I.8.5 Circumcision 203

volume disease (prophylactic lymphadenectomy) has a I.8.4.6 survival benefit compared to the delayed treatment of Results of Treatment clinically involved nodes. The improved survival for It is usually possible to provide good local control for some patients must be balanced with considerable penile cancer by all approaches for early disease (Ta– morbidity of lymphadenectomy. Tumour grade does T2), but for more advanced disease surgery is usually have some prognostic significance. This probably re- the preferred option. flects the propensity of poorly differentiated tumours The survival figures of penile cancer are summa- to metastasize, but it should not be forgotten that well- rized in Table I.8.10. differentiated tumours also metastasize.

Table I.8.10. Survival figures for penile cancer. Percentages are I.8.4.8 mean 5-year survivals from various reported studies Prevention Treatment Survival (%) at tumour stage As has been described previously, early circumcision I II III IV can prevent the development of penile cancer, but re- Surgery6542270 cent epidemiological studies from Scandinavia have Radiotherapy 68 51 21 5 suggested that good hygiene associated with improved Adapted from Gillenwater J, Howards S, Grayhack J, Mitchell socioeconomic status can lead to a decreased incidence ME (2001) Adult and Pediatric Urology, 4th edn. Lippincott, of this disease. Wilkins & Williams, Philadelphia, p. 1990 I.8.4.9 I.8.4.7 Other Prognosis An increased incidence of cervical and vulval cancer As can be seen in the preceding section, patients with has been demonstrated in partners of patients with pe- localized disease have a good prognosis; however, nile cancer. This observation certainly appears to con- when there is evidence of spread (except in cases with firm that there is likely to be a common transmissible minimal inguinal node involvement) the results of factor in the development of these diseases. Recently treatment are rather disappointing. Several retrospec- there has been hope expressed that vaccination against tivestudieshaveshownthepresenceoflymphnodal HPV will prevent cervical cancer and one would hope involvement has a marked impact on survival. Others that a similar approach might bear fruit in preventing I.8 have additionally demonstrated that removal of low- the development penile cancer in some patients.

I.8.5 Circumcision C.F. Heyns, J.N. Krieger

Key Messages ■ Circumcision is the most ancient surgical ficiencyvirus(HIV),maybetwotoeighttimes procedure known, and has generated more higher in uncircumcised men, but there is not controversy than any other operation. yet any evidence that circumcision is a cost- ■ Medical indications for circumcision include effective strategy to reduce the infection rate. pathological (cicatrizing) phimosis, recurrent ■ Neonatal circumcision confers a threefold paraphimosis, recurrent balanitis, condylo- reduced risk of penile cancer, but almost two mata acuminata involving the foreskin and complications of circumcision can be expected glans, recurrent coital injury of the prepuce, for every case of penile cancer prevented. and placement of a penile prosthesis. ■ Although scientific evidence demonstrates ■ Neonatal circumcision may confer a three- to some medical benefits of circumcision, these sevenfoldreducedriskofurinarytractinfec- data are not yet sufficient to recommend tion (UTI), but the risk of UTI in an uncircum- routine neonatal circumcision. cised male infant is only about 1%. ■ The risk for acquiring sexually transmitted infections (STI), including human immunode- 204 I.8 Benign Lesions and Malignant Tumours of the Male Genital Tract

I.8.5.1 I.8.5.2 Introduction Epidemiology of Circumcision

Circumcision is the oldest surgical procedure in the There are substantial differences in circumcision rates world, and remains one of the most controversial sub- in different parts of the world, but approximately 80% jects in medicine. It has been practised for thousands of of the world’s males are uncircumcised. The prevalence years among certain peoples on all the inhabited conti- of neonatal circumcision is influenced by religious af- nents,andinEgypttheprocedurecanbedatedbackto filiation, country of origin, ethnicity, residential area, at least 6,000 years ago (Fig. I.8.16). The Jewish practice maternal education, socioeconomic status, type of of circumcision precedes its documentation in the To- health insurance and the attitudes of parents and physi- rah by over 1,000 years, and it is not a prerequisite for cians (Kaplan 1983; Laumann et al. 1997; Lerman and being Jewish. Circumcision was a common