Journal of Medicine in 1987 [7], it can no longer be denied that pain is felt by the male infant during circumcision. Although the Gomco Clamp may have been designed to reduce the risk of bleeding, it has produced excruciating pain in every infant on which it is used. Even if anesthesia is used, the postioperative pain originating in a pleasure center can be expected to have serious untoward consequences.

One of the functions of the foreskin is to be available to loosely cover the enlarged and lengthened shaft of the adult penis during an erection. Use of the Gomco Clamp or the Plastibell increases the likelihood that so much foreskin is removed that loose coverage of the erect penile shaft becomes impossible.

  2. Taylor J.R., Lockwood A.P., Taylor A.J. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br. J. Urol. 1996; 77:291-295.

  3. Bigelow, J. The Joy of Uncircumcising, Hourglass Books 2nd edition 1995 p55

  4. Yellen, H.S. Bloodless circumcision of the newborn. Am. J. Obstet. Gynecol. 1935; 30:146-47.

  5. Hunter R.H. Notes on the development of the prepuce. J. Anat. 1935; 70:68-75.

  6. Gairdner D. The fate of the foreskin. B.M.J. 1949; 2:1433-47.

  7. Personal testimonials of adults circumcised without complete anesthesia.

  8. Anand K.J.S., Hickey P.R. Pain and its effects in the human neonate and fetus. N. Engl. J. Med. 1987; 317:1321-1326.

[Table of Contents]

ABSTRACTS AND ANALYSIS

(Comments by Robert S. Van Howe, M.D. F.A.A.P. except where indicated)


O'Brien T.R., Calle E.E., Poole W.K.

Incidence of neonatal circumcision in Atlanta, 1985-1986.

South. Med. J. 1995; 88: 411-5.

ABSTRACT:

We reviewed Atlanta area hospital records to determine the following regarding neonatal circumcision: incidence in July 1985; incidence after publicized serious complications of circumcision in August 1985; medical record documentation; and the complication rate. After stratified sampling from hospital birth logs, we abstracted information from medical charts and calculated weighted estimates and P values. The circumcision incidence was 89.3% in July 1985, 87.5% in September 1985, and 84.3% in September 1986. Circumcision was recorded on the medical record face sheet for 84.3% of circumcised boys. The complication rate was 3.1%; no serious complications were recorded. We conclude the following: circumcision incidence was high during the study period; publicity regarding adverse outcomes may have decreased the subsequent incidence of the procedure; hospital discharge data, which rely on medical record face sheet information, underestimate the true incidence of neonatal circumcision; and neonatal circumcision is usually safe, but serious complications may occur.

COMMENT:

This publication of data, which is almost ten years old, may be the most important publication related to the prepuce in 1995.

The authors abstracted the records of 1951 boys of which 1696 were circumcised (86.9%). Unexpected findings included blacks being more likely to circumcise their sons than whites (OR = 3.59, 95% Confidence Interval = 1.51-8.50). This observation documents a demographic shift in who is being circumcised in America. Forty years ago circumcision was performed on white middle and upper class boys born in hospitals. At the American Medical Association meeting in 1947 Dr. Eugene Hand called for blacks to be circumcised to control their sexual proclivities and prevent the spread of venereal diseases. This obviously racist recommendation has come to fruition, but the benefits have not been realized.

Being black in America is associated with a variety of diseases, where poverty is perhaps the most important vector. As more and more boys born in poverty are circumcised at birth these illnesses, which have been erroneously linked to the prepuce, have shown an increase in the circumcised population.

There were 55 (3.24%) immediate complications out of 1696 circumcisions. This complication rate is several orders of magnitude higher than that reported by others such as Wiswell {0.19% (193 of 100157)}. When compared to Wiswell's study, O'Brien found significantly more complications (OR = 17.36, 95% confidence interval = 12.81-23.52). One explanation for this huge difference is that the 100,157 charts in Wiswell's study could not have been studied with the thoroughness of O'Brien. Wiswell's figure is often cited, but the large number of charts render his results suspect. To properly review a child's chart takes between 5 and 10 minutes. 100,157 charts would consume between 8,000 and 16,000 man hours. With only two authors listed, reliable data would be physically impossible. For this reason alone, Wiswell's figures should not be taken too seriously.

