The practice of circumcision is thought to be at least 15,000 years old, yet its origins and medical history are not well known. Few surgical procedures in infants and children generate as much controversy as circumcision. Still, the majority of male infants in the United States are circumcised as newborns, and the cost of newborn circumcision in this country is estimated at more than $50 million per year. ' The Committee of the Fetus and Newborn of the American Academy of Pediatrics (AAP) stated in 1971 "there are no valid medical indications for routine circumcision in the neonatal period."2 In 1975, an Ad Hoc Task Force of the same committee restated "there is no absolute medical indication for routine circumcision of the newborn."3 Recently, because of new data regarding circumcision and its possible relation to urinary tract infections and sexually transmitted diseases, a new Task Force on Circumcision was appointed by the AAP to review available data on circumcision. The report is forthcoming.4
EMBRYOLOGY OF THE PENIS AND NATURAL HISTORY OF THE FORESKIN
During the third month of pregnancy, the glans and foreskin develop from a common block of tissue at the distal portion of the phallus. What will become the prepuce begins as a fold at the base of the glans, and the developing prepuce grows more rapidly dorsally than ventrally. Fusion occurs between the stratified squamous epithelium of the glans and the epithelium of the prepuce of the developing fetal foreskin by the fifth month. As the squamous epithelial cells degenerate, clefts appear between the glans and prepuce shortly before birth. The clefts slowly increase in size, and separation of the glans and prepuces gradually occurs. At birth, this separation is incomplete such that only a small percent of newborn males have a retractable foreskin.5
The natural history of the foreskin in terms of retractability was studied by Gairdner in 1949. 6 He found that the foreskin was fully retractable in 4% of newborn males, the glans could be uncovered enough to reveal the urethral meatus in 54%, and the tip of the glans could not be uncovered in the remaining 42%. The foreskin was retractable in 25% of 6-month-old babies, 50% of 1-year-olds, 80% of 2-year-olds, and 90% of 4-year-olds. Although he noted a nonretractable foreskin in 6% and a partially retractable foreskin in 14% of 200 uncircumcised boys aged 5 to 13, Gairdner also stated that "after about 3 years of age steps should be taken to render the prepuce of all boys retractable and capable of being kept clean." The foreskin should never be forcibly retracted, however, since that is a painful and psychologically traumatic procedure in any child.
NORMAL ANATOMY OF THE FORESKIN
The normal anatomy of the foreskin is shown in the Figure. The foreskin, or prepuce, is the free fold of skin that covers the glans penis. The preputial space is the space between the glans and the foreskin, and the preputial ring is the opening from the preputial space to the outside of the foreskin. Phimosis is a stenosis of the preputial ring with resultant inability to retract a fully differentiated foreskin. Paraphimosis is retention of the preputial ring proximal to the coronal sulcus, which creates a tension greater than lymphatic pressure resulting in subsequent edema of the prepuce and glans distal to the ring. Balanitis is inflammation of the glans penis, and posthitis is inflammation of the prepuce; these entities usually occur in conjunction (balanoposthitis). Meatitis is inflammation of the urethral meatus. Circumcision is excision of the foreskin to the level of the coronal sulcus.
SURGICAL INDICATIONS FOR CIRCUMCISION
Definite indications for circumcision include phimosis, paraphimosis, and recurrent balanitis. It is estimated that 5% to 14% of uncircumcised boys will need circumcision to treat these conditions.7,8 Phimosis may be present in even young infants after the first year of life if there is a true stenosis of the preputial ring so that the foreskin cannot be retracted to at least expose the urethral meatus. Recurrent posthitis alone is only a relative indication for circumcision, and some authors consider the foreskin as protecting the glans from becoming inflamed.1
Cancer of the Penis
Cancer of the penis occurs almost exclusively in uncircumcised males,9'11 and circumcision essentially eliminates the chance of developing this malignancy. If a newborn boy is not circumcised there must be a lifetime commitment to careful, diligent penile hygiene. The lifetime risk of developing cancer in an uncircumcised penis is estimated at 1 in 600 in the United States,12 with a yearly incidence of 0.7 to 0.9 per 100,000 men per year. ' i In highly developed countries such as Japan, Norway, and Sweden where neonatal circumcision is not routinely performed, the incidence of penile cancer is 0.3 to 1.0 per 100.000 men per year. ,4 In underdeveloped countries with less stringent standards of hygiene, the incidence of cancer of the penis in uncircumcised men is 3 to 6 per 100,000 men per year.15
Figure. Normal anatomy of the foreskin.
