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UNJ June 2006 C To Circ or Not to Circ: Indications, O N Risks, and Alternatives to T I N Circumcision in the Pediatric U I Population with Phimosis N G Barbara Steadman Pamela Ellsworth E D gyptian mummies and Circumcision, the removal of the foreskin, is perhaps the oldest iden- U wall carvings offer some tified and currently the most frequently performed elective surgical C of the earliest recorded procedure for males throughout the world. Neonatal circumcision history of circumcision may be performed for medical, cultural, or religious reasons. A review A Edating over 15,000 years ago. of risks and benefits of circumcision, individual indications for cir- T Ritualistic circumcision has been cumcision, as well as both medical and surgical alternatives to cir- I carried out in West Africa for cumcision in the pediatric population with phimosis are presented. O over 5,000 years and in the The intent is to offer providers and parents current information that N Middle East for at least 3,000 will assist them in making a responsible decision about pediatric cir- years (Warner & Strashin, 1981). cumcision. Muslims incorporated ritualistic circumcisions as a pubertal rite of passage into manhood among Soon the list of medical indica- Neonatal Circumcision: older boys. tions grew, and physicians in The World’s Most The transformation of this England and America began to Controversial Operation ancient ritual into a routine med- offer circumcision for masturba- ical operation began late in the Today, approximately 25% of tion, headache, strabismus, rectal men globally are circumcised for 19th century. This was primarily prolapse, asthma, enuresis, and the result of several published religious, cultural, medical, or gout (Gollaher, 1994). By the parental choice reasons (Moses, works by prominent physicians early 20th century, there was of the time. They believed that Bailey, & Ronald, 1998). They are near universal agreement among largely concentrated in the constriction of the glans by the physicians that circumcision prepuce led to nervous irritation United States, Canada, countries should be done on a routine in the Middle East and Asia with in other organ systems. Several basis. published works cited “reflex Muslim populations, and large Rates of circumcision began portions of Africa. Circumcision neuroses,” puzzling syndromes to drop in Britain in 1948, when with no somatic explanation, as is a widely observed religious a nationalized health care system practice performed almost uni- being caused by constriction of analyzed cost versus benefit. the glans (Alanis & Lucidi, 2004). versally among Jewish and Circumcision is currently avail- Islamic societies. Jewish males able through National Health are usually circumcised on the Barbara Steadman, MS, NP, is a Insurance for medical indica- 8th day after birth in a ceremony Urology Nurse Practitioner, UMass tions only. In the early 1970s, called the Bris Milah. Memorial Medical Center, Worcester, both the Australian and the A review of the literature MA. Canadian Pediatric Societies fol- about circumcision yields a mul- lowed, stating that routine titude of information that is Pamela Ellsworth, MD, is a Pediatric neonatal circumcision was not solidly anti or pro circumcision. Urologist, UMass Memorial Medical medically indicated. Despite The pro-circumcision argument Center, Worcester, MA. these changes, rates of circumci- is that infant circumcision pro- sion remained high in the United vides a valid prevention against Note: CE Objectives and Evaluation States. Form appear on page 197. infections and diseases. The UROLOGIC NURSING / June 2006 / Volume 26 Number 3 181 C Table 1. O Circumcision Incidence Percentage Rate by Region N Region Year T 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 I N Northeast 69.6 68.3 66.5 68.3 68.0 65.4 64.6 66.9 68.9 64.7 U North Central 80.1 79.8 80.9 81.6 82.9 81.4 81.4 81.0 81.0 77.8 I South 64.7 66.1 63.6 64.5 64.6 64.1 63.9 62.5 64.0 57.7 N West 34.2 42.6 36.3 38.0 38.3 36.7 37.3 40.9 32.6 31.4 G All Regions 62.7 64.1 60.2 62.8 63.2 61.5 62.4 63.1 60.1 55.9 E Source: Bollinger, 2005 D U C emphasis is on an increased risk chological problems interfere scientific evidence demonstrates of cancer and AIDS, arguing that with sexual health and well- potential medical benefits of A a full circumcision is the best being. Emphasis should be newborn male circumcision; T prevention over partial proce- placed upon individual solutions however, these data are not suffi- I dures or medical treatment to individual problems, depend- cient to recommend routine (Stuart, 2005). ing upon the degree of severity of neonatal circumcision” (Task O It is the general feeling of the phimosis, variation in cul- Force on Circumcision, 1999, p. N anti-circumcision advocates that ture, preferences, etc. Parents, 693). from an ethical or moral stand- who have the responsibility of