After an extensive review of the literature Williams and Kapila determined that a reasonable rate of complication was between 2 and 10%. This study falls into that range. The two largest studies of complications in postineonatal circumcision have found complication rates of 1.7 and 1.75%. The results of this study suggest that neonatal circumcision results in higher rate of complications than later circumcisions. This challenges the longistanding myth proclaimed by Wiswell and others that neonatal circumcision has fewer complications.

The inaccuracy of reporting circumcisions on the hospital medical record face sheet, which hospitals depend on for reimbursement, has enormous impact on the validity of any study that estimates circumcision rates without inspecting individual patients. The data published by Wiswell concerning a possible association between urinary tract infection and circumcision deserves special scrutiny. In reviewing the charts of 217,116 boys of military families, where correct face sheets are not a factor in reimbursement, it is very likely that only data from the face sheets were used to calculate circumcision rates. Applying O'Brien's 84.3% figure, which may be conservative, reveals that 32,651 (78.11%) of the 41,331 boys classified as having foreskins may have been circumcised. Depending on whether the boys with urinary tract infections were properly classified, the incidence of urinary tract infections in circumcised boys ranges from 0.09% to 0.27% while the incidence in intact boys ranges from 1.12% to 5.12%. The odds ratio varies more than tenifold {4.18 (95%CI = 3.38-5.17) to 58.04 (95%CI = 49.02-68.73)}. This huge potential variation casts a large shadow of doubt over Wiswell's conclusion concerning an association between the foreskin and urinary tract infections. This is an excellent example of statistics only telling you about numbers. Once again it is very doubtful whether Wiswell and his associates closely examined 217,116 charts to accurately determine either circumcision or urinary tract infection rates. The high number of patients gives a very narrow 95% confidence interval of 8.69 to 12.15, but only one (of several) methodological flaws expands this interval from 3.38 to 68.73 and casts a shroud of doubt over the validity of the data gathering.

For example, in Wiswell's study there were unexplained yearly fluctuations in the incidence of urinary tract infections in circumcised boys ranging between 0.07% and 0.21%, and he has reported the incidence of urinary tract infections in intact boys to be as high as 4.12%. These wide variations are consistent with 72.8% of boys labeled as intact being misclassified.

O'Brien's findings clearly demonstrate that any past or future studies that estimate circumcision rates based on chart reviews suffer from a serious methodological flaw that renders any findings derived from them suspect.

What O'Brien and his colleagues have done (what Wiswell should have done originally) is take a number of patients (enough to establish some statistical credibility but not so many that data reliability becomes suspect) and thoroughly investigate their charts. This study, by using good research techniques, reveals the slipshod nature of Wiswell's previous work. Two studies of the same procedure in similar populations should not give a 17 fold difference in complication rates. It is now obvious that for every complication Wiswell found he missed at least 12 others. This may be a low estimate, because retrospective studies always underestimate complications.

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Cuckow P.M., Rix G., Mouriquand P.D.

Preputial plasty: a good alternative to circumcision.

J. Pediatr. Surg. 1994; 29: 561i3.

ABSTRACT:

Since 1991, boys needing surgery for tight nonretractile foreskin have been offered a choice of preputial plasty or circumcision, providing that there is no clinical evidence of preputial scarring. We compared two similar groups of 50 boys that underwent each procedure, through our routine audit and questionnaires sent to their parents. Of the boys with circumcisions, 20% required an overnight stay after the operation; 14% had anesthetic complications, and 6% required reoperation because of bleeding. Only 8% of patients with preputial plasty had an overnight stay, and no bleeding was observed. Parental assessment of both operations showed that morbidity was significantly less and of shorter duration for the preputial plasty group. Two patients in the preputial plasty group (4%) had recurrent narrowing of the foreskin caused by scarring and contraction of the incision. Parents were pleased with the longiterm results of both procedures. This simple alternative to circumcision is easy to perform and allows full mobilization of the foreskin, preserving its function and providing an excellent cosmetic result.

COMMENT:

A procedure which provides a better cosmetic outcome, half the number of complications, and one-third the recovery time will most likely have trouble being accepted as standard therapy in the United States. The reasons for this are confusing. American urologists have been trained that circumcision is the answer to any penile problem involving the prepuce or the glans. There is no cultural barrier to removing the prepuce since a vast majority of adult men do not have one.