Urinary Tract Infections
Recently, there have been many reports citing an increased incidence of urinary tract infections (UTI) in uncircumcised male infants. Ginsberg and McCracken16 noted that there was a predominance of males in a series of infants with UTI (as opposed to a female predominance in older children), and that 95% of the males with UTI were not circumcised. Wiswell has shown 10 to 20 times greater incidence of UTI in uncircumcised infants in US Army hospitals17 and has also noted that over the years as the rate of circumcision fell the incidence of UTI rose. l8 Wiswell also found that the high incidence of UTI in the first month of life in uncircumcised males was accompanied by high percentages of bacteremia and meningitis. iy Although the etiology of these increased infections has not yet been totally delineated, investigators have shown adherence of p-fimbriated Escherichia coli to the mucosal surface of the prepuce but not to the outer skin surface of the foreskin. 20 Others have shown a greater quantity of periurethral bacteria in uncircumcised infants.21 Both of these studies suggested that circumcision prevents bacterial colonization and thus protects against UTl. Presently, the majority of studies regarding the incidence of UTI in uncircumcised males have been retrospective and noncohort controlled; further prospective, well-controlled studies are necessary to clarify this connection.
SEXUALLY TRANSMITTED DISEASES
A relation between circumcision and sexually transmitted diseases (STD) has been suggested, but reports linking them are conflicting. Chancroid, syphilis, human papilloma vims, herpes simplex II virus, and even AIDS have been postulated to have an increased incidence in uncirumcised men.21-25 Conflicting reports show both increased and decreased incidence of gonococcal and nonspecific urethritis in either circumcised or uncircumcised males.23,26 Although most of these studies show an increased incidence of STD in uncircumcised men, they are not well-controlled, prospective studies and do not eliminate variables in access to medical care, geographic location, hygiene, lifestyle, race, or socioeconomic factors. Because of these methodologic problems, the AAP's most recent Task Force on Circumcision found these reports to be inconclusive.4
Surgical Techniques for Newborn Circumcision
Although squamous cell carcinoma of the cervix appears to be a venereal disease and carcinoma of both the cervix and penis have been linked to human papilloma virus types 16 and 18, there is no conclusive evidence linking uncircumcised men to cervical carcinoma.
CONTRAINDICATIONS TO CIRCUMCISION
Newborn circumcision is contraindicated if a baby is sick, unstable, or premature (<2500 g). It is also contraindicated in the presence of any blood dyscrasia; a family history of bleeding disorder necessitates appropriate laboratory studies before considering any elective surgery. The presence of hypospadias or other penile anomalies, such as isolated chordee without hypospadias, is also a contraindication since the foreskin may be necessary to facilitate later reconstruction. If there is a question of any of the above problems existing in a given baby, circumcision should be postponed until the problems have been clearly elucidated.
TECHNIQUE OF CIRCUMCISION
Circumcision is a safe surgical technique if performed by a trained, experienced operator using strict technique. As outlined by Kaplan,27 there are four main technical principles: (1) asepsis; (2) adequate but not excessive excision of outer and inner preputial layers to the level of the coronal sulcus, exposing the glans completely; (3) hemostasis; and (4) cosmesis.
There are many possible techniques, each having specific advantages and disadvantages. If done well, however, all are safe and effective. The most common methods are freehand excision and use of a clamp to facilitate excision. The clamp methods are most commonly used in newborns, especially the Mögen and Gomco clamps and the Plastibell™ . Suggested surgical techniques for newborn circumcision are listed in the Table.
LOCAL ANESTHESIA FOR NEWBORN CIRCUMCISION
Neonatal responses to pain have been well studied.28 Cardiorespiratory changes during newborn circumcision without anesthesia include increases in heart rate and blood pressure, increasing or decreasing transcutaneous partial pressure of oxygen, and palmar sweating. Neonates undergoing circumcision without anesthesia have markedly increased plasma Cortisol levels during and after the procedure.29 Behavioral changes also occur in babies who do not receive anesthesia, such as recognizable alterations in the cry pattern correlating with the intensity of pain, ability to quiet themselves when disturbed, irritability, and altered sleep pattern.30,31 Transitory changes in infant-maternal interaction for the first few hours after circumcision without anesthesia have also been noted. n No long term psychologic effects have been discovered.33
Many of these cardiorespiratory, hormonal, and behavioral changes are not observed when local anesthesia is used with circumcision. Dorsal penile nerve block using 1% lidocaine without epinephrine in appropriate doses (3 to 4 mg/kg) may reduce much of the pain of neonatal circumcision. 29,34-37 Although effective, however, using a local penile block prolongs the procedure and has its own risks, the most common of which is failure to achieve adequate anesthesia.