practice in Liao 2001). pre-Islamic Arabia and is considered an external sym- In the United States, the rate of neonatal circumci- bolofbeingaMuslim,butnotaconditionforbecoming sion declined from about 90% in the 1950s to around one. 60–70% in the 1980s, while recent studies have re- The real motives for circumcision in ancient cul- ported rates varying from 65% to 82%. Circumcision is tures are open to speculation, but theories suggest that veryuncommoninEuropeancountries,Centraland it originated as a: South America and Asia. In the UK, circumcision rates fell from about 30% in 1940 to 6% by 1975. South Korea 1. Rite of passage or initiation ceremony is the only Asian country where circumcision has been 2. Mark of defilement imposed on slaves or prisoners widely performed since the Korean war in the 1950s, of war with a circumcision rate for high school boys above 3. Form of social control in patriarchal societies 90% (Gairdner 1949; Frisch et al. 1995; Niku et al. 1995; 4. Method of “pain imprinting” to enhance the child’s Dunsmuir and Gordon 1999; Goldman 1999; Ham- ability for survival later in life mond 1999; Rickwood 1999; Quayle et al. 2003; Alanis 5. Mark of cultural identity and Lucidi 2004). 6. Fertility rite 7. Hygienic or preventive health intervention 8. Measure to control male sexuality I.8.5.3 9. Rite of male bonding Embryology and Function of the Foreskin (Gairdner 1949; Kaplan 1983; Dunsmuir and Gor- Development of the prepuce begins at 8–12 weeks I.8 don 1999; Elchalal et al. 1999; Glass 1999; Goldman of intrauterine life and is usually complete by 16– 1999; Goodman 1999; Hammond 1999; Rizvi et al. 20 weeks. The epithelium of the inner prepuce and 1999; Lerman and Liao 2001; Alanis and Lucidi glansisstratifiedsquamousintype,withbothlayers 2004).

Fig. I.8.16. Modern replica on papyrus of a decoration from the tomb of Ankh- Mahor at Saqqara (2400 BCE), depicting circumcision in ancient Egypt I.8.5 Circumcision 205 initially fused to each other. Separation of the prepuce duringthe1styearoflife.Afterabout5yearsofage,pe- from the glans begins by 24 weeks of gestation, but is riurethral colonization by uropathogens is found only usually incomplete at birth. Thus, the normal neonatal in boys who get recurrent UTIs (Gairdner 1949; Øster prepuce is not retractable. During the first 3–4 years of 1968; American Academy of Pediatrics 1999; Cold and life, the prepuce and glans separate as a consequence of Taylor 1999). several processes, including growth of the penile body, The prepuce is often regarded as a redundant vesti- accumulation of epithelial debris (smegma) and inter- gial structure, but its functions may include: mittent penile erections. Ventral or dorsal preputial de- 1. Preventing meatal ulceration due to injury of the velopmentisusuallydeficientwithhypospadiasand glans by contact with sodden nappies epispadias, respectively (Kaplan 1983; Niku et al. 1995; 2. Enhancing the pleasure of sexual activity by means Cold and Taylor 1999; Lerman and Liao 2001). of its sensory innervation Gairdner (1949) found that the incidence of a nonre- 3. Providing lubrication for atraumatic vaginal inter- tractable prepuce progressively decreased from 96% in course newborns to 6% in boys aged 5–13 years. Similarly, 4. Forming part of the cutaneous mucosal immune Øster (1968) found that the foreskin was retractable in system, because it contains Langerhans cells almost all boys by 17 years of age (Fig. I.8.17). 5. Being a source of live human fibroblasts for cell- Kayaba et al. (1996) classified preputial status into culture research five types based on retractability and found that the in- 6. Providing tissue for genital tract reconstructive cidenceoftypeVprepuce(easyexposureofthewhole surgery glans) increased from 0 in boys younger than 1 year to (Gairdner 1949; Cold and Taylor 1999; Dunsmuir 63% in those 11–15 years old. A tight prepuce, defined and Gordon 1999; Hammond 1999). as a stenotic ring that prevented the prepuce from being retracted, decreased from 84% at ages 0–6 months to 9% at 11 –15 years. I.8.5.4 Smegma is a white, creamy material consisting of desquamated epithelial cells which may collect under Indications for Circumcision theprepuce.Malesmegmacontainssteroids,sterols Indications for circumcision include: and fatty acids which may have a protective function. 1. Pathological phimosis In boys 5–13 years old, inspissated smegma may be- 2. Recurrent paraphimosis come malodorous, which does not occur in younger 3. Recurrent balanitis or balanoposthitis boys. The production of smegma increases in quantity 4. Lichen sclerosus of the penis (balanitis xerotica ob- I.8 at the age of 12 –13 years. literans) Uropathogenic bacteria adhere to and readily colo- 5. Condylomata acuminata (if extensive) and rare le- nize the mucosal (inner) surface of the foreskin. In sions such as lymphogenous cysts of the prepuce, newborn boys, the periurethral area is colonized with and chronic penile lymphoedema aerobic bacteria, especially Escherichia coli, enterococ- 6. In preparation for placement of a penile prosthesis ci and staphylococci, but this colonization disappears (not always necessary)