point, routine infant circumci- making the decision on behalf of Epidemiology sion is an infringement of per- their sons should be made aware Circumcision today is uncom- sonal rights. Terms such as “bar- of the most recent literature con- mon in Asia, South America, baric” and “mutilation” are fre- cerning the potential health ben- Central America, and most of quently heard in association with efits and risks as well as alterna- Europe. In Canada, 48% of boys circumcision. A great majority of tives to circumcision. are circumcised; in the United anti-circumcision supporters are In the United States, the Kingdom, the number is approxi- extremists, and are not only American Academy of Pediatrics mately 24% (Blecher, 2001). against routine infant circumci- (AAP) (1971) has vacillated on its More recent surveys show a sion but also any form of circum- stance regarding circumcision. In continuing decline in the inci- cision or operation. Anti-circum- 1971, the American Academy of dence of circumcised males in cision proponents maintain that Pediatrics Task Force on Great Britain, and predict only phimosis is a rarity, occurring at Circumcision concluded that 1.5% of boys born today will be a frequency of only 1%. “there are no valid medical indi- circumcised by their 15th birth- However, recent literature cations for circumcision in the day if current trends continue reports that between 2.4% and neonatal period” (AAP, 1977, p. (Rickwood, 2000). 14% of uncircumcised youths 110). Similar views were Circumcision rates in the experience phimosis (Stuart, expressed in 1975 and 1977. United States vary according to 2005). When new evidence showed that racial, ethnic, and socioeconom- Both extremes suggest rou- circumcision effectively reduced ic factors, as well as geographic tine approaches with no consid- male urinary tract infections region. Whites are considerably eration for appropriate individ- (UTIs) and sexually transmitted more likely to be circumcised ual measures. A complete evalu- diseases, the AAP concluded that than blacks or Hispanics (81% ation and physical examination newborn male circumcision “has vs. 65% or 54%). Over the past of the genitalia and the expertise potential health benefits and 10 years, circumcision rates have in being able to identify any mal- advantages as well as disadvan- declined in Caucasians, Hispanics, formation before puberty is para- tages and risks” (Task Force on and African-Americans, but have mount. In that way, any abnor- Circumcision, 1989, p. 391). increased in Asians and American malities can be monitored, and However, the AAP returned to a Indians. In the United States, the conservative treatment can be more cautious view on routine frequency of circumcision varies initiated before physical and psy- circumcision, stating “existing directly with maternal educa- 182 UROLOGIC NURSING / June 2006 / Volume 26 Number 3 tion, a marker for socioeconomic Figure 1. C status (Laumann, Masi, & Physiologic Phimosis: Normal, Nonretractile O Zuckerman, 1997). Prepuce of Infancy Geographically, circumcision N rates have fluctuated over the T past 10 years. From 2002 to 2003, I declines occurred in all four regions of the United States. N Non-circumcision has been a U norm in the West for more than a I decade. The North Central Region continues to have the N highest incidence of circumci- G sion rates (see Table 1). Overall, it is estimated that E less than 60% of American boys are circumcised at birth. These D rates have changed since the U 1970s, when approximately 90% C of all newborn boys were circum- cised in the United States. A Changes in health care coverage T are likely to contribute further to I the decline of circumcision in the United States. Currently, 13 O states are no longer funding new- N born circumcision through Source: Belman, 1990 Medicaid as of 2004. Physiologic or Pathologic term, when applied to neonates, Table 2. Phimosis? refers to a physiologic process in Physiologic Preputial As a result of the declining which there may be an inability Retraction neonatal circumcision rate in the to retract the foreskin due to nat- Percentage of United States, pediatricians are urally occurring adhesions Boys Able to seeing more uncircumcised between the prepuce and glans. Age Retract Foreskin males than in the past. Many of The natural shedding of skin these physicians are unfamiliar cells from the foreskin lining and At birth 4% with the normal process of fore- the glans helps in the process of At 6 months 20% skin retraction, and will refer separation of these two struc- these male infants and children tures. The epithelial debris At 3 years 90% to pediatric urologists, recom- which has been shed forms a mending circumcision for phi- white cheesy substance known At 17 years 99% mosis. The term “phimosis” as infant smegma which accumu- Source: Choe, 2005 remains ambiguous to many lates under the foreskin.
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