Circumcision

EDITORIAL

A Rose by Any Other Name...

The language selected to describe or name a phenomenon can influence how that phenomenon is perceived. In a letter to the editor of the New England Journal of Medicine, Edgar Schoen, long­time champion of routine infant male circumcision, rebuked Nahid Toubia for using the term "female circumcision" instead of "female genital mutilation" for fear that anyone might equate the horrors of female genital mutilation with his favorite procedure. Why not refer to "male circumcision" as "male genital mutilation?" This battle of terminology has been festering for a long time without a clear resolution in sight.

How does one refer to the normal penis? In most medical records of males in the United States, the term "normal male genitalia" is used to describe men who do not, in fact, have "normal" genitalia. The medical literature often refers to the normal male penis as "uncircumcised." Unfortunately, this term has been usurped by circumcised men who are attempting to restore their foreskins. By undoing their circumcision they are "uncircumcising" their penis. This term, now ambiguous, has outlived its usefulness. The term "non­circumcised" has also appeared in the medical literature. Whether "uncircumcised" or "non­circumcised" are employed, there is the underlying assumption that circumcision is the preferred state for the penis. This would be akin to describing a women with both of her breasts as "unmastectomized."

The term most used by those who oppose routine infant male circumcision is "intact." Webster's II New Riverside University Dictionary defines "intact" as "not damaged in any way, having all parts."

The other term proposed by those who oppose routine infant male circumcision is "natural," because this is the penis that Nature provided, but the term is imprecise. The reason for all of this silliness is that a "normal" penis is not the norm in the United States. Should the circumcised penis be called the "popular" penis, the "surgically altered" penis, the "mutilated" penis, etc.?

When writing for medical journals in the United States only the terms "uncircumcised" and "non­circumcised" are acceptable. Since these terms are unacceptable on a connotative level, I have learned to substitute "men with foreskins" or "boys with foreskins" as if they were provided with extra equipment from their Maker.

"Circumcision," which means to cut in a circle, is not up to the task either. This euphemism has attained the status of common usage. Alternative terminology bantered about include: male genital mutilation, male genital alteration, posthectomy, male sexual mutilation, surgical alteration of the genitalia.

Recently, some controversy has arisen over whether circumcision constitutes "surgery." In a recent deposition, Thomas E. Wiswell, M.D. testified that circumcision is not surgery. This is odd considering that Wiswell has referred to circumcision as "the most commonly performed surgical procedure in the United States" in the opening of most of his articles on the subject. He tried to distinguish between "traditional surgery" performed in the operating room and neonatal circumcision performed in the newborn nursery.

Thomas Ritter and George Denniston would agree with Wiswell, but for different reasons. Quoting David Grimes, they state, "Circumcision is not surgery, by definition. In his classic History of Surgery, Welch has defined surgery to include: repair of wounds, extirpation of diseased organs or tissue, reconstructive surgery, and physiologic surgery (e.g., sympathectomy). Routine infant circumcision eludes classification." If it is not surgery, what is it? According to Denniston and Ritter, if routine circumcision has no clear medical purpose, it cannot be termed surgery. If one excludes the term surgery, the logical conclusion is that circumcision is battery, a term that would make most of the physicians performing circumcisions shudder.

I recently encountered a term that is accurate and non­inflammatory - surgically altered genitalia. It can apply to the procedures performed on both males and females. As far as how to refer to the penis with all of its original equipment, I have not found a term that is accurate without evoking protest from at least one element of the wide spectrum of opinion on the circumcision issue.

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

ORIGINAL ARTICLE

Circumcision in Canada: A Twenty Year Decline

George C. Denniston, M.D. M.P.H.
Department of Family Medicine
University of Washington

ABSTRACT:

Objective: What has happened to the rate of infant circumcision paid for by Provincial Health Agencies (PHA) in Canada between 1975 and 1995?

Design: The number of infant circumcisions paid for by PHA and the number of live male births each year was collected over a period of years by requesting the data from each Province and Territory by letter.

Results: A marked reduction in the rate of circumcision in Canada has occurred between 1975 and 1995. In 1975, the rate of infant circumcisions paid for by all Provincial Health Agencies was forty­four percent (44%). In 1995, that same circumcision rate was four percent (4%).

Conclusions: Health providers and policy makers across Canada, representing 88% of all male births, have decided not to pay for routine infant circumcision.

Introduction

In 1985, of one hundred and fifty­nine (159) United Nation member countries, only four (Australia, Canada, New Zealand and the United States) performed circumcisions on significant numbers of their newborn male citizens without religious reasons. Since 1985 the circumcision rate has declined in all four countries. Only the United States continues to remove a part of the normal penis from a majority of its newborn males.

This survey covers the past twenty years of circumcision in Canada (1975­1995).

Materials

Commencing in the late 1960's, every circumcision performed in Canada was covered by Provincially administered health insurance. It is therefore possible to have remarkably accurate information on the numbers of circumcisions performed. This data has been carefully retrieved from each Province, along with the number of live male births. After a Province stops payment for the procedure ("except for medical necessity"), the numbers paid for drop under 1%. The number of circumcisions that continue to be done, paid for by parents, is not known. (Data is missing for the following Provinces or Territories for the following years, and is therefore interpolated on the graphs: PE, 1986, 1987; Yukon, 1979, 1981.)

Results

In 1975 the circumcision rate for Canada was 44%. [Nova Scotia (NS), New Brunswick (NB) and the Northwest Territories (NWT) are excluded, because no data is available for 1975. They represent 7% of the total live births.]

By 1985 the circumcision rate in Canada paid for by PHA's had declined to 27%. By 1989, the circumcision rate in Canada, paid for by PHA's, had dropped to 19%. By 1995, the routine circumcision rate for Canada, paid for by PHA's, had dropped to 4 percent (4%) of live male births.

Beginning in 1984, Provinces and Territories discontinued payment for this procedure as a routine, while still continuing to pay for those "medically necessary."

By 1995, provinces and territories where 88% of male births in Canada occur had stopped paying for routine infant circumcision.

Discussion

The data presented here is based on actual payments by Provincial health agencies for circumcisions performed in each Province. Every newborn was covered by this insurance. Thus it was possible for every male to have a circumcision without any out­of­pocket costs to the parents. Since every hospital would insist on reimbursement, there is reason to believe that these data are accurate.

There are, however, other reasons for minor discrepancies.[1] Live births are reported by calendar year, while some Provinces changed their procedure reporting to a fiscal year. The resulting errors are less than 2%. Different procedure codes also permit minor discrepancies, but do not significantly affect the overall trends.

It would appear that Canada has heeded warnings voiced in the famous paper, Fate of the Foreskin, by Douglas Gairdner MD (1949)[4], but has not been as successful as Great Britain in eradicating this contra­indicated procedure. The National Health Service in Great Britain has not paid for routine infant circumcisions since 1949.

Warnings were voiced in the United States in 1971 by the American Academy of Pediatrics. They were joined in 1975 by the American College of Obstetrics and Gynecology. The Academies stated, "There are no absolute indications for routine neonatal circumcision."[5] It would appear that Canada heeded this warning more consistently than the United States, whose circumcisions actually increased after the warning, before falling sharply (from 89% to 56%).[6]

Although Provinces and Territories began the 1970's with widely differing rates of circumcision, each Province and Territory performed fewer circumcisions by the mid­1990's.

Why did Quebec drop from 31% in 1971 to virtually nil in 1989? A partial explanation is that Quebec looked to France for guidance, where circumcision is anathema. The French recognize that the disadvantages of circumcision are considerable.

Newfoundland (NF), Nova Scotia (NS), and the Northwest Territories (NWT) already (1975) had low rates of circumcision.