7. As part of genital reconstructive surgery for hypo- % spadias or urethral stricture 100 8. Nonmedical indications: religious, cultural (paren- 90 tal advice), social (peer pressure), or personal (en- 80 Gairdner – Non-retractable prepuce hanced sexuality or self-image of a larger penis) (Niku et al. 1995; Cold and Taylor 1999; Kim et al. 70 Øster – Phimosis 1999; Rickwood 1999; Fink et al. 2002). 60 50 I.8.5.4.1 40 Pathological Phimosis 30 Physiological phimosis (nonretractable foreskin) seen 20 in the infant is not an indication for circumcision. 10 Whenonedrawsthepenileshaftskintowardsthebase 0 of the penis, a pinpoint opening is frequently noted, 0 0.25 0.5 1 2 3 4 5 6–7 8–9 10– 12– 14– 16– creating the impression of pathological phimosis. How- 11 13 15 17 Age (years) ever, if one were to draw the prepuce distally instead, Fig. I.8.17. Incidence of a nonretractable prepuce and phimosis one would see that the preputial opening is quite wide related to age (data derived from Gairdner 1949; Øster 1968) and would not interfere with voiding. This is often mis- 206 I.8 Benign Lesions and Malignant Tumours of the Male Genital Tract

takenly termed pin-hole meatus, but it is not an indica- liberating ammonia from the urea in urine. Other cases tion for circumcision. of balanoposthitis are related to contact dermatitis, True pathological phimosis is characterized by a fixed drug eruption, or psoriasis. white, scarred and/or indurated meatal orifice, with no The incidence of balanoposthitis is about 3% in un- “flowering” on attempted retraction of the foreskin. circumcised male children, and only one-third of these True phimosis is rare below the age of 5 years, and af- experience recurrences. It occurs most often in boys fectsonly0.6–4%ofboysbytheageof17,and0.9%of between 5 and 11 years old, suggesting that it is ulti- men aged 19–31 years. Pathological (cicatrizing) phi- mately self-limiting. In adult men, balanitis may occur mosis shows histological appearances characteristic of five times more often in uncircumcised men, especially balanitis xerotica obliterans (BXO), identical to those monilial balanitis in the setting of diabetes mellitus. of vulval lichen sclerosus et atrophicus. Some authors However, circumcised carriers are more likely to be believe that secondary phimosis may be due to at- asymptomatic, potentially making these men a more tempts to retract the prepuce, causing tissue damage insidious vector for the spread of yeast infections to and scar formation, or that chronic inflammation of the women. Clinical experience suggests that diabetics foreskin may lead to scarring. True pathological phi- with recurrent balanoposthitis benefit substantially mosis that is resistant to topical corticosteroid treat- from circumcision, but there are no prospective studies ment represents an absolute indication for circumci- on the value of prophylactic circumcision in diabetic sion. However, some patients may prefer to avoid ste- men. Zoon’s balanitis may require circumcision, but roid therapy and to proceed directly to circumcision topical steroid cream or carbon dioxide laser therapy (Gairdner 1949; Øster 1968; Kaplan 1983; Rickwood are alternative treatments (Gairdner 1949; Kaplan 1983; 1999; Kim et al. 1999; Larsen and Williams 1990). Kayaba et al. 1996; Rickwood 1999; Van Howe 1999; Lerman and Liao 2001). I.8.5.4.2 Recurrent Paraphimosis I.8.5.4.4 Penile Prosthesis Paraphimosis (phimotic prepuce retracted behind the glans with swelling) is not so rare, especially on a uro- Some authors advise circumcision before placement of logical service where many cases occur after proce- a semi-rigid penile prosthesis to avoid an oedematous dures, but most can be managed conservatively, so that inner-tube deformity of the subglanular skin. However, neonatal circumcision to prevent paraphimosis is not in men who prefer to remain uncircumcised, satisfacto- I.8 warranted. Reduction under local or general anaesthet- ry results may be obtained after the initial preputial oe- ic is almost always possible without requiring a dorsal dema resolves. If balanoposthitis is present, a