With the results that Cuckow has provided, is it in the patient's best interest to have them undergo radical circumcision? From the descriptions Cuckow provides, preputial plasty appears to be technically an easier procedure than radical circumcision. The small cut versus a circumferential scar suggests the plastic procedure would be less painful. Add to this the finding that nearly 10% of radical circumcisions result in meatal stenosis and this condition has not been found after preputial plasty [Persad R., Sharma S., McTavish J., Imber C., Mouriquand P.D. Clinical presentation and pathophysiology of meatal stenosis following circumcision. Br. J. Urol. 1995; 75: 91-3.].

Based on this study and others showing the effectiveness of topical corticosteroids in treating preputial stenosis ("phimosis"), radical circumcision should become an obsolete procedure.

[Table of Contents]

Niku S.D., Stock J.A., Kaplan G.W.

Neonatal circumcision.

Urol. Clin. North. Am. 1995; 22: 57i65.

ABSTRACT:

Circumcision remains the most common operation performed in males in the United States. When performed by an experienced operator, circumcision is usually a safe and simple operation. The medical benefits of circumcision appear to exceed the risks of the procedure. The history, embryology, indications, techniques, and complications of neonatal circumcision are discussed.

COMMENT:

Reading the abstract then reading the review I came away with the impression that they had very little to do with one another. The review is schizophrenic at times. It has old information which has since been refuted by newer studies. An interesting section on the embryology of the penis is included.

The authors recklessly misrepresent the findings of Fergusson et al. when they state, "It is estimated that as many as 18% of uncircumcised boys may develop one of the aforementioned indications [for circumcision] by 8 years of age." Fergusson found that 18% of intact boys had penile problems by 8 years of age. Nearly all of these were minor and treated topically and there is no mention that any of these boys required circumcision for any of these problems. This estimate is also six to nine times higher than the number of boys who had post-neonatal circumcision for a medical indication in Wiswell's study and 18 times higher than what Gordon and Collins estimate the need for circumcision to be. The authors erroneously report that, "The American Academy of Pediatrics' most recent task force on circumcision found these reports [on HIV transmission] to be inconclusive." The 1989 Task Force report never made any mention of HIV. The authors fail to cite the three studies which have shown HIV infections to be higher in circumcised men as well as the fact that the United States has both the highest circumcision rate and the highest HIV infection rate of all the developed nations.

The authors conveniently omit Maden's study of penile cancer in which 37% of the men with penile cancer (110 patients) had been circumcised, mostly in the newborn period. They also report without citation that HPV is "found more often in uncircumcised males than in circumcised males." Nothing could be further from the truth. Aynaud et al. found HPV to be equally prevalent in both groups of men while Cook et al. have found genital warts to be significantly more likely to be found on the circumcised penis. Donovan found genital warts equally in both groups.

When citing the complication rates for neonatal circumcision, the numbers they supply (0.2% and 0.6%) do not agree with their footnotes or their comments on the individual complications. In the first footnoted study, Gee and Ansell found a complication rate of 1.9%. The second footnote, Harkavy, was a letter to the editor which had nothing to do with this. The authors may have been referring to Wiswell's study on complications, but this study as pointed out in the O'Brien review is so hopelessly flawed, it should never have been published. They fail to mention William and Kapila's review of the complication literature, which estimated the complication rate to be realistically between 2 and 10%.

The authors state, without citation, that the treatment of concealed penis is repeat circumcision. There is strong evidence that most boys will outgrow this condition and the number requiring surgery is actually very small. In my practice of mostly circumcised boys close to 30% of those under age three have a concealed penis. None of the boys over age 10 have a concealed penis. None of them received surgery. One boy had a repeat circumcision at six months of age for this. At two years of age he still has a concealed penis. The best way to prevent concealed penis is to not perform neonatal circumcision.

The authors include a fairly inclusive laundry list of complications from neonatal surgery (although they omit coronal adhesions which affected 25% of my population), giving the proper impression that circumcision has a number of very nasty complications.