Yukon Territory had a precipitous drop in its circumcision rate between 1978 and 1980, going from 48% to 18%. The numbers involved are quite small (102 to 45), and since 80% of all births in Yukon Territory take place at Whitehorse General Hospital, this dramatic drop could be explained by the retirement or transfer of a single circumcising doctor from that hospital. However, staff present at the time do not recall such an event. They do recall doctors talking against circumcision, and pamphlets against the procedure circulating among staff and patients.

The percentage drop for Quebec (PQ) is even more remarkable. Circumcisions declined from 10,746 in 1975 to 2,750 in 1985. This is a drop from 22% to 6%.

On Prince Edward Island (PE), the numbers of circumcisions in recent years are small and occur only on one side of the island.

While several Provinces and Territories have stopped payment on circumcisions, other Provinces have not yet accomplished this.

At the same time, Provincial Health agencies need to look closely at what constitutes "medically necessary" circumcisions, and withhold payment when strict criteria cannot be met. Since the rate of neonatal circumcision in Finland, where the intact (whole, entire) penis is highly valued, is essentially zero, and the risk of needing a circumcision later in life is one in sixteen thousand, six hundred and sixty­seven (1/16,667), it should be evident that almost all of the alleged "medically necessary" circumcisions in Canada and the United States are fraudulent.

None of the customary terms used for "medical necessity" are valid reasons to circumcise (Phimosis is normal; peripheral adhesions can be dealt with conservatively; ballooning is normal; and balanitis can be treated with warm soaks, and antibiotics as needed).

Although no one fully understands why these contra­indicated circumcisions continue, a leading hypothesis is that of denial. Doctors and fathers who have been cut deny that anything is wrong, and insist on cutting others. Considerable courage is required to overcome this denial. Millions of North American parents have demonstrated that courage.

The data provide evidence that doctors do not do circumcisions solely for the money they are paid. For a number of years, Canadian Provinces were paying, yet the numbers of circumcisions performed were going down.

The threat of a lawsuit does not appear to have been a major factor in this dramatic reduction. In the 1970's, malpractice insurance premiums in Canada were very low (around $35 per year) and patients were rarely suing doctors over circumcision.

Concern over female genitals being cut in Canada is increasing. Human Rights activists recognize that genital mutilation is genital mutilation, whether it be female or male.

Circumcision rates, by province and territory (figures 2­13).

The author wishes to thank a colleague who prefers to remain anonymous for help in the collection of this data.

1. Wirth JL. Current Circumcision Practices: Canada. Pediatrics 1980; 66:705­708.
2. Finnish National Board of Health 1970
3. Kluge EH. Female circumcision: when medical ethics confronts cultural values. Can Med Assoc J 1993; 482:288­9
4. Gairdner, D. Fate of the Foreskin. Br Med J.1949; 2:1433­1437
5. Thompson HC, King LR, Knox E, Korones SB. Report of the ad hoc task force on circumcision. Pediatrics 1975; 56:610­1
6. National Center for Health Statistics, USA

Caldwell J.C., Caldwell P.

The African AIDS epidemic

Sci. Am. 1996; 274(3): 62­3, 66­8.

ABSTRACT:

In parts of sub­Saharan Africa, nearly 25 percent of the population is HIV­positive as a result of heterosexual transmission of the virus. Could lack of circumcision make men in this region particularly susceptible?

COMMENT:

This article, published in a more mainstream medium, is an excellent example of pseudoscience utilized to perpetuate an irrational social custom. The authors provide maps of Africa showing that areas of Africa that have the highest rates of AIDS are also the areas with the lowest circumcision rates. This is enough proof for the authors that circumcision may prevent AIDS. Unfortunately, the methods the authors used do not allow them to control for all of the many risk factors that are currently accepted as increasing the likelihood of acquiring and disseminating the HIV virus. It should also be pointed out that some of these areas with high rates of HIV­infection also have high circumcision rates. Utilizing the same methods, but applying them to the first world countries of Israel, Europe, North America, Japan, and Australia, the circumcised penis may be a risk factor for acquiring and disseminating the HIV virus. At best, the work of the authors calls attention to the need to study circumcision as a possible risk factor with more appropriate methods. To reach any conclusion beyond this is unscientific.

Mbugua G.G., Muthami L.N., Mutura C.W., Oogo S.A., Waiyaki P.G., Lindan C.P., Hearst N.

Epidemiology of HIV infection among long distance truck drivers in Kenya

East Afr. Med. J. 1995; 72: 515­8.

ABSTRACT:

A total number of two hundred eighty three long distance truck drivers and their assistants (loaders) who ferry goods between Kenya and Zaire were included in a cross­sectional study between September 1991 and April 1992. Twenty six percent of the study subjects were seropositive for HIV­1 and none were HIV­2 seropositive. Countries of birth and residence were significantly associated with HIV infection (X2 = 23.6, P = 0.0006). Significant associations were also found between HIV seropositivity and level of education from secondary school and above (OR = 3.4, 95% C.I. = 1.01­11.55); being circumcised was more protective, (OR = 0.38; 95% C.I. = 0.19­0.76), history of many years of driving (X2 = 9.3, p = 0.0254) and income (OR = 11.13, 95% C.I. = 1.35­91.95). When a stepwise multiple logistic regression model was fitted to all the variables observed to be significant in the univariate analysis, the following risk factors attained statistical significance: lack of circumcision (OR = 3.75); income greater than Ksh. 2000 (OR = 7.24); being employed in long distance driving more than 11 years (OR = 3.98); and secondary school education and above (OR = 4.06, 95% C.I. = 1.18­13.98). Reference for all the above Odds Ratios was 1.

COMMENT:

Comment: This is a study of a high risk population. Participants were recruited after indicating their willingness to participate. It is not mentioned if circumcision status was confirmed by physical exam. The actual numbers are not included in the study (just the odds ratios). There was no attempt made to control for other possible factors. This study has obvious problems that limit its usefulness.

Sassan­Morokro M., Greenberg A.E., Coulibaly I.M., Coulibaly D., Sidibe K., Ackah A., Tossou O., Gnaore E., Wiktor S.Z., De Cock K.M.

High rates of sexual contact with female sex workers, sexually transmitted diseases, and condom neglect among HIV­infected and uninfected men with tuberculosis in Abidjan, Cote d'Ivoire.

J. Acquir. Immune Defic. Syndr. Hum. Retrovirol 1996; 11: 183­7.

ABSTRACT:

To characterize human immunodeficiency virus (HIV) risk practices among men with tuberculosis, and to determine what factors are associated with HIV infection in this population, we conducted a case­control analysis of data collected during enrollment in a prospective cohort study in the two large tuberculosis treatment centers of Abidjan, Cote d'Ivoire. Demographic information and data on risk factors for HIV infection, including history of sex with female sex workers (FSWs) and history of sexually transmitted diseases (STDs), were collected on 490 HIV­infected and 239 HIV­uninfected men diagnosed with pulmonary tuberculosis between 1989 and 1992. HIV­infected men were significantly more likely than uninfected men to have had sex with FSWs in their lifetime [83 versus 63%, odds ratio (OR) 2.9, 95% confidence internal (CI) 2.0­4.2], genital ulcer disease in the past 5 years (38 versus 15%, OR 3.4, 95% CI 2.2­5.2), urethritis in the past 5 years (44 versus 23%, OR 2.6, 95% CI 1.8­3.8), and sex with FSWs in the past year (43 versus 25%, OR 2.3, 95% CI 1.6­3.3); no difference was found in the proportion with at least one non­FSW partner in the past year (84 versus 79%, OR 1.3, 95% CI 0.9­2.0). Among all men, 74% never used condoms, and only 1.4% always used condoms. In a multivariate analysis, sex with FSWs, genital ulcer disease, urethritis, and lack of circumcision were all significantly associated with HIV. This study demonstrates the critical roles of commercial sex, STDs, and condom neglect in fueling the HIV/AIDS epidemic in Abidjan, and illustrates the urgent need for widespread HIV education both in the general population and in men with tuberculosis.