first- slit. Circumcision should be considered only for the stage circumcision is advised to reduce the risk of infec- rare case experiencing recurrent episodes of paraphi- tion (Lewis and Jordan 2002). mosis, in patients whose paraphimosis cannot be reduced, or in uncircumcised elderly men who require I.8.5.5 intermittent or chronic bladder catheterization, and who may have a higher risk of paraphimosis (Gairdner Contraindications for Circumcision 1949; Dunsmuir and Gordon 1999; Rickwood 1999; Contraindications to performing neonatal circumci- Lerman and Liao 2001). sion include: 1. Prematurity, or if there is any concern about the I.8.5.4.3 well-being of the neonate Recurrent Balanitis/Balanoposthitis 2. Any blood dyscrasia, haemophilia, or family history of a bleeding disorder Infection or inflammation of the glans (balanitis) and 3. If the ventral foreskin is short or absent foreskin (posthitis) may occur in isolation, but simulta- 4. A dorsal hood deformity neous involvement of both structures (balanoposthitis) 5. Hypospadias or epispadias is much more common. Acute balanoposthitis is char- 6. Ventral or dorsal chordee, with or without hypo- acterized by erythema and oedema of the prepuce and/ spadias or purulent discharge from the preputial orifice. Com- 7. Megameatus with an intact prepuce mon causative organisms are E. coli and Proteus vulga- 8. Megalourethra ris, although in about 30% of cases in children the pre- 9. A webbed, small or inconspicuous penis putial discharge is sterile. In adults, most cases are re- (Kaplan 1983; Niku et al. 1995; Glass 1999). lated to mixed infection, often including anaerobes and fungi, especially in diabetics. Posthitis may be part of an ammonia dermatitis due to urea-splitting bacteria I.8.5 Circumcision 207

are minor and of no clinical consequence, but fatal hae- I.8.5.5.1 morrhage may be caused by bleeding disorders (Gaird- Redundant Prepuce ner 1949; Kaplan 1983). Ammonia dermatitis involving the prepuce may cause thickening of the skin, and this is often labelled a “re- I.8.5.6.2 dundant prepuce”, a misnomer that may lead to unnec- Infection essary circumcision. Preputial dimensions vary little between individuals, therefore true “redundant fore- Wound infection is the second most common compli- skin” does not exist and the term, like “pin-hole mea- cation, with a reported incidence of 0.2–10%. Most of tus”, should be discarded (Gairdner 1949; Kim et al. these infections are minor and of no consequence. Hes- 1999; Rickwood 1999). itancy and dysuria is seen in as many as 60% of older boys, and UTI may occur. Ritual circumcision in rural areas of developing countries often takes place under I.8.5.5.2 unsanitary conditions, which may contribute to infec- Ballooning of the Foreskin tive complications (Kaplan 1983; Crowley and Kesner A nonretractile foreskin is often associated with bal- 1990; Wiswell et al. 1993; Niku et al. 1995; Senkul et al. looning of the prepuce during micturition. In child- 2004). hood, the condition is self-limiting, there is no evidence that it signifies urinary tract obstruction and it I.8.5.6.3 does not require circumcision (Gairdner 1949; Rick- Recurrent Phimosis wood 1999; Babu et al. 2004). When insufficient skin has been removed, the cosmetic appearance is such that the penis does not appear to I.8.5.5.3 have been circumcised. If there is contraction or fibro- Preputial Adhesions sis of the preputial ring, true recurrent phimosis can be Preputial adhesions are usually harmless and self-lim- produced, which manifests as a concealed penis (Ka- iting and give rise to symptoms only when their break- plan 1983; Williams et al. 2000; Lerman and Liao 2001; down results in minor episodes of inflammation. The Blalock et al. 2003). “separation of preputial adhesions” represents unnecessary treatment (Øster J 1968; Rickwood 1999). I.8.5.6.4 Skin Bridge I.8 I.8.5.6 A skin bridge between the penile shaft and the glans Complications of Circumcision may tether the erect penis, with resultant pain or penile The true incidence of complications after circumcision curvature. It may result from injury to the glans, or is unknown, because the reported rates vary widely, de- from failure to completely free the inner preputial epi- pending on the type of study (survey vs chart review vs thelium from the glans at the time of circumcision (Ka- prospective), setting (medical facility vs community), plan 1983). operator (physician vs ritual circumciser), type of in- strument used, definitions of specific complications, I.8.5.6.5 and length of follow-up. Some studies have reported a Meatitis/Meatal Stenosis complication rate of 