The authors conclude that, "The medical benefits of circumcision appear to exceed the risks of the procedure," when nothing in their review supports this conclusion. Their enumerated risks and their percentages far outnumber any percentage who may theoretically reap a potential, but to date unproven, benefit. Kaplan, one of the coiauthors and the guest editor of this edition of Urology Clinics of North America, has a reputation for excellent, balanced scholarship. He should have read the text more carefully before adding his name to it. In this article there are too many inaccuracies (some of which would result in unnecessary surgeries) and far too many convenient omissions of recent studies to call it a review. It would best be termed a proicircumcision opinion piece.

[Table of Contents]

Donovan B., Bassett I., Bodsworth N.J.

Male circumcision and common sexually transmissible diseases in a developed nation setting.

Genitourin Med 1994; 70: 317i320.

ABSTRACT:

OBJECTIVE - To determine whether the circumcision status of men affected their likelihood of acquiring sexually transmissible diseases (STDs).

DESIGN - A crossisectional study employing an anonymous questionnaire, clinical examination and type specific serology for herpes simplex virus type 2 (HSVi2).

SETTING - A public STD clinic in Sydney, Australia.

SUBJECTS - 300 consecutive heterosexual male patients.

MAIN OUTCOME MEASURES - Associations between circumcision status and past or present diagnoses of STDs including HSVi2 serology and clinical pattern of genital herpes.

RESULTS - 185 (62%) of the men were circumcised and they reported similar ages, education levels and lifetime partner numbers as men who were uncircumcised. There were no significant associations between the presence or absence of the male prepuce and the number diagnosed with genital herpes, genital warts and nonigonococcal urethritis. Men who were uncircumcised were no more likely to be seropositive for HSVi2 and reported symptomatic genital herpes outbreaks of the same frequency and severity as men who were circumcised. Gonorrhoea, syphilis and acute hepatitis B were reported too infrequently to reliably exclude any association with circumcision status. Human immunodeficiency virus infection (rare among heterosexual men in the clinic) was an exclusion criterion.

CONCLUSIONS - From the findings of this study, circumcision of men has no significant effect on the incidence of common STDs in this developed nation setting. However, these findings may not necessarily extend to other setting where hygiene is poorer and the spectrum of common STDs is different.

COMMENT:

This important prospective study in a first world nation, where the number of men who were circumcised approximately equaled those who were not, demonstrated that the prepuce was not a risk factor for developing sexually transmitted diseases.

When comparing circumcised to intact men, intact men were more likely to finish high school, but were equally likely to finish tertiary education. The two groups were nearly the same for HSVi2 serology, genital warts, nonigonococcal urethritis, and syphilis. Circumcised men were more likely to have gonorrhea (OR = 1.53, 95% confidence interval = 0.65-3.62) and undiagnosed genital ulcers or recurrent itch (OR = 2.08, 95% confidence interval = 0.70i7.47), but the size of the study prevents making any claims of statistical significance. Interestingly, both of these have been linked to an increased risk of developing HIV infections.

As opposed to other studies the authors point out that "lack of circumcision was not a marker of lower socioeconomic status." Also of importance is that the lifetime number of sexual partners was controlled for. In past retrospective studies, both the socioeconomic status and sexual habits of the two groups differed. This study adequately controls for those two variables and finds that the prepuce is not a factor in developing sexually transmitted diseases, and circumcised men may be at higher risk for gonorrhea and genital ulcers. The authors correctly warn that their findings may not apply to third world countries, but they do apply to the United States.

The change in propensity to acquire sexually transmitted diseases suggests that sociological factors may be of importance. It is also interesting to note that circumcision was more common in men of lower educational levels, a finding similar to O'Brien's.

[Table of Contents]

Perlmutter D.F., Lawrence J.M., Krauss A.N., Auld P.A.

Voiding after neonatal circumcision.

Pediatrics 1995; 96: 1111i2.

ABSTRACT:

OBJECTIVE. To determine whether it is necessary to delay discharge of newly circumcised male neonates to observe voiding.

SUBJECTS AND METHODS. A prospective study was conducted in 1992 and 1993 of 51 healthy male, newly circumcised neonates between 0 and 10 days of age. The neonates were observed for the time of first voiding after circumcision was performed.