COMMENT:

Men with tuberculosis would be considered a high­risk population. Among these men those with foreskins were at higher risk (odds ratio = 2.22, 95% confidence interval = 1.29­3.81, relative risk 1.24, attributable risk 19.1%), but the significance of this is small compared to other risk factors. Men with two or more genital ulcers in the previous five years had an odds ratio of 7.6 compared to those who never had a genital ulcer. Likewise the odds ratio for men with 10 or more lifetime female sex worker partners was 4.0 compared to those who had none. As with studying any high­risk population, there is a population bias because cases and controls are not obtained randomly.

Seed J., Allen S., Mertens T., Hudes E., Serufilira A., Carael M., Karita E., Van de Perre P., Nsengumuremyi F.

Male circumcision, sexually transmitted disease, and risk of HIV.

J. Acquir. Immune Defic. Syndr. Hum. Retrovirol 1995; 8: 83­90.

ABSTRACT:

Our objective was to describe associations among male circumcision, behavioral and demographic variables, ulcerative and nonulcerative sexually transmitted disease (STD), and human immunodeficiency virus (HIV) infection via a cross­sectional study in Kigali, the capital of Rwanda. Our subjects were 837 married men who volunteered for HIV testing and counselling. Uncircumcised men had a relatively low­risk profile in that they reported fewer lifetime sexual partners and prostitute contacts than circumcised men and were more likely to live in rural areas with lower HIV prevalence rates. Uncircumcised men were also less likely to report a history of sexually transmitted disease (64% versus 73%, p = 0.01), although they were more likely to report genital ulceration (GUD) (24% versus 17%, p < 0.03) and to have inguinal adenopathy noted on physical exam (42% versus 29%, p = 0.009). Despite the low­risk profile, uncircumcised men had a higher prevalence of HIV infection than circumcised men (29% versus 21% HIV positive, p = 0.02), which was most marked in men reporting five or more lifetime sex partners (36% versus 23% HIV positive, p = 0.005) or contact with prostitutes (35% versus 23% HIV positive, p = 0.009). Circumcision remained a predictor of HIV infection in multivariate analyses (multivariate odds ratio 1.69, 95% confidence interval 1.16­2.47). Lack of circumcision is associated with a higher risk of HIV infection in Rwandan men. Further research is needed to determine whether this higher risk is due in part to poor hygiene or to complex mechanisms operating through the acquisition of other sexually transmitted diseases. Circumcision may be an appropriate risk reduction approach for men with known exposures to the virus when there are constraints to alternatives, such as condom use.

Grosskurth H., Mosha F., Todd J., Senkoro K., Newell J., Klokke A., Changalucha J., West B., Mayaud P., Gavyole A., et al.

A community trial of the impact of improved sexually transmitted disease treatment on the HIV epidemic in rural Tanzania: 2. Baseline survey results.

AIDS 1995; 9: 927­34.

OBJECTIVES: To determine baseline HIV prevalence in a trial of improved sexually transmitted disease (STD) treatment, and to investigate risk factors for HIV. To assess comparability of intervention and comparison communities with respect to HIV/STD prevalence and risk factors. To assess adequacy of sample size. SETTING: Twelve communities in Mwanza Region, Tanzania: one matched pair of roadside communities, four pairs of rural communities, and one pair of island communities. One community from each pair was randomly allocated to receive the STD intervention following the baseline survey. METHODS: Approximately 1000 adults aged 15­54 years were randomly sampled from each community. Subjects were interviewed, and HIV and syphilis serology performed. Men with a positive leucocyte esterase dipstick test on urine, or reporting a current STD, were tested for urethral infections. RESULTS: A total of 12,534 adults were enrolled. Baseline HIV prevalences were 7.7% (roadside), 3.8% (rural) and 1.8% (islands). Associations were observed with marital status, injections, education, travel, history of STD and syphilis serology. Prevalence was higher in circumcised men, but not significantly after adjusting for confounders. Intervention and comparison communities were similar in the prevalence of HIV (3.8 versus 4.4%), active syphilis (8.7 versus 8.2%), and most recorded risk factors. Within­pair variability in HIV prevalence was close to the value assumed for sample size calculations. CONCLUSIONS: The trial cohort was successfully established. Comparability of intervention and comparison communities at baseline was confirmed for most factors. Matching appears to have achieved a trial of adequate sample size. The apparent lack of a protective effect of male circumcision contrasts with other studies in Africa.

COMMENT:

There have been a variety of articles published that look directly or indirectly at any link between the foreskin and the acquisition and transmission of HIV. The studies fall into four basic categories. Geographic studies, such as the one by Caldwell and Caldwell, look at a map and see if the area of high HIV prevalence and low circumcision rates overlap. These studies tell the investigator very little other than that further study is indicated. When studying a question of this nature the next logical step is to study high risk populations. These studies have been performed on clients of sexually transmitted disease clinics. There are several methodological problems with studying this population, so the data from these studies has to be taken with a certain degree of skepticism. The next step it to study the general population, or representative portions of it. This is the most difficult study to perform, but the most reliable way of attaining accurate information. The studies by Grosskurth et al. and Seed et al. fall into this category. It is interesting that this type of study has nearly always shown either that circumcision status is a minor factor in the transmission of HIV or circumcised men are at higher risk of acquiring or disseminating the virus. Why is it that no one has heard about these studies? Now that we have this information, what do we do with it. If Seed's data are correct the foreskin would be responsible for only 27% of AIDS cases. In the United States, with an AIDS­prevalence of 16.0 per 100,000 and life­time cost per circumcision of $414.38, using Seed's data it would cost 9.6 million dollars to prevent one case of AIDS by implementing routine male circumcision.

Sherman J, Borer JG, Horowitz M, and Glassberg KI.

Circumcision: successful glanular reconstruction and survival following amputation.

J. Urol. 1996 156: 842­6.

Purpose: Circumcision remains the most common operation performed on male individual in the United States. Unfortunately various complications may occur during circumcision ranging from trivial to tragic. We report 7 cases of traumatic amputation of the glans penis and/or urethra during circumcision. In addition, errors in circumcision technique as probable mechanisms of injury, principles of repair and limits of tissue viability are discussed. Materials and Methods: The medical records of 7 patients who underwent traumatic circumcision amputation of the glans penis and/or urethra were reviewed. Glanular amputation occurred in 6, 8­day­old neonates during ritual circumcision and in 1, 5­month­old infant circumcised by a physician. Results: Excised glanular tissue remained viable for up to 8 hours after injury. Followup ranged from 8.5 to 108 months. All patients had an acceptable cosmetic result. No long­term complications developed in the 8­day­old group but a distal urethral fistula formed in the 5­month­old patient. Conclusions: Careful selects of technique and device as well as strict attention to detail at circumcision should eliminate most injuries. On the basis of our results we recommend reanastomosis of the glans and/or urethra following distal amputation even when there is a delay in surgical repair of up to 8 hours.