Technique of Local Penile Block
A local penile block is based on the anatomic principle of a local field block of the dorsal penile nerves, which emerge under the symphysis pubis in the midline at the penile root and surface at about the 10 o'clock and 2 o'clock positions dorsolaterally.
After the penis is prepared and draped for circumcision, the inferior border of the symphysis pubis is palpated with the index and middle fingers of one hand. With the other hand, a 3 cc syringe with a half inch 25-gauge needle containing 1.0 to 1.2 cc of 1% lidocaine without epinephrine (3-4 mg/kg) is inserted through the skin and directed 0.25 to 0.5 cm toward the 10 o'clock position just under the symphysis pubis. After aspirating the plunger to ensure accidental intravascular injection does not occur, 0.25 to 0.5 cc of anesthetic is injected. The needle is withdrawn and the procedure is repeated at the 2 o'clock position. The remaining anesthetic should be injected subcutaneously along the ventral surface of the scrotum just below the penoscrotal junction.
COMPLICATIONS OF CIRCUMCISION
The true incidence of postoperative complications following circumcision is unknown. In large series of newborn circumcisions, the complication rate was found to be only 0. 2% to 0.6%. 18^° Kaplan's review of the complications reported the incidence of complications to vary from 0. 1% to 35%. 27 The most common complications are infection, bleeding, and failure to remove an adequate amount of foreskin resulting in a "retained" foreskin or adhesions to the glans. Although meatitis and meatal stenosis are often listed as complications of circumcision, there are no wellcontrolled, cohort related studies to document this relation. Circumcision "disasters," such as necrosis of the glans or skin sloughs, are very rare. Recent reports have noted no deaths from circumcision in 500,000 patients in New York City41 or 175,000 patients in US Army hospitals.40
There are no absolutes regarding circumcision, and the decision to circumcise a child as a newborn or otherwise must be made after carefully weighing the alternatives to, and risks and benefits of, this common surgical procedure. These alternatives, risks, and benefits must be fully explained to parents considering circumcision, and informed consent must be obtained. In well-trained, experienced hands, circumcision is a safe procedure that effectively eliminates proven problems such as cancer of the penis, and may eliminate the problems of increased risk of urinary tract infection and sexually transmitted diseases.
1. Kaplan G: Circumcision, an overview. Curr Probl Pediatr 1977; 7:1-33.
2. Standards inni Recommendations for Hospital Care of Newborn Infants, ed 5. American Academy of Pediatrics. 1971. p 110.
3. Ad Hoc Task Force on Circumcision. Pediatrics 1975; 56:609-611.
4. Sehnen EJ. Anderson GF. Bohon C, et al: Report itfthe AAP Task Fune un Crrcumcisum. American Academy of Pediatrics. 1988. in press.
5. Oster J: Further fate of the foreskin. Arch Dis Child 1968; 43:200-203.
6. Gairdner D: The fate of the foreskin: A study of circumcision. Br Med I 1949; 2:1433-1437.
7. Anand KS. Hickey PR: Pain and its effects in the human neonate and fetus. N Eng J Med 1987: 317:1321-1329.
8. Herzig LW. Alvarez SR: The frequency of foreskin problems in uncircumcised children. Am J Dis Child 1986: 140:254-256.
9. Dagher R. Selzer ML. Lapides J: Carcinoma of the penis and the anti-circumcision crusade. J Und 1973: 110:79-80.
10. Hadner GJ. Bhanalaph T. Murphy GP, et al: Carcinoma of the penis: Analysis of therapy in 100 consecutive cases. J Urol 1972: 108:428-430.
11. Persky L. DeKemion J: Carcinoma of the penis. CA 1986: 253:251-273.
12. Kochen M. McCunly S: Circumcision and the risk of cancer of the penis: A lite-table analysis. Am J Dis Child 1980: 134:484-486.