RESULTS. All neonates voided after circumcision at a mean age of 5.3 +/- 2.5 hours, and there were no complications noted in the study population.

CONCLUSION. Healthy male infants who are circumcised without obvious complications can be expected to void, and it is unnecessary to delay hospital discharge to make this observation.

COMMENT:

For my comments I have inserted a letter to the editor I submitted in response to Permutter's article. Without providing a reason, Pediatrics decided not publish the letter or its response.

To the Editor:

Perlmutter's conclusion that all boys void following circumcision reminds me of the quip that all bleeding stops, eventually. In an insurance climate where most boys are being circumcised under 24 hour of age and legislative attempts are being made to extend stays to 48 hours, I find it hard to apply data where the average age at circumcision was 3 days. It has been documented that 1% of male neonates have vesicoureteral reflux [2,3] and circumcision can result in urinary retention [4,5] as well as obstructive uropathy[6] and acute renal failure. [7] How many of these cases would be missed by sending boys home before they void? While the study provides evidence that this small number of boys voided after circumcision. Among the important information not provided by this study, which is needed before contemplating any recommendations, would be the delay of voiding as it relates to the age at which the procedure is performed, the role of a surgical delivery, the role of dorsal penile nerve block, the delay in voiding after a painful procedure (such as a blood draw) in infant females and intact boys, and the relation of delayed voiding to urinary tract pathology. A recent study found that neonatal circumcision prolonged hospital stays regardless of route of delivery at an annual cost of $234 million to $527 million beyond the charges for the procedure itself. [8] The contribution of postisurgical observation to this finding is unknown. Whether Perlmutter's recommendation will significantly shorten hospital stays is clearly the hope of the insurance companies, but it may not be in the best interest of the patient. If insurance companies are truly interested in saving money, they should consider withholding payment for circumcision, which has not been shown to be cost effective. [9-11]

References

  1. Perlmutter D.F., Lawrence J.M., Krauss A.N., Auld P.A.M. Voiding after neonatal circumcision. Pediatrics 1995; 96: 1111-2.

  2. Lich R., Howerton L.W., Goode L.S., Davis L.A. The ureterovesical junction of the newborn. J. Urol 1964; 92: 436-8.

  3. Jones B.W., Headstream J.W., Vesicoureteral reflux in children. J. Urol. 1958; 80: 114-5.

  4. Ochsner M.G. Acute urinary retention: causes and treatment. Postgrad. Med. 1982; 71: 221-6.

  5. Berman W. Letter: Urinary retention due to ritual circumcision. Pediatrics 1975; 56: 621.

  6. Craig J.C., Grigor W.G., Knight J.F. Acute obstructive uropathy - a rare complication of circumcision. Eur. J. Pediatr. 1994; 153: 369-71.

  7. Eason J.D., McDonnell M., Clark G. Male ritual circumcision resulting in acute renal failure. Br. Med. J. 1994; 309: 660-1.

  8. Mansfield C.J., Hueston W.J., Rudy M.A. Neonatal circumcision: associated factors and length of hospital stay. J. Fam. Pract. 1995; 41: 370-6.

  9. Lawler F.H., Bisonni R.S., Holtgrave D.R. Circumcision: a decision analysis of its medical value. Fam. Med. 1991; 23: 587-93.

  10. Ganiats T.G., Humphrey J.B., Taras H.L., Kaplan R.M. Routine neonatal circumcision: a cost-utility analysis. Med. Dis. Making 1991; 11: 282i93.

  11. Chessare J.B. Circumcision: is the risk of urinary tract infection really the pivotal issue? Clin. Pediatr. Phila. 1992; 31: 100-4.

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Craig J.C., Knight J.F., Sureshkumar P., Mantz E., Roy L.P.

Effect of circumcision on incidence of urinary tract infection in preschool boys.

J. Pediatr. 1996; 128: 23i7.

ABSTRACT:

OBJECTIVE: To determine whether circumcision decreases the risk of symptomatic urinary tract infection (UTI) in boys less than 5 years of age.