COMMENT:

In a recent article in the New York Times (Sunday May 19, 1996), pediatric urologist Terry W. Hensle of Columbia College of Physicians and Surgeons stated that he believed that mohels, ritual lay circumcisors, are "probably the best" at performing circumcisions. If that is the case, why are most of the horrendous complications from circumcision reported in the medical literature performed by mohels? There are three possible explanations. 1.) Mohels may have more horrendous complications. Medically trained professionals could attribute this to the mohel's lack of proper medical training. 2.) Mohels may have the same rate of horrendous complications, but because these complications enter the sphere of medical care from the outside, special attention is given to them. 3.) Mohels may have a lower rate of horrendous complications, but because the complication did not occur at the hands of a medical professional, there is one less hurdle to publishing these complications in the medical literature. The fear of medicolegal liability may be enough to keep any severe complication from the hands of medical professionals under wraps. The horrific complications from neonatal circumcision reported in the medical literature may only be the tip of the iceberg.

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: 91­3.

OBJECTIVE: To describe the clinical presentation and pathophysiology of meatal stenosis occurring after circumcision.

CONCLUSION: Preservation of the frenular artery at circumcision, or the use of an alternative procedure (preputial plasty), may be advisable when foreskin surgery is required, to avoid meatal stenosis after circumcision.

COMMENT:

During the three year time span of the study, 88 circumcisions and 91 preputial plasties were performed. Seven of the circumcision patients and none of the preputial plasty patients developed meatal stenosis (odd ratio = 16.84, 95% confidence interval = 0.94 - 299.49, p = 0.0061). In spite of overwhelming evidence, Thomas E. Wiswell maintains that "Furthermore, these physicians have incorrectly included meatal stenosis among complications of neonatal circumcision. As the American Academy of Pediatrics Task Force on Circumcision pointed out, meatal stenosis does not result from the procedure." [Wiswell TE. Circumcision questions. Pediatrics 1994; 94: 407­8.] The 1989 Task Force stated "(t)here is no evidence that meatitis leads to stenosis of the urethral meatus." It had nothing to say about the relation of circumcision to meatal stenosis. The relation between the circumcised penis and meatal stenosis has been recognized since the turn of the century. The common potentially serious complication of meatal stenosis should be part of every informed consent discussion.

Cartwright P.C., Snow B.W., McNees D.C.

Urethral meatotomy in the office using topical EMLA cream for anesthesia

J. Urol. 1996; 156: 857­9.

Purpose: We determined the effectiveness of lidocaine and prilocaine (EMLA) topical cream for anesthesia during urethral meatotomy performed in the office setting. Materials and Methods: Meatotomy was performed in 58 patients 1 hour after topical application of EMLA cream to the glans. Results: Of the 58 patients 55 had no pain, while early in our experience 3 had limited discomfort because EMLA cream as applied in too small a volume or it became dislodged. Results have been good in 57 patients, which partial restenosis developed in 1. Conclusions: Urethral meatotomy in an office setting with EMLA cream for anesthesia is generally painless, well tolerated, successful and cost­effective versus operative meatotomy.

COMMENT:

The authors correctly state that meatal stenosis is not uncommon in circumcised boys, but do not mention the circumcision status of their patients. Because meatal stenosis is extremely rare in the normal penis, can it be assumed that all of the patients in the study were circumcised? The patients in this study presented over a 12 month time span. In comments following the article by Terry W. Hensle, a pediatric urologist, he speculates that polyacrylate in supra­absorbent diapers may be responsible for the dramatic increase of meatal stenosis in the past decade. This dramatic increase would not be possible without the high prevalence of neonatal circumcision in Salt Lake City. Hensle fails to mention this.

Magoha G.A., Kaale R.F.

East Afr. Med. J. 1995; 72: 359­61.

Thirty one patients with carcinoma of penis were studied retrospectively at Kenyatta National Hospital, Nairobi, over a 20­year period (1971­1990). The majority of patients presented late with symptomatology of over one year duration. 88% of patients with carcinoma were uncircumcised, while the three (12%) patients who were circumcised but developed carcinoma were all circumcised late in adolescence and adulthood, confirming that late circumcision may not protect one from developing penile carcinoma as reported in literature. These findings also indicate that carcinoma of penis may be rare in this locality but is still common among the uncircumcised African tribes.

COMMENT:

This article adds to the mounting evidence that circumcision after the newborn period is associated with a higher risk of penile cancer than for those men who were never circumcised. There is no apparent explanation for this observation. One possible explanation is that circumcision is a marker for penile problems, such as phimosis, that have been linked in some studies to have an increased risk of penile cancer. Although discredited, some have suggested that naturally occurring secretion, smegma, may be to blame. If smegma were carcinogenic, it would be the only naturally secreted substance secreted in physiological amounts to cause cancer. The extreme rarity of penile cancer, considering the large number of penises exposed to smegma, make this theory untenable. In addition, the exposure to smegma of men who are never circumcised is much longer than those circumcised after the newborn period. Increased exposure to a potential carcinogen should increase the risk of cancer. In this case it decreases the risk of cancer. Is there something about the procedure itself that increases the cancer risk? The circumcision scar is often found to be the focus of cancerous growth. Why does the timing of the surgery alter the cancer risk? No one has provided an reasonable explanation.

Joseph V.T.

A new approach to the surgical correction of buried penis.

J. Pediatr. Surg. 1995; 30: 727­9.

Buried penis has been variously attributed to obesity with excessive suprapubic fat, severe phimosis with trapping of the penis within the prepubic tissues, and inadequate fixation of the penile shaft skin at the base resulting in tenting. Previous attempts at surgical correction, by excising suprapubic fat, fixing penile shaft skin to the base of the penis, and circumcising, have failed to give satisfactory results and, indeed, procedures like circumcision will make the condition even worse. The technique developed by the author is based on the recognition that this condition exists because of the displacement of the root of the penis below its normal position, resulting in the surrounding fat and dartos tissues enveloping the penile shaft. In this procedure, dissection at the root of the penis is carried out deep down to the corporal bodies. All fibrotic tissue that binds the penile shaft is excised. The lengthened penile shaft is anchored at its base by suturing the surrounding tissue onto the tunica. This technique has been applied in 22 patients ranging in age from 5 months to 11 years. Apart from two technical problems, all other patients had satisfactory correction with good functional results.

COMMENT:

The author of this study has the advantage of being in a culture where routine infant male circumcision is almost unheard of. In the United States, most cases of buried or hidden penis present after the prepuce has been removed. Circumcision makes the condition worse because the connections that are present be between inner lining of the prepuce and glans hold the glans in an everted position. Once the prepuce is removed, there is nothing to prevent the glans from disappearing into the suprapubic fat pad. This condition is often misinterpreted as an "inadequate" circumcision and circumcision revision surgery is performed, which makes things even worse. If a boys penis looks too small to safely circumcise, it is prudent to wait.

Smith D.P., Rickman C., Jerkins G.R.

Ultrasound evaluation of normal penile (corporeal) length in children

J. Urol. 1995; 154: 822­4

Previous studies have established normal penile length for patient age and stage of sexual development. To our knowledge penile length has only been determined to date by measuring the stretched distance from the symphysis to the glans tip. Pilot studies at our institution showed that ultrasound corpora cavernosa length determinations were possible using a 7.5 MHz. linear transducer probe. To determine whether ultrasound is a more accurate modality in assessing penile length, male subjects 0 to 24 months old with normal penile anatomy and palpably descended testicles were enrolled in a prospective analysis. Longitudinal ultrasound images of the flaccid penis were obtained from the dorsal surface. The whole corporeal bodies were easily imaged and measured. In a blinded fashion a separate investigator performed a conventional stretched penile length determination. A total of 27 male subjects 1 week to 22 months old was evaluated and 2 were excluded. Corpora cavernosa measurements using ultrasound revealed a mean length of 32.3 +/- 4.7 mm. (range 22.4 to 44.9). Stretched penile lengths of the same subjects revealed a mean length of 46.8 +/- 8.2 mm. (range 31 to 63). Circumcision status (p = 0.036) and age (p < 0.001) significantly correlated with stretched length determinations. Ultrasound measurements did not significantly vary with patient circumcision status or age. Penile length and race were not correlated when using stretched or ultrasound measurements. Ultrasound determination of corporeal body length is possible in young subjects. From infancy to age 22 months ultrasound measurements are not significantly affected by age or the presence of foreskin. Our experience suggests that corporeal body evaluation by ultrasound may offer a more accurate assessment of functional penile length.