0.2–0.6% for neonatal circumcision, whereas others have mentioned figures ranging Meatitis and meatal ulcers probably occur because the from 1.5% to 10%. The most common complications glans is no longer protected by the prepuce from the ef- are haemorrhage, infection, meatal stenosis, frenular fect of ammonia produced by bacterial action on urine, ulcer, buried (trapped) penis, preputial adhesions, and and the reported incidence is 8–31%. Ulcerative mea- incomplete or inadequate circumcision (Gee and An- titis may lead to meatal stenosis, with a reported inci- sell 1976; Kaplan 1983; Niku et al. 1995; Ahmed et al. dence of 5–10%. Meatal stenosis may also possibly re- 1999; Rizvi et al. 1999; Amir et al. 2000; Christakis et al. sult from devascularization caused by cutting of the 2000; Sylla et al. 2003; Alanis and Lucidi 2004). frenular artery during circumcision (Gairdner 1949; Kaplan 1983; Niku et al. 1995; Cold and Taylor 1999; Rickwood 1999). I.8.5.6.1 Haemorrhage Haemorrhage is the most common complication, with a reported incidence of 0–35%. Most of these episodes 208 I.8 Benign Lesions and Malignant Tumours of the Male Genital Tract

I.8.5.6.6 Pain There is evidence that during and after neonatal circumcision, babies experience significant pain which can disrupt breast-feeding, mother–infant bonding and sleeping patterns (Goodman 1999; Van Howe et al. 1999; American Academy of Pediatrics 1999; Alanis and Lucidi 2004).

I.8.5.6.7 Rare Complications Rare but serious complications may occur after cir- Fig. I.8.18. Gangrene of the penis probably due to use of a tour- cumcision, although their true incidence is unknown, niquet after ritual circumcision in a young adult who subse- becausewehavenodenominatordata.Rarebutserious quently died of systemic sepsis and multi-organ failure despite infective complications include septicaemia, Fournier’s emergency penile amputation and treatment in an intensive gangrene (necrotizing fasciitis), staphylococcal scalded care unit skin syndrome (toxic epidermal necrolysis), meningi- tis, neonatal tetanus, and poststreptococcal glomerulo- Howe 1999; Patel et al. 2001; Ncayiyana 2003; Gesund- nephritis. Tuberculosis of the penis and genital HSV-1 heit et al. 2004). infection have been described after Jewish ritual circumcision in which a mohel (ritual circumciser) performed oral metzitzah (sucking on the baby’s penis to I.8.5.7 stop the bleeding). Hepatitis B and C may also be trans- Current Controversies About Circumcision mitted during ritual circumcision. I.8.5.7.1 Chordee can be produced by a dense scar on the ven- Prevention of Genital Cancer trumofthepenis.Bothhypo-andepispadiashavebeen produced by inadvertently splitting the glans. Epider- Neonatal circumcision offers some protection against mal inclusion cysts may be produced by the rolling-in invasive penile cancer, but it has a less protective effect I.8 of epidermis at the time of suturing, or by the implanta- against carcinoma-in-situ. Circumcision after the neo- tion of smegma in the circumcision wound. Penile natal period still carries the risk of development of pe- lymphoedema may occur, especially if the wound sepa- nile carcinoma, while adult circumcision offers little or rates or becomes infected. Urinary retention may occur no protection. There appears to be at least a threefold secondary to a tight haemostatic bandage, and may increased risk of penile cancer in uncircumcised men, lead to urosepsis, systemic infection, renal failure or and phimosis increases this risk further. However, the bladder rupture. Urethrocutaneous fistula may be estimated annual incidence of penile cancer is low, caused by crushing the urethra with the circumcision ranging from 0.1/100,000 men in Israel to 1/100,000 in clamp, incising it with a knife or with a suture placed the United States and 10.5/100,000 in India. Therefore, for haemostasis, or by tissue damage due to electrocau- even if the risk is increased more than threefold, the tery. likelihood of penile cancer developing in an uncircum- Amputation of the distal glans or penis with a Mo- cised man is very low. Moreover, there are alternative gen clamp, and penile denudation or degloving injury preventive measures, such as maintaining genital hy- may occur. Necrosis and slough of the glans or entire giene. One study estimated that circumcision decreases penis may result from infection, the use of solutions the number of quality-adjusted life years by a mean of containing epinephrine, attempts at haemostasis with 14 h, while another found a mean increase of just suture or cautery, prolonged use of a tourniquet or tight 10 days. It has been estimated that with neonatal cir- bandage, or using contact laser (Fig. I.8.18). Other rare cumcision almost two complications can be expected complications include acute heart failure, pneumotho- foreverycaseofpenilecancerprevented(Gairdner rax, gastric rupture, pyogenic granuloma, and subgla- 1949; Kaplan 1983; Ganiats et al. 1991; Lawler et al. nular stricture causing a mushroom-like deformity. 