STUDY DESIGN: A case-control study (1993 to 1995) in the setting of a large ambulatory pediatric service. Case subjects and control subjects were drawn from the same population. One hundred forty-four boys less than 5 years of age (median age, 5.8 months) who had a microbiologically proven symptomatic UTI (case subjects), were compared with 742 boys (median age, 21.0 months) who did not have a UTI (control subjects). The proportion of case and control subjects who were circumcised in each group was compared with the use of the chiisquare test, with the strength of association between circumcision and UTI expressed in terms of an odds ratio. To determine whether age was a confounder or an effectimodifier, we stratified the groups by age (< 1 year; > or = 1 year) and analyzed by the method of Mantel-Haenszel.

RESULTS: Of the 144 preschool boys with UTI, 2 (1.4%) were circumcised, compared with 47 (6.3%) of the 742 control subjects (chi-square value = 5.6; p = 0.02; odds ratio, 0.21; 95% confidence intervals, 0.06 to 0.76). There was no evidence that age was a confounder or modified the protective effect of circumcision on the development of UTI (Mantel-Haenszel chi-square value = 6.0; p = 0.01; combined odds ratio, 0.18; 95% confidence intervals, 0.05 to 0.71; Breslow-Day test of homogeneity chi-square value = 0.6; p = 0.4).

CONCLUSIONS: Circumcision decreases the risk of symptomatic UTI in preschool boys. The protective effect is independent of age.

COMMENT:

Of interest is that this study was done where the majority of boys are not circumcised during the newborn period. The results differ dramatically from the studies performed by Wiswell. The odds ratio is significantly lower than Wiswell's as are the rates of bacteremia. This study had twice the number of cases as Wiswell, but no cases of meningitis (Wiswell had two; Fischer's exact test p = 0.054). The reasons for these differences are easily explained. Wiswell looked at boys under one month of age. These boys had systemic infections acquired transplacentally which seeded the urinary tract. Because of the infection the boys were "too sick" to circumcise. One third of the intact boys in Wiswell's study population were intact for this reason.

Craig et al. did not find a statistically significant difference in the incidence of UTIs in boys under one year of age or in boys over one year of age. It is only when the numbers are combined that a statistically significant difference is found. When the numbers are combined, however, there is a statistically significant difference between cases and controls in regards to age. But as pointed out above, when controlled for age, there is no statistically significant difference. The numbers are too small to make any statistical claim. If only one more circumcised boy had a UTI, then combined result would not have been statistically significant.

More than a third of intact boys with UTIs had their urine collected without swabbing the urethra with disinfectant. The authors cite a study that swabbing did not affect the contamination rate. This cited study found no difference only because the size of the study was not big enough. The cited study found an asymptomatic rate of bacteriuria of 2%. These cases cleared without intervention.

So eleven years after Wiswell's first UTI study, here is where the UTI issue stands. The two prospective studies, (Craig et al. and Crain & Gershel) neither of which controlled for urine collection method, found an odds ratio of approximately 4.8. No long term studies have been performed. No studies have looked to see if intact boys are more likely to have genitourinary anomalies. No prevalence studies have been done looking for genitourinary anomalies. No studies have controlled for race, hygienic practices, socioeconomic status, education level of parents, urine collection methods, pyuria etc. Of the studies that have been published, most have discredited Wiswell's results or his methodology. Edgar Schoen describes the UTI evidence as unequivocal. This may shed some light on why high ranking members of the American Academy of Pediatrics now consider him an embarrassment.

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Frisch M., Friis S., Kjaer S.K., Melbye M.

Falling incidence of penis cancer in an uncircumcised population (Denmark 1943-90).

BMJ 1995; 311: 1471.

NO ABSTRACT.

COMMENT:

This brief report in the British Medical Journal points out that despite a circumcision rate of 1.6% Denmark has had a steadily decreasing incidence of penile cancer. The authors link this phenomenon to an increase of indoor bathrooms. Other interesting findings are that Denmark still has a lower rate of penile cancer than the United States and that urban unmarried men were more likely to get penile cancer.

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Gunnar M.R., Porter F.L., Wolf C.M., Rigatuso J., Larson M.C.

Neonatal stress reactivity: predictions to later emotional temperament.