COMMENT:

Can this technology be used to settle the age­old question of whether circumcision makes the penis longer or shorter?

Zwang G.

Quel avenir pour la circoncision? [What is the future of circumcision?]

Contracept. Fertil. Sex 1995; 23: 348­54.

Systematic ablation of the prepuce of male children is a sexual mutilation based on the principle of metaphysical sacrifice. It is a painful but partial excision carried out on an organ destined to give pleasure, in order to purchase the right to use what's left. All the other justifications from hygiene to reinforced virility are spurious and have no scientific value. Circumcision is still imposed by African customs and most of monotheistic religions; it is an out­model practice which is destined to vanish as is the Chinese custom of foot­binding of young girls. In the meantime, we can suggest temporary measures which make their mark without mutilation.

COMMENT:

Zwang, a famous French sexologist, is certainly outspoken on this issue. He refers to male circumcision as "sexual mutilation" in a culture where neonatal circumcision is almost unheard of and viewed with the same disgust that Americans view female genital mutilation. Would an American medical journal publish the same views?

Snellman L.W., Stang H.J.

Prospective evaluation of complications of dorsal penile nerve block for neonatal circumcision.

Pediatrics. 1995; 95: 705­8.

OBJECTIVE. To evaluate the complications of the dorsal penile nerve block (DPNB) when used for routine neonatal circumcisions.

RESULTS. Questionnaires were returned for 491 (85%) eligible patients. The only complication of DPNB found was bruising at the site of injection in 54 patients (11%). All bruising had resolved by the 2­week visit, and none was thought to have any clinical significance. CONCLUSION. DPNB is a safe method of decreasing the pain and stress of neonatal circumcision.

COMMENT:

Minneapolis appears to be the epicenter of the dorsal penile nerve block movement. Beginning with Gunnar's excellent work on the distress experienced by infant boys circumcised without anesthesia it now clear that circumcision is an extremely painful, physiologically stressful event. While dorsal penile nerve block lessens the pain and cortisone response, it is not eliminated completely. Some have anecdotally claimed a high failure rate of the anesthetic. Theoretically, the block should be effective. One possible explanation for the apparent failures is that the ventral surface of the penis may not receive a complete block. The highest concentration of nerves in the penis is located in the frenulum on the ventral surface of the penis. The severing the frenulum may be responsible for this pain breakthrough as well as most bleeding complications, meatal stenosis, and urethral fistulae. While this study sets aside the safety issue of dorsal penile nerve block, its overall efficacy may be over­rated. Currently, a physician has no excuse not to use an anesthetic when performing the procedure.

Taddio A., Goldbach M., Ipp M., Stevens B., Koren G.

Effect of neonatal circumcision on pain responses during vaccination in boys.

Lancet 1995; 345: 291­2.

Using data from one of our randomised trials, we investigated post­hoc whether male neonatal circumcision is associated with a greater pain response to routine vaccination at 4 or 6 months. Pain response during routine vaccination with diphtheria­pertussis­tetanus (DPT) alone or DPT followed by Haemophilus influenzae type b conjugate (HIB) was scored blind. 42 boys received DPT and 18 also received HIB. After DPT, median visual analogue scores by an observer were higher in the circumcised group (40 vs 26 mm, p = 0.03). After HIB, circumcised infants had higher behavioural pain scores (8 vs 6, p = 0.01) and cried longer (53 vs 19 s, p = 0.02). Thus neonatal circumcision may affect pain response several months after the event.

COMMENT:

It is clear that infant male circumcision is a traumatic event. It is also clear that male circumcision performed on 5 year olds has profound psychological impact [Cansever G. Psychological effects of circumcision. Br J Med Psychol 1965; 38: 321­31.] What has remained unknown is whether infant male circumcision has any long­term impact. It is now known that repeated child abuse leave its impact on the brain and leads to post­traumatic stress disorder. This study demonstrates that infant male circumcision does have a long­term negative impact.

Roberts J.A.

Neonatal circumcision: an end to the controversy?

South. Med. J. 1996; 89: 167­71.

The incidence of urinary tract infections is 10 times higher in the uncircumcised male than in those circumcised. An extensive review of bacterial adherence, the initiating factor in urinary tract infections, is presented to show that bacterial adherence to the prepuce is necessary for pyelonephritis to occur. Colonization with maternal bacteria occurs at birth; thus the incidence of pyelonephritis in infants born of bacteriuric mothers is much higher than it is in infants born of nonbacteriuric mothers. The significant morbidity of acute pyelonephritis in infants is one reason for encouraging neonatal circumcision, but a more important reason is that acute pyelonephritis in the first years of life often leads to significant renal damage that may progress to end­stage renal disease during adolescence. Since circumcision can now be done under local anesthesia, the newborn infant can have a painless prophylactic operation that will prevent urinary tract infections, pyelonephritis, and end­stage renal disease.

COMMENT:

The following are portions of a letter submitted to Southern Medical Journal that was not published. Roberts' piece was extremely one­sided, the response was equally one­sided in hopes of providing some balance.

To the editor:

The end of the controversy regarding neonatal circumcision will only come about when American medical journals stop publishing articles such as the one recently written by Roberts.[1] It is obvious from reading the distorted misinformation provided by the urologist that neonatal circumcision was never a controversial subject for him. However, defending this ritual does not reflect well on a profession that adheres to a code to above all, do no harm.

As a service to your readership, the following errors in Roberts piece need to be pointed out. While both Wiswell and Schoen fervently believe that neonatal circumcision prevents phimosis, there is not a single study in the medical literature to support this. In fact, the incidence of phimosis in intact boys in a study by Wiswell et al[2] is nearly identical to the incidence of phimosis in circumcised boys reported by Kaweblum et al.[3] Similarly, the only studies which have compared the rates balanoposthitis in circumcised and intact boys have found no significant difference between the two groups.[4,5]

Roberts is quick to mention a study that found an association between the foreskin and HIV infections but fails to mention the number of studies which have found circumcised men to be at statistically significantly higher risk of contracting HIV.[6­9]

While several studies have demonstrated that local anesthesia can reduce the pain of circumcision, it is clear that the procedure with anesthesia produces a significant cortisol response when compared to those boys whose prepuce is left alone.[10]

Roberts mentions that Wiswell, using retrospective chart reviews, found a 10 fold increase in the rate of urinary tract infections (UTIs) among intact boys, but fails to mention that the only two prospective studies found the odds ratio to be only 4.8.[11­12] In the more recent of the two, the difference in the rates of UTIs between circumcised and intact boys under a year of age was not statistically significant.[12]

While Roberts readily cites the neonatal circumcision complication rate reported by Wiswell of 0.2%, he fails to explain how two investigators were able to review over 100,000 charts with any degree of accuracy. In a study recently published in Southern Medical Journal, investigators from the Center for Disease Control carefully reviewed 1696 charts of boys circumcised as neonates and determined that the neonatal circumcision complication rate was 3.1%:[13] 17 times greater than the rate reported by Wiswell. The only logical explanation for this vast difference is that two investigators were not able to adequately review 100,000 charts.