1991; Frisch et al. 1995; American Academy of Pediat- Death after circumcision may occur due to haemorrha- rics 1999; Van Howe et al. 1999; Christakis et al. 2000; ge, sepsis, or anaesthesia (Gairdner 1949; King 1982; Schoen et al. 2000; Lerman and Liao 2001; Alanis and Kaplan 1983; Sotolongo et al. 1985; Crowley and Kesner Lucidi 2004). 1990; Niku et al. 1995; Laumann et al. 1997; Dunsmuir Despite conflicting evidence, it appears that male and Gordon 1999; Glass 1999; Rizvi et al. 1999; Van circumcision, together with factors such as monogamy, I.8.5 Circumcision 209 sexual hygiene and the use of barrier contraceptives, circumcision status, which could bias studies linking may reduce the incidence of cervical cancer in female STIs to lack of circumcision. However, in recent studies partners (Niku et al. 1995; Shanta et al. 2000; Castells- there appears to be a consistent trend indicating that ague et al. 2002). uncircumcised males may be two to seven times more susceptible to genital ulcer disease (GUD), i.e. herpes, syphilis and chancroid, with lymphogranuloma vene- I.8.5.7.2 reum (LGV) in some populations, while circumcised Prevention of Urinary Tract Infection men are more prone to urethritis. The ulcerative STIs Bacterial adherence to the epithelial cells of the fore- (GUD) are especially important as they are associated skin leading to periurethral colonization of the prepu- with breaks in the genital skin and recruitment of in- tial sac may predispose to UTI, which may be prevented flammatory cells, with a two- to fourfold increase in the by circumcision. Recent studies, using cohort and rate of HIV infection and transmission. It has been pro- case–control design, indicate a three- to sevenfold in- posed that, in populations in which safe sexual prac- creased risk of UTI in uncircumcised boys, with the tices are not adhered to, routine circumcision may help greatest risk in infants younger than 1 year of age. How- to prevent STIs (Cook et al. 1994; Laumann et al. 1997; ever, the absolute risk of developing a UTI in an uncir- Goldman 1999; Lavreys et al. 1999; VanHowe 1999; Dis- cumcised male infant is low (at most about 1%). The eker et al. 2001; Alanis and Lucidi 2004; Reynolds et al. relationship between young age at first symptomatic 2004). UTI and subsequent renal scar formation and decreased glomerular filtration is not well defined, and I.8.5.7.4 there is a lack of information on the sequelae of UTI in Prevention of Human Immunodeficiency Virus Infection infants with a normal urogenital tract. The total cost of managing UTI in uncircumcised males may be ten Studies on the relationship between circumcision sta- times higher than for circumcised males, but there is no tus and the risk of HIV infection have produced con- evidence that neonatal circumcision is a cost-effective flicting results, and it is possible that behavioural fac- prophylactic measure in the management of UTI in tors may be more important than circumcision. How- children. It has been estimated that it may take 80–100 ever, it appears likely that there is at least a two- to neonatal circumcisions to prevent one UTI, while six eightfold increased risk of HIV infection among uncir- UTIs can be prevented for every complication of cir- cumcisedmenathighriskforHIV.Theageatcircumci- cumcision endured. UTI develops more often in uncir- sion may be a critical factor, with the strongest protec- cumcised patients with vesico-ureteric reflux (VUR), tive effect seen in those circumcised before the age of I.8 because antibiotic prophylaxis is not effective in reduc- 12, and no effect in those circumcised after the age of ing bacterial colonization of the prepuce. Therefore, a 20. Recommending circumcision as a public health persuasive case can be made for circumcision in male measure for the prevention of HIV should await the re- infants known to have major VUR or other significant sults of controlled clinical trials which are at present structural urinary tract abnormalities. UTI may occur being conducted. However, the fact that up to 30% of in up to 5% of hospitalized premature infants, suggest- circumcised African men believe that circumcision ing that neonatal circumcision may prove beneficial in protects them completely against HIV and that they these babies, although the operative risk may be higher could safely have sex with multiple partners, may ne- (Wiswell et al. 1993; American Academy of Pediatrics gate any beneficial effects of removing the foreskin. 