Child Dev. 1995; 66: 1-13

ABSTRACT:

To investigate the relations among popular measures of neonatal stress and their link to subsequent temperament, 50 full-term newborns from a normal care nursery were examined responding to a heelstick blood draw. Baseline and heelstick measures of behavioral state, heart period, vagal tone, and salivary cortisol were obtained. Recovery measures of behavioral and cardiac activity were also analyzed. Mothers completed Rothbart's Infant Behavior Questionnaire when their infants reached 6 months of age. Baseline vagal tone predicted cortisol in response to the heelstick, suggesting that baseline vagal tone reflects the infants' ability to react to stressors. Greater reactivity to the heelstick (more crying, shorter heart periods, lower vagal tone, and higher cortisol) was associated with lower scores on "Distress-to-Limitations" temperament at 6 months. This finding was consistent with the expectation that the capacity to react strongly to an aversive stimulus would reflect better neurobehavioral organization in the newborn. Recovery measures of cardiac activity approximated and were correlated with baseline measures indicating the strong self-righting properties of the healthy newborn. Finally, vagal tone and salivary cortisol measures were not significantly related, suggesting the importance of assessing both systems in studies of the ontogeny of stressitemperament relations.

COMMENT:

The take-home lesson from this study is that in order to get a complete picture of a infant's pain response, behavioral state, heart rate, vagal tone, and salivary cortisol all need to be considered because not all of them will respond to pain. So in the study that looked at the behavioral state during circumcision using a sucrose soaked nipple as the only form of anesthesia, it is unknown how the other parameters responded. Gunnar in previous work found that the sucrose nipple did not suppress the cortisol response.

The other finding, which I think the investigators were surprised to find, was that circumcised boys had a lower vagal tone going into the heelistick procedure (the circumcised boys had received local anesthesia). This confirms what Taddio found, that circumcision may alter (perhaps permanently) how an individual responds to pain. In an accompanying article [Davis M, Emory E. Sex differences in neonatal stress reactivity. Child. Dev. 1995; 66: 14-27.] circumcised boys had a significantly higher response in heart rate in response to heel stick than boys who weren't circumcised.

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Desrochers A., St. Jean G., Anderson D.E.

Surgical management of preputial injuries in bulls: 51 cases (1986-1994).

Can. Vet. J. 1995; 36: 553-6.

ABSTRACT:

The purpose of this study was to compare success rates for preputial surgery depending on the initial diagnosis, ability to extend the penis, use of sedation and local anesthesia versus general anesthesia for surgery, and surgical technique. Medical records of 51 bulls treated surgically for preputial injury were reviewed. The mean age of the bulls was 2.5 years ranging from 1 to 5 years. Bos taurus breeds (82.3%) were more often affected than Bos indicus breeds (17.7%). The most common breeds represented in this study were Angus (45.1%), Simmental (11.8%), and brangus (9.8%). The seasonal incidence of preputial injuries was higher during the period of May-July (52.9%) and November-February (33.3%). The overall success rate was 70%. Posthioplasty was more successful than circumcision (90% to 43%) (P < 0.05). The success rate for surgeries performed under inhalation anesthesia in the surgery suite was 100% compared with a success rate of 63% for those animals operated on with injectable and local anesthesia in a rotary chute (P < 0.05). The success rate was 88% if the penis could be extended before the surgery and 36% if extension was not achieved (P < 0.05).

COMMENT:

This is the ultimate in anthropomorphism: let's inflict circumcision on animals. Guess what! Preputial plasty works better for bulls, too! This study demonstrates that circumcision is a procedure desperately seeking an indication.

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Council on Scientific Affairs, American Medical Association.

Female genital mutilation.

JAMA 1995; 274: 1714-6.

ABSTRACT:

Female genital mutilation is the medically unnecessary modification of female genitalia. Female genital mutilation typically occurs at about 7 years of age, but mutilated women suffer severe medical complications throughout their adult lives. Female genital mutilation most frequently occurs in Africa, the Middle East, and Muslim parts of Indonesia and Malaysia, and it is generally part of a ceremonial induction into adult society. Recent political and economic problems in these regions, however, have increased the numbers of students and refugees to the United States. Consequently, US physicians are treating an increasing number of mutilated patients. The Council on Scientific Affairs recommends that US physicians join the World Health Organization, the World Medical Association, and other major health care organizations in opposing all forms of medically unnecessary surgical modification of the female genitalia.