13. Young JL. Percy CL, Asire AJ: Surveillance, epidemiology and end results, incidence and mortality data 1971-1977. Natl Cancer Inst Mumug 1981: 57:17.
14. Wallerstein E: Circumcision. The uniquely American medical enigma. Und Clin North Am 1985; 12:121-112.
15. Gartinkel L Circumcision anJ penile cancer. CA 1983:33:320.
16. Ginsberg CM. McCrackcn GH: Urinary tract infections in circumcised mole infants. Pediatrics 1982; 69:409-412.
17. Wiswell TE. Smith FR. Buss JW: Decreased incidence of urinary track infections in circumcised male infants. Pediatrics 1985: 75:901-903.
18. Wiswell TE. Erccnaucr RW. Holron ME. et al: Declining frequency of circumcision. Implications for changes in the absolute incidence and male to female sex ratio of urinary tract infecrions in early infancy. Pediatrics 1987; 79:338-342.
19. Wiswell TE. Geschke DW: Risks from circumcision during the lust month of life compared wir those of the non-circumcised state. Pediatrics 1988; in press.
20. Roberts JA: Circumcision and urinary tract infections. Presented, at the Annual Meeting of the American Academy of Pediatrics. New Orleans. Nov 3, 1987.
21. Wilson RA: Circumcision and venereal disease. Con Med Assoc J 1947: 56:54-56.
22. Fink AJ: A possible explanation for heterosexual male infection with AIDS. N Engl J Med 1986; 316:1167.
23. Parker SW. Stewart AJ. Wren MN, et al: Circumcision and sexually transmissable disease. Med J Aust 1983; 2:288-290.
24. Tactor PK, Rodin P: Herpes geniralis and circumcision. Br J Vener Dis 1975; 51:274-277.
25. Thirumuothy T, Ing EH, Doraisingham; S. et at Purulent penile ulcers of patients in Singapore. Genitanium Med 1986; 62:253-255.
26. Smith GL. Greenup R. Takafuji ET: Circumcision as a risk factor for urethritis in racial groups. Am J Public Health 1987; 77:452-454.
27. Kaplan GW: Complications of circumcision. LM Clin North Am 1983; 10:543-549.
28. Wamer E, Strashin E: Benefits and risks of circumcision. Can Med Assoc J 1981; 125:967-976.
29. Stang HJ, Cunnar MR. Snellman L. et al: Local anesthesia for neonatal circumcision. Effect on disrress and cortisol response. JAMA 1988; 259:1507-1511.
30. Dixon S, Snyder J, Holve R, et al: Behavioral effects of circumcision with and without anesthesia. J Der Behav Pediatr 1984; 5:246-250.
31. Marshall RE, Stratton WC Moore JA. et al: Circumcision: Effects upon newborn behavior. Infant Behav Dev 1980; 3:1-14.
32. Marshall RE. Porter FL. Rogers AC. et al: Circumcision: II. Effects upon motherinfant interaction. Early Hum Der 1982; 7:367-374.
33. Calnan M. Duuglas JW, Goldstein H: Tonsillectomy and circumcision:Comparison of two cohorts. Int J Epidemiol 1978; 7:79-85.
34. Holve RL, Bromberger BJ. Growerman HD. et al: Regional anethesia during newborn circumcision: Effect on infant pain response. Clin Pediatr 1983; 22:813-818.
35. Kirya C. Wenthmann MW: Neonatal circumcision and penile dorsal nerve Mock: A painless procedure. J Pediatr 1978; 96:998-1000.
36. Maxwell LG. Vaster M, Werzel RC: Penile nerve Hock reduces the physiologic stress of newborn circumcision, abstracted. Anesthesiology 1986; 65:432.
37. Williamson PS. Williamson ML: Physiologic stress reduction by a local anesthetic dunng newborn circumcision. Pediatrics 1983; 71:16-40.
38. Gee WF, Ansell JS: Neonatal circumcision: A ten-year interview with comparison of the Gomco clamp and the Plastibell device. Pediatrics 1976; 58:824-827.
39. Harkavy KL: The circumcision debate. Pediatrics 1987; 79:649-650.
40. Wiswell TE: Reply to Harkavy. Pediatrics 1987: 79:649-650.
41. King LR: Neonatal circumcision in the United States in 1982. J Urol 1982: 128:1135-1136.
Surgical Techniques for Newborn Circumcision