In an attempt to perpetuate another long­standing myth, Roberts inaccurately reports that intact men are more susceptible to sexually transmitted diseases. Recent studies have shown circumcised men to be at higher risk of developing syphilis, gonorrhea,[14] non­gonococcal urethritis,[15] and genital warts.[16,17] Herpes simplex virus[18] and human papillomavirus infections[19] have been shown to affect both groups of men equally.

Roberts also applies his own bias when he alludes to the findings of the published studies regarding the cost­utility of neonatal circumcision. Ganiats et al found that neonatal circumcision impaired health and cost money making it poor health care policy. This conclusion did not change unless intact boys were 48 times as likely to develop UTIs as circumcised boys.[20] Lawler et al found that the reported benefits of preventing UTIs was a relatively insignificant factor in their financial and quality­adjusted survival analysis.[21] Roberts fails to mention the study by Chessare, which concluded that the rate of UTIs would need to equal or exceed 29% in intact boys for neonatal circumcision to be cost effective.[22]

It if fun to speculate how the prepuce may predispose a boy to UTIs, but to date there have been no studies performed to confirm this speculation. There are, however, a myriad of questions that remain unanswered. If the prepuce in a necessary step in acquiring an ascending UTI, why do a number of circumcised boys develop UTIs? If the prepuce is such a breeding ground for pathogenic bacteria, why are UTIs relatively uncommon? If the prepuce predisposes a boy to UTIs, why is the rate of UTIs the same as the rate of asymptomatic bacteriuria?[23] Is there an anatomically equivalent procedure that could reduce the UTI rate in females?

A recently published study by Craig et al[12] found a significantly lower incidence of concomitant bacteremia than published previously by Wiswell and Geschke.[24] The reason for this is easily explained by some of the data Roberts provides. Newborns with bacteria in their urine have bacteria in their urine because they have bacteria in their blood. They have bacteria in their blood because their mother had bacteria in her blood and passed it to the baby transplacentally. Somehow, much to the chagrin of Roberts and Wiswell, the prepuce was bypassed in the process. These bacteremic boys were over represented in Wiswell's intact column because they were too sick to circumcise. In the population studied by Wiswell, boys who were too sick to circumcise made up a third of his intact population.[2]

Another phenomenon, which has yet to be explained, is the high incidence of genitourinary (GU) anomalies and dysfunction among intact boys with UTIs.[25,26] Would Roberts suggest that the prepuce causes primary megaureter, a horseshoe malformation, duplex collecting systems, and vesicoureteral reflux? If the prepuce is not responsible for these congenital anomalies, how many GU anomalies are being missed in circumcised boys until significant permanent damage has occurred? The sparse data currently available suggest that circumcised boys with UTIs are more likely to have vesicoureteral reflux.

The disproportionately low occurrence of vesicoureteral reflux and other GU abnormalities in infants with febrile UTI found by Rushton and Majd in the infants under six months (when the percentage of intact males having febrile UTIs was higher) suggests that UTIs discovered in intact males under six months of age have a weaker association with vesicoureteral reflux.[27]

Likewise, in the International Reflux Study in Children, 5 (38%) of 13 boys enrolled from the United States were intact. This proportion does not differ significantly from the circumcision rate currently seen in the United States. In order for this difference to be significant, the circumcision rate in the United States would need to be over 85%.[28] If UTIs occur 4 to 10 times more commonly in intact boys, why does reflux appear to affect both groups equally? This also suggests that circumcised boys with UTIs are as likely to go onto end­stage renal failure as intact boys.

Roberts mentions that mechanical factors may assist in the ascent of bacteria from the periurethral area, such as honeymoon cystitis. This phenomenon may help explain Wiswells dramatic results. The parents in Wiswells study were instructed to gently retract the foreskin to allow the easily exposed portion of the glans to be cleansed.[29] This non­physiologic opening the of the prepuce not only allowed pathogenic bacteria into the subpreputial space, but may have encouraged their ascent up the urinary tract.

The rise in UTIs reported by Wiswell in Army hospitals in the 1980s was attributed to the fall in the circumcision rate. Unfortunately, Wiswell fails to address other internal inconsistencies in his data. In a study of 10 years of data Wiswell compared the first three years to the last three years of the study and found that the UTI rate in circumcised boys dropped significantly from 0.16% to 0.07% (OR = 2.16, 95%CI = 1.47­3.18) while the rate in intact boys increased from 0.87% to 1.09% (OR = 1.25, 95%CI = 0.97­1.62). No explanation was offered for this highly significant change.[30]

The study published in Southern Medical Journal last year shed light on this unexplained significant difference. In carefully looking through 1951 charts of newborn males, the investigators revealed that only 84.3% of the neonatal circumcisions were reported on the medical record face sheets. The incidence of circumcision at the time of the study was 89.3%.[13] If an investigator only looked at the face sheet of the medical record, the incidence would have been reported as only 75.3%, a discrepancy of 14%.

The inaccuracy of reporting circumcisions on the hospital medical record face sheet, which hospitals depend on to be properly reimbursed, carries enormous weight when interpreting Wiswells data.[30] 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 only data from the face sheets was used to calculate circumcision rates. Applying OBriens 84.3% figure, which may be conservative, reveals that 78% boys classified as having foreskins may have been circumcised. This would decrease the odds ratio from 10.27 to 4.18 and increase the incidence of UTI in circumcised boys from 0.11% to 0.27%. If circumcision status of the infected boys was correctly classified, then the odds ratio could be as high as 58.04, the incidence of UTIs in boys with foreskins would increase from 1.12% to 5.12%, and decrease in circumcised boys to 0.09%. Wiswells unexplained yearly fluctuations in the incidence of UTIs in circumcised boys between 0.07% and 0.21%,[31] and his 4.12% incidence of UTIs in intact boys[29] are consistent with 72.8% of boys labeled as intact being misclassified. While the large numbers reported in Wiswells studies make his results statistically significant they also make the accuracy of the data collected extremely suspect.

While several studies suggest an association may exist between the prepuce and UTIs, Roberts fails to mentions studies which have shown circumcision to increase a boys risk of developing a UTI.[32­34]

It is also unclear whether these boys had UTIs or incidental bacteriuria. Several studies of UTIs in infants have found a significant proportion do not have any inflammatory cells in their urine.[11,35,36] It has been shown that children with fever, positive urine cultures, but no pyuria who were not treated with antibiotics experienced a spontaneous clearing of their bacteriuria.[37] Finally, the incidence of UTIs in intact boys is similar to the prevalence of bacteriuria in asymptomatic term infants[38] and older boys.[23]

Another pitfall in accurately making the diagnosis of UTI is the method of urine collection. Ureteral catherization can introduce microorganism into the bladder,[39] and has been shown to yield a contaminated urine culture more often than suprapubic cultures.[40] Urine bag collection may be reliable in circumcised boys, but the rate of contamination in intact boys is unacceptably high.[41] Midstream collection in intact boys has a 3% to 7% contamination rate.[23] All of the studies to date have been flawed by inconsistent or unreliable urine collection methods.

Until a study controlling for rooming in,[42] breast feeding,[43­45] parental education and social status, hygienic practices,[46­49] race,[50] urine collection method, and diagnostic criteria is performed, no definitive claims of the protective effect of neonatal circumcision can be made. The claims that neonatal circumcision prevents end­stage renal disease are completely unfounded and do not conform with the presently available data. Before any such claim can be spouted, the prevalence of GU anomalies in all boys needs to be elicited.