COMMENT:

Comment is a letter to the editor written by Christopher Cold, M.D. The letter was not published. No reason was provided by JAMA.

To the Editor:

The American Medical Association Council on Scientific Affairs report on Female Genital Mutilation [1] was a scholarly, informative and sexist article. Regardless of gender, is any medically unnecessary modification of the genitalia acceptable in children unable to give informed consent?

In the United States, physicians excise the prepuce of male infants with the misguided intent of preventing penile cancer, masturbation, sexually transmitted diseases and urinary tract infections. The medical literature supporting the medical benefits of male circumcision consist of poorly controlled retrospective studies that do not consider a variety of confounding factors. [2] Since the medical community supports this form of genital mutilation because of its speculative medical benefits, [3] then why not perform poorly controlled studies on 'sunna' or a subtotal clitoridectomy before condemning it? If the removal of the clitoral prepuce affords women the same unproven benefits as removing the penile prepuce, then the procedure should be studied more closely. More likely investigators will discover that the prepuce in both females and males protects an exquisitely sensitive area of the external genitalia: the clitoris and the glans penis.

Although genital mutilation is a time honored religious and cultural tradition, physicians should 'primum non nocere' and distance themselves from this practice. The current sexist policy statement is indefensible because the opposition to unnecessary surgical modification of genitalia should include both females and males. Additionally, contrary to current practices, the individual being operated on needs to be educated about the risks and benefits of the surgery before giving consent. [4]

Christopher J. Cold, M.D.
Marshfield Clinic - Lakeland Center
Minocqua, Wisconsin

  2. Council on Scientific Affairs, American Medical Association. Female Genital Mutilation. JAMA. 1995; 274: 1714-1716.

  3. Wiswell T.E., Smith F.R., Bass J.W. Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics. 1985; 75: 901-3.

  4. Weiss G.N., Weiss E.B. A perspective on controversies over neonatal circumcision. Clin. Pediatr. 1994; 33: 729-730.

  5. Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics. 1995; 95: 314-317.

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Mansfield C.J., Hueston W.J., Rudy M.

Neonatal circumcision: associated factors and length of hospital stay.

J. Fam. Pract. 1995; 41: 370-6

ABSTRACT:

BACKGROUND. Controversy exists regarding the efficacy of routine neonatal circumcision of male infants. Little is known about parental or provider characteristics or the use of medical resources associated with this procedure.

METHODS. Records of 3703 male infants born during 1990 and 1991 at four US sites were analyzed to discern associations between circumcision and the above factors. Analyses were limited to healthy infants.

RESULTS. Eighty-five percent of the infants in the study population were circumcised. White and African-American male infants were much more likely to be circumcised than those of other races (odds ratios [ORs], 7.3 and 7.1, respectively, P < .001).Compared with selfipay patients, those covered by private insurance were 2.5 times more likely to be circumcised in the hospital an average of one fourth of a day longer than did those who were not circumcised (mean difference, 0.26 days; 95% confidence interval, 0.16 to 0.36).

CONCLUSIONS. Mother's insurance status and race as well as surgical interventions during delivery are related to circumcision. Associations with episiotomy and cesarean section suggest physician and/or parental preference for interventional approaches to health care. Generalizing the difference in hospital length of stay to the United States suggests an annual cost between $234 million and $527 million beyond charges for the procedure itself.

COMMENT:

This study has substantial implications. First the increased length of stay is more costly than the procedure itself. The impact that this has on a costiutility analysis of neonatal circumcision is significant. To date this has not been factored into the cost of neonatal circumcision.

The circumcision rate among African-Americans confirms O'Brien's findings that most African-American boys are being circumcised.

The other interesting finding was that in deliveries where the knife was used (episiotomy or cesarean section) the boy was significantly more likely to be circumcised. There are some women who consider both episiotomy and male circumcision to be genital mutilation. This also confirms an observation most medical students make that doctors who like to cut - like to cut. It also may reflect a money motivation. An episiotomy shortens the duration of the pushing phase of labor and the time an obstetrician needs to be present, a physician is paid more for a cesarean section than a vaginal delivery, and circumcision is $100 to $200 for five minutes work.

Unfortunately, Journal of Family Practice has a small circulation and is considered by Family Practitioner to be a "throw away" journal.

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