1999; Rickwood 1999; Cason et al. 2000; Christakis et al. Furthermore, the cost-effectiveness of circumcision as 2000; Schoen et al. 2000; Cascio et al. 2001; Alanis and a preventive measure against HIV transmission needs Lucidi 2004; Mingin et al. 2004). to be carefully considered (Laumann et al. 1997; Ameri- can Academy of Pediatrics 1999; Lavreys et al. 1999; Van Howe 1999; Quinn et al. 2000; Weiss et al. 2000; Ler- I.8.5.7.3 man and Liao 2001; Siegfried et al. 2003; Alanis and Lu- Prevention of Sexually Transmitted Infection cidi 2004; Reynolds et al. 2004). Most of the earlier studies linking uncircumcised status with STIs were not adequately adjusted for potentially I.8.5.7.5 confounding factors, such as race, age, socioeconomic Sexual and Psychological Consequences of Circumcision status, level of education, number of lifetime sexual partners, frequency of sexual contacts or previous STIs, It has been suggested that the severe pain of circumci- or cultural, ethnic and healthcare-seeking differences. sion and the disrupted mother–infant bond may have Moreover, a substantial percentage of boys and men re- long-lasting negative emotional consequences such as port their circumcision status incorrectly, and even feelings of mutilation, low self-esteem, rage, resent- physicians commit errors in the classification of male ment,depression,andasenseofviolationorparental 210 I.8 Benign Lesions and Malignant Tumours of the Male Genital Tract

betrayal. Decreased sensitivity of the penis after adult bovic et al. 1996; Monsour et al. 1999; Rickwood 1999; circumcision may be perceived as favourable, giving Webster and Leonard 2002; Ashfield et al. 2003). more control over orgasm, or as an irretrievable loss. Surveys of adult men before and after circumcision I.8.5.8.2 found no significant difference with regard to sexual Retraction of the Foreskin drive, erection, ejaculation or overall satisfaction, although the mean ejaculatory latency time was signifi- Attempting to free the prepuce forcibly from the glans cantly longer (Goldman 1999; Hammond 1999; Kim et in small boys usually results in pain and bleeding, and al. 1999; O’Hara and O’Hara 1999; Senkul et al. 2004). runs the risk of glanular excoriation and injury, with resultant scarring and phimosis, as well as psychological trauma. Forcible retraction of the foreskin can lead I.8.5.7.6 to paraphimosis, and should be avoided (Gairdner Ethical and Legal Issues 1949; Kaplan 1983; Niku et al. 1995; Cold et al. 1999; Organizations for the protection of children’s rights as- Rickwood 1999). sert that neonatal circumcision is unethical, because children should not be subjected to prophylactic inter- I.8.5.8.3 ventions “in their best interests” or for public health Dorsal Slit and Preputioplasty reasons when alternatives exist. It has also been suggested that offering the parents medically unnecessary Thedorsalslitisrarelytoberecommendedasthecos- surgery that will benefit the physician and hospital but metic result is unsatisfactory. However, it is useful in el- not the patient is unethical. Some authors have chal- derly men with multiple medical problems who have lenged the legality of neonatal circumcision and argued severe balanoposthitis or recurrent paraphimosis. Pre- that it constitutes child abuse, assault and even torture. putioplasty may take the form either of a limited dorsal Several countries have passed specific legislation to slit, with transverse suture, or longitudinal incision of prohibit all forms of female genital mutilation (FGM), the “constrictive ring” proximal to the preputial mea- whereas other countries consider it illegal under exist- tus, again with transverse suture. However, it has been ing child-abuse laws. It has been argued that courts suggested that preputioplasty is a treatment for unre- have the duty to extend the protection against FGM to tractile foreskin, and not for pathological phimosis, male neonatal circumcision. It has also been pointed where the operation is either ineffective from the out- outthatproponentsoftheargumentthatFGMand set, or later becomes so as the disease process resteno- I.8 male circumcision are radically different, provide no ses the orifice (Cuckow et al. 1994; Rickwood 1999; Bar- principled basis and little empirical support for treat- ber et al. 2003). ing male and female genital alteration differently (Lau- mann et al. 1997; Elchalal