Roberts plea has little to do with UTIs. Antibiotics are currently available that adequately treat UTIs in both boys and girls. He is concerned with maintaining circumcision in the United States, even if this means missing or delaying the diagnosis of a GU anomalies in circumcised boys. If female genital mutilation was found to decrease the number of UTIs in women by a factor of 5, would that justify its adoption as routine prophylactic surgery in the United States? Before we institute a therapy, the medical researchers typically establish its effectiveness before recommending it to the rest of the medical community. When Roberts states that neonatal circumcision may prevent UTIs there is the equally likely possibility, based on the flawed methodology of the present studies, that it may not. Using a surgical procedure that permanently removes the most neurologically complex portion of the penis[51] to treat a risk factor (not an actual illness), which has yet to be clearly established as a risk factor, for an illness that is easily treated with a short course of oral antibiotics defies every tenet of modern ethical medicine. Until the American medical community recognizes neonatal circumcision as simply a ritual, it will continue to be a procedure desperately seeking a valid medical indication.

1. Roberts JA. Neonatal circumcision: an end to the controversy? South Med J 1996; 89: 167­71
2. Wiswell TE, Tencer HL, Welch CA, Chamberlain JL. Circumcision in children beyond the neonatal period. Pediatrics 1993; 92: 791­3.
3. Kaweblum YA, Press S, Kogan L, Levine M, Kaweblum M. Circumcision using the Mogen clamp.Clin Pediatr Phila 1984; 23: 679­82.
4. Herzog LW, Alvarez SR. The frequency of foreskin problems in uncircumcised children. Am J Dis Child 1986; 140: 254­6.
5. Fergusson DM, Lawton JM, Shannon FT. Neonatal circumcision and penile problems: an 8­year longitudinal study. Pediatrics 1988; 81: 537­41.
6. Chao A, Bulterys M, Musanganire F, Habimana P, Nawrocki P, Taylor E, Dushimimana A, Saah A. Risk factors associated with prevalent HIV­1. infection among pregnant women in Rwanda. National University of Rwanda­Johns Hopkins University AIDS Research Team. Int J Epidemiol 1994; 23: 371­80.
7. Carael M, Van de Perre PH, Lepage PH, Allen S, Nsengumuremyi F, Van Goethem C, Ntahorutaba M, Nzaramba D, Clumeck N. Human immunodeficiency virus transmission among heterosexual couples in Central Africa. AIDS 1988; 2: 201­5.
8. Guimaraes M, Castilho E, Ramos­Filho C, et al. Heterosexual transmission of HIV­1: a multicenter study in Rio de Janeiro, Brazil. VII International Conference on AIDS. Florence, June 1991. [abstract MC3098].
9. Grosskurth H, Mosha F, Todd J, Senkoro K, Newell J, Klokke A, Changalucha J, West B, Mayaue P, Gavyole A, Gabone R, Mabey D, Hayes R. A community trial of the impact of improved sexually transmitted diseas treatment on the HIV epidemic in rural Tanzania: 2. Baseline survey results. AIDS 1995; 9: 927­34.
10. Stang HJ, Gunnar MR, Snellman L, Condon LM, Kestenbaum R. Local anesthesia for neonatal circumcision. Effects on distress and cortisol response. JAMA 1988; 259: 1507­11.
11. Crain EF, Gershel JC. Urinary tract infections in febrile infants younger than 8. weeks of age. Pediatrics 1990; 86: 363­7.
12. Craig JC, Knight JF, Sureshkumar P, Mantz E, Roy LP. Effect of circumcision on incidence of urinary tract infection in preschool boys. J Pediatr 1996; 128: 23­7.
13. OBrien TR, Calle EE, Poole WK. Incidence of neonatal circumcision in Atlanta, 1985­1986. South Med J 1995; 88: 411­5.
14. Donovan B, Bassett I, Bodsworth NJ. Male circumcision and common sexually transmissible diseases in a developed nation setting. Genitourin Med 1994; 70: 317­20.
15. Parker SW, Stewart AJ, Wren MN, Gollow MM, Straton JA. Circumcision and sexually transmissible disease. Med J Aust 1983; 2: 288­90.
16. Cook LS, Koutsky LA, Holmes KK. Circumcision and sexually transmitted diseases. Am J Public Health 1994; 84: 197­201.
17. Cook LS. Koutsky LA. Holmes KK. Clinical presentation of genital warts among circumcised and uncircumcised heterosexual men attending an urban STD clinic. Genitourin Med 1993; 69: 262­264.
18. Bassett I, Donovan B, Bodsworth NJ, Field PR, Ho DW, Jeansson S, Cunningham AL. Herpes simplex virus type 2. infection of heterosexual men attending a sexual health centre. Med J Aust 1994; 160: 697­700.
19. Aynaud O, Ionesco M; Barrasso R. Penile intraepithelial neoplasia. Specific clinical features correlate with histologic and virologic findings. Cancer 1994; 74: 1762­7.
20. Ganiats TG, Humphrey JB, Taras HL, Kaplan RM. Routine neonatal circumcision: a cost­utility analysis. Med­Dis Making 1991; 11: 282­93.
21. Lawler FH, Bisonni RS, Holtgrave DR. Circumcision: a decision analysis of its medical value. Fam Med 1991; 23: 587­93.
22. Chessare JB. Circumcision: is the risk of urinary tract infection really the pivotal issue? Clin Pediatr Phila 1992; 31: 100­4.
23. Saez Llorens X, Umana MA, Odio CM, Lohr JA. Bacterial contamination rates for non­clean­catch and clean­catch midstream urine collections in uncircumcised boys. J Pediatr. 1989; 114: 93­5.
24. Wiswell TE, Geschke DW. Risks from circumcision during the first month of life compared with those for uncircumcised boys. Pediatrics 1989; 83: 1011­5.
25. Rockney RM, Caldamone AA. Circumcision and urinary tract abnormalities [letter]. Am J Dis Child 1989; 143: 1261­2.
26. Hopp L. Circumcision and urinary tract abnormalities [letter]. Am J Dis Child 1989; 143: 1262.
27. Rushton HG, Majd M. Pyelonephritis in male infants: how important is the foreskin? J Urol 1992; 148: 733­6; discussion 737­8.
28. Weiss R, Tamminen­Mvbius T, Koskimies O, Olbing H, Smellie JM, Hirche H, Lax­Gross H. Characteristics at entry of children with severe primary vesicoureteral reflux recruited for a multicenter, international therapeutic trial comparing medical and surgical management. J Urol 1992; 148: 1644­9.
29. Wiswell TE, Smith FR, Bass JW. Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1985 May; 75(5): 901­3.
30. Wiswell TE, Roscelli JD. Corroborative evidence for the decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1986; 78: 96­9.
31. Thompson RS. An opposing view. J Fam Pract 1990; 31: 189­96.
32. Amir J, Varsano I, Mimouni M. Circumcision and urinary tract infection in infants. Am J Dis Child 1986; 140: 1092.
33. Amir J, Alpert G, Reisner SH, Nitzan M. Fever in the first year of life. Israel J Med Sci 1984; 20: 447­8.
34. Cohen HA, Drucker MM, Vainer S, Ashkenasi A, Amir J, Frydman M, Varsano I. Postcircumcision urinary tract infection. Clin Pediatr Phila 1992; 31: 322­4.
35. Krober MS, Bass JW, Powell JM, Smith FR, Seto DS. Bacterial and viral pathogens causing fever in infants less than 3. months old. Am J Dis Child 1985; 139: 889­92.
36. Bonadio WA. Urine culturing technique in febrile infants. Pediatr Emerg Care 1987; 3: 75­8.
37. Hoberman A, Hickey R, Wald E, et al. Pyuria as a marker of infection vs colonization of the urinary tract in febrile children 1­24 months. Pediatric Research 1995; 37: 138A.
38. Edelmann CM, Ogwo JE, Fine BP, Martinez AB. The prevalence of bacteriuria in full­term and premature newborn infants. J Pediatr 1973; 82: 125­32.
39. Pryles CV. Percutaneous bladder aspiration and other methods of urine collection for bacteriologic study. Pediatrics 1965; 36: 128­31.
40. 40. Pyrles CV, Atkin MD, Morse TS Welch KJ. Comparative bacteriologic study of urine obtained from children by percutaneous suprapubic aspiration of the bladder and by catheter. Pediatrics 1959; 24: 983­91.
41. Schlager TA, Hendley JO, Dudley SM, Hayden GF, Lohr JA. Explanation for false­positive urine cultures obtained by bag technique. Arch Pediatr Adolesc Med 1995; 149: 170­173.
42. Winberg J, Bollgren I, Gothefors L, Herthelius M, Tullus K. The prepuce: a mistake of nature? Lancet 1989; 1: 598­9.
43. Pisacane A, Graziano L, Zona G. Breastfeeding and urinary tract infection. Lancet 1990; 336: 50.
44. Piscane A, Graziano L, Mazzarella G, Scarpellino B, Zona G. Breast­feeding and urinary tract infection. J Pediatr 1992; 120: 87­9.
45. Coppa GV, Gabrielli O, Giorgi P, Catassi C, Montanari MP, Varaldo PE, Nichols BL. Preliminary study of breastfeeding and bacterial adhesion to uroepthelial cells. Lancet 1990; 335: 569­71.
46. Malleson P. Prepuce Care. Pediatrics 1986; 77: 265.
47. Harkavy KL. The circumcision debate [letter] Pediatrics 1987; 79: 649­50.
48. Watson SJ. Care of the Uncircumcised Penis. Pediatrics 1987; 80: 765.
49. Cunningham N. Circumcision and urinary tract infections [letter] Pediatrics 1986; 77: 267­9.
50. Herzog LW. Urinary tract infections and circumcision. A case­control study. Am J Dis Child 1989; 143: 348­50.
51. 51. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996; 77: 291­5.