et al. 1999; Freeman 1999; I.8.5.8.4 Goodman 1999; Van Howe et al. 1999; Hodges et al. Uncircumcision 2002). Surgicalprocedurestorestoretheprepucewerefirst describedbyCelsus2,000yearsago,andseveralmodi- I.8.5.8 fications have been described in the twentieth century. Alternatives to Circumcision More recently, some members of the “genital-integrity movement”haveseverelycriticizedneonatalcircumci- I.8.5.8.1 sion and have propounded the merits of uncircumci- Topical Steroids sion. For the surgeon undertaking preputial restora- Topical steroid treatment with betamethasone, triam- tion surgery, it is essential to carefully counsel the pa- cinolone, clobetasol or mometasone cream twice daily tient about the potential complications, cosmetic re- for 1 month has reported success rates of 67–95% with sults and unusual nature of the surgery (Kaplan 1983; no side-effects. Appropriate candidates are boys older Brandes and McAninch 1999). than 3 years who have persistent phimosis and no evidence of infection. Topical steroids were found to be I.8.5.9 successful in 87%, 88% and 75% of patients with phimosis alone, coexisting balanitis and a history of uri- Conclusions nary tract infection, respectively. Sceptics suggest that Male circumcision has long been used for religious and most of these boys had physiological phimosis (unre- cultural reasons to provide and reinforce group identi- tractable foreskin), but advocates of the treatment ty. These differences and preferences result in wide var- maintain that they included only boys in whom BXO iation in circumcision rates among different geograph- was diagnosed clinically by cicatricial phimosis (Golu- ic areas and in various groups. I.8.5 Circumcision 211

Male circumcision for specific medical indications Cason DL, Carter BS, Bhatia J (2000) Can circumcision prevent clearly confers advantages. Well-established and gener- recurrent urinary tract infections in hospitalized infants? ally accepted indications for male circumcision include Clin Pediatr (Phila) 39:699–703 Castellsague X, Bosch FX, Munoz N, Meijer CJ, Shah KV, de pathological phimosis, recurrent paraphimosis, recur- Sanjose S, Eluf-Neto J, Ngelangel CA, Chichareon S, Smith rent balanoposthitis, extensive condylomata acumina- JS, Herrero R, Moreno V,Franceschi S; International Agency ta, and as part of genital reconstructive surgery. forResearchonCancerMulticenterCervicalCancerStudy Currently, there are at least four major controversies Group (2002) Male circumcision, penile human papilloma- virus infection, and cervical cancer in female partners. N in male circumcision: Engl J Med 346:1105–1112 1. The risk of genital cancer is definitely decreased by Cherpes TL, Meyn LA, Krohn MA, Hillier SL (2003) Risk factors for infection with herpes simplex virus type 2: role of neonatal circumcision, but from the perspective of smoking, douching, uncircumcised males, and vaginal flo- the risk-benefit ratio it is not a compelling preven- ra. Sex Transm Dis 30:405–410 tive health measure. ChristakisDA,HarveyE,ZerrDM,FeudtnerC,WrightJA, 2. The risk of UTI in boys is decreased after neonatal Connell FA (2000) A trade-off analysis of routine newborn circumcision, and the risk-benefit ratio is better circumcision. Pediatrics 105:246–249 Cold CJ, Taylor JR (1994) The prepuce. BJU Int [Suppl 1]:34–44 than with regard to genital cancer, but still not Cook LS, Koutsky LA, Holmes KK (1994) Circumcision and sex- good enough to recommend routine neonatal cir- ually transmitted diseases. Am J Public Health 84:197–201 cumcision. Crowley JP, Kesner KM (1990) Ritual circumcision (Umkwe- 3. The reduced risk of HIV infection is a very impor- tha) among the Xhosa of the Ciskei. Br J Urol 66:318–321 Cuckow PM, Rix G, Mouriquand PD (1994) Preputial plasty: a tant question for high-risk populations and one good alternative to circumcision. J Pediatr Surg 29:561–563 that is under active investigation, but evidence Diseker RA 3rd, Lin LS, Kamb ML, Peterman TA, Kent C, Zenil- from prospective clinical trials should be awaited manJ,LentzA,DouglasJMJr,RhodesF,MalotteKC,Iatesta before circumcision is propagated as an HIV pre- M (2001) Fleeting foreskins: the misclassification of male ventive measure. circumcision status. Sex Transm Dis 28:330–335 Dunsmuir WD, Gordon EM (1999) The history of circumci- 4. With regard to reduced sexual pleasure and ad- sion. BJU Int 83 [Suppl 1]:1–12 verse psychological effects, there is some anecdotal Elchalal U, Ben-ami B, Brzezinski A (1999) Female circumci- evidence, but this is generally not supported by sion: the peril remains. 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