Holman J.R., Lewis E.L., Ringler R.L.

Neonatal circumcision techniques.

Am. Fam. Physician 1995; 52: 511­8, 519­20.

Neonatal circumcision is most commonly performed using one of three techniques - the Mogen clamp, the Gomco clamp or the Plastibell device. With all three techniques, careful selection and preparation of patients is essential. Informed consent must be obtained from parents or guardians, based on an objective understanding of the medical and social implications of circumcision, including potential complications from the procedure. Measures for creating an aseptic field, anesthesia and positioning of the infant do not vary with the technique selected. Both the Mogen and Gomco clamps protect the glans while producing crush injury to the prepuce, which is then surgically removed. The Plastibell device induces necrotic tissue, which is sloughed off, along with the plastic shield, within a week or so. Although complications from neonatal circumcision are rare, hemorrhage, local infection, sepsis, meatal ulceration and poor cosmetic results have been reported.

Hopper DH. Techniques for performing neonatal circumcision [letter] Am Fam Physician 1996; 53: 96, 98.

Philgreen DE. Techniques for performing neonatal circumcision [letter] Am Fam Physician 1996; 53: 96

Taylor HA. Techniques for performing neonatal circumcision [letter] Am Fam Physician 1996; 53: 92, 96.

Reynolds RD. Techniques for performing neonatal circumcision [letter] Am Fam Physician 1996; 53: 92.

Filardo TW. Use of 'normal' to describe penile appearance after circumcision [letter] Am Fam Physician 1996; 53: 2440.

Storms MR. AAFP fact sheet on neonatal circumcision: a need for updating. Am Fam Physician 1996; 54: 1216­8.

Reynolds R. Use of the Mogen Clamp for Neonatal Circumcision. Am Fam Physician 1996, 54: 177­82.

COMMENT:

American Family Physician has recently had an outpouring of articles and letters to the editor on the techniques of infant male circumcision complete with full color pictures. The American Academy of Family Practice is in the process of reassessing their position on routine male infant circumcision. Each of the authors has commented on the good cosmetic results of their favored technique. Filardo correctly points out that "these writers are basing their interpretations of 'normal' on some construct of aesthetics different from one based on natural, unaltered anatomy." He concludes that, "no rational discussion of this subject should include such misinterpretations of 'normal' or inject personal taste into a scientific discussion." Storms points out the changes in the medical literature since the AAFP last issued their position on infant male circumcision in 1991.

Etchells E., Sharpe G., Walsh P., Williams J.R., Singer P.A.

Bioethics for clinicians: 1. Consent

Can. Med. Assoc. J. 1996; 155: 177­80.

Patients are entitled to make decisions about their medical care and to be given relevant information on which to base such decisions. The physician's obligation to obtain the patient's consent to treatment is grounded in the ethical principles of patient autonomy and respect for persons and affirmed by Canadian law and professional policy. A large body of research supports the view that the process of obtaining consent can improve patient satisfaction and compliance and, ultimately, health outcomes. An exception to the requirement to obtain is emergency treatment of incapable persons, provided there is no reason to believe that the treatment would be contrary to the person's wishes if he or she were capable.

COMMENT:

While this article does not address the issue of infant male circumcision directly, it provides an excellent primer on the issue of informed consent. For example, the article states, "Under common law, treating a patient without his or her consent constitutes battery, whereas treating a patient on the basis of inadequately informed consent constitutes negligence." Whether an infant consents to circumcision and whether adequate consent is given are currently unresolved issues.

American Academy of Pediatrics Committee on Bioethics.

Informed consent, parental permission, and assent in pediatric practice.

Pediatrics 1995; 95: 314­7.

COMMENT:

The following letter was submitted to Pediatrics and, for reasons that are not clear, was not published.

To the Editor:

The American Academy of Pediatrics (AAP) Committee on Bioethics is to be commended on its recent pronouncement on informed consent, parental permission, and patient assent in pediatric practice.[1] In light of the re­analysis of these important issues, the issue of consent in routine neonatal circumcision requires a sober reevaluation.

Since 1989, the AAP[2] has suggested the physician seek informed consent on the part of parents for this surgical procedure. Such consent does not now apply, since only a competent patient can give informed consent. The concept of patient assent does not apply to an infant because he is developmentally incompetent to grant such assent. The concept of informed parental permission does not apply either, since the Committee's concept of informed parental permission allows only for medical interventions in situations of clear and immediate medical necessity, i.e., disease, trauma, or deformity: The natural human penis fits none of these conditions.

Furthermore, since it is the infant (not the parent) who must live the rest of his life with the .consequences of this amputative 'prophylactic' treatment, the individual's legal and moral right to refuse such treatment as well as the right to seek alternative treatment has been unjustly violated. Likewise, the basic human right to autonomy, self­determination and the right to an intact body as outlined in Article 5.1 of the American Convention on Human Rights (1969) and Article 1.1 of the International Convention on Human, Civil and Political Rights (1966) are violated by the performance of routine circumcision. The notions of 'social', 'cosmetic', or 'religious' circumcision of infants are not medical issues, and have no place in medical practice.

The AAP position on routine neonatal circumcision is in conflict with AAP position on consent. By the AAP's own definition, the continuance of physician assisted circumcision is incompatible with medical ethics. It is time for the AAP to coordinate its laudable stand on consent with its position on routine circumcision by firmly opposing the procedure on ethical, moral, human rights, and legal grounds.

Paul M. Fleiss, M.D., M.P.H.
Los Angeles, California

1. Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics. 1995;95:314­7.
2. AAP Task Force on Circumcision. Report of the task force on circumcision. Pediatrics. 1989;84:388­391.