Note:
This report by Fergusson et al. has received considerable attention as it has been cited by several medical societies in their position statements on male circumcision. It is, therefore, worthy of careful examination.
Pediatrics, Volume 81, Issue 4: Pages 537-541, April 1988.
From the Christchurch Child Development Study, Department of Paediatrics, Christchurch School of Medicine, Christchurch Public Hospital, Christchurch, New Zealand
The prevalence of penile problems was examined in a birth cohort of more han 500 New Zealand children studied from birth to 8 years of age. By 8 years, circumcised children had a rate of 11.1 problems per 100 children, and uncircumcised children had a rate of 18.8 per 100. The majority of these problems were for penile inflammation including balanitis, meatitis, and inflammation of the prepuce. However, the relationship between risks of penile problems and circumcision status varied with the child's age. During infancy, circumcised children had a significantly higher risk of problems than uncircumcised children, but after infancy the rate of penile problems was significantly higher among the uncircumcised. These associations were not changed when the results were adjusted statistically for the effects of a series of potentially confounding factors.
Pediatrics 1988;81:537-541; circumcision, penis.
During the last two decades there has been mounting opposition to the practice of routine neonatal circumcision. The extent of the opposition is well illustrated by the joint statement from the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists which concluded that "there is no absolute medical indication for routine circumcision."1 However, this strong conclusion has been challenged by recent evidence that has suggested that there is a higher rate of urinary tract infection among uncircumcised male infants2-4 and that uncircumcised children are more susceptible to penile problems.5 Although the evidence for a possible link between circumcision and reduced rates of urinary tract infection in infancy is controversial,6-9 the general trends in the research evidence suggest that circumcised and uncircumcised children may differ with respect to their medical history.
To cast further light on this issue, we studied longitudinally a birth cohort of more than 500 New Zealand boys from birth to 8 years of age. The aims of this research were twofold: (1) to examine the association between the child's neonatal circumcision status and risks of penile problems during early and middle childhood and (2) to adjust any apparent correlation between neonatal circumcision status and risks of penile problems for the potentially confounding effects of a number of social and perinatal factors.
The data were collected during the first nine stages of the Christchurch Child Development Study in which a birth cohort of 1,265 children born in the Christchurch (New Zealand) urban region was studied at birth, 4 months, and annual intervals until the age of 8 years. At each time, information about the health, family conditions, and social background of the children was collected by a structured interview with the child's mother and supplemental information was obtained from other sources including hospital medical records, general practitioner notes, and a diary record of the child's medical attendances kept by the mother. The method of data collection and quality control of the data has been described in previous papers.10,11 The following measures were used in the analysis.
When the child was 4 months of age, information concerning his circumcision status was collected by maternal report and from existing records.
During the period from birth to 8 years, information about the child's history of medical attendance for penile problems was collected routinely from maternal reports, supplemented by information from a diary record kept by the mother and from medical records. From this information, the child's history of medical attendance was reconstructed and the following measures of penile problems were obtained: (1) the number of episodes of inflammation of the penis experienced by the child. Penile inflammation included balanitis, meatitis, inflammation of the prepuce, and conditions in which the penis was described as sore or inflammed without any further diagnostic elaboration; (2) the number of episodes of phimosis experienced by the child. These episodes included all times the child sought medical attention for phimosis and associated symptoms. However, episodes for which the child was brought to medical attention for "tight" or "nonretractable" foreskin but was not treated were not classified as phimosis because it was likely that most of these attendances were the result of parental anxiety or uncertainty about the development of the foreskin rather than any pathologic condition in the child; (3) inadequate circumcision requiring repair or recircumcision; and (4) postoperative infection following circumcision.
It is important to recognize that the data on medical attendance for penile problems was collected as part of a much larger longitudinal study of child health and development in which the primary concern was not with the issue of the longterm consequences of circumcision. This feature of the data collection process places a number of restrictions on the quality of the collected data. Specifically, data relating to immediate postcircumcision problems and penile problems that were treated at home without medical attention were not available. Also, diagnostic details of medical attendances for penile problems were limited. The net result of these imprecisions in the data collection process is that the incidence and prevalence of penile problems probably underestimated and the problems can only be described in terms of broad diagnostic categories. Nonetheless, we believe that the trends that emerge from the analysis are likely to reflect general differences in the medical histories of circumcised and uncircumcised children.
Information was available about the following aspects of the child's family social background: (1) maternal age; (2) maternal education - this was classified as mother lacked formal educational qualifications, mother had secondary school qualifications (New Zealand school certificate, university entrance) or, mother had tertiary qualifications (university degree, professional qualifications); (3) ethnicity children were classified as Polynesian (ie, Maori or Pacific Islander) or white; (4) family socioeconomic status - this was based on the Elley and Irving'12 scale of socioeconomic status for New Zealand. This divides the population into six social classes on the basis of male occupation. Children whose parents were unemployed or whose family depended on social welfare benefits for their major support were defined as having "unclassified" socioeconomic status level.
Measures of the child's birth weight and gestational age were obtained from medical records of the birth.
The present analysis is based on all male children observed at each year during the period from birth to 8 years. All children studied at each year were used so that all available data could be used and the analysis could have the maximum statistical sensitivity.13 Sample numbers varied from 591 for the group of boys studied at 1 year to 553 for the group of boys studied at 8 years. The sample studied at 8 years represented 87% of the 635 boys who entered the study at birth and 93% of those boys who were resident in New Zealand at 8 years.
The rates of penile problems per 100 children 0 to 8 years of age related to the child's circumcision status are given in Table 1. The majority of these problems related to various forms of penile inflammation (75%) with phimosis (16%), inadequate circumcision (4%), and postcircumcision infections (4%) accounting for the remaining problems. (A number of children who were not circumcised during the neonatal period are shown as having postcircumcision infections. These were children who were circumcised after the age of 1 year and thus were at risk for post circumcision infection.) By 8 years of age, the uncircumcised boys had a higher rate of penile problems (18.8 per 100) than the circumcised boys (11.1 per 100). This difference was marginally statistically significant (χ2/2 = 5.75, P > .10).
Table 1. Penile Problems in Boys 0 to 8 Years of Age by Circumcision Status* Condition Circumcised Uncircumcised Penile inflammation 7.6 (11) 14.4 (62) Phimosis 0.0 (0) 3.7 (16) Inadequate circumcision 2.8 (4) 0.0 (0) Postcircumcision infection 0.7 (1) 0.7 (3) Total 11.1 (16) 18.8 (78) * The number of problems per 100 boys at risk are in parentheses |
The comparisons given in Table 1 do not take into account the age at which penile problems occurred. This is shown in Table 2, where annual rates of penile problems related to neonatal circumcision status are given. During infancy, circumcised children were at greater risk for penile problems: the circumcised group had a rate of 5.5 problems per 100 children, in contrast to 1.1 problems per 100 for the uncircumcised group (χ2/1 = 9.70, P < .01). After infancy, uncircumcised children were at greater risk for penile problems: the circumcised group had a rate of 5.6 problems per 100 children, in contrast to 17.7 problems per 100 for the uncircumcised boys (χ2/2 = 9.97, P < .01).
Collectively, these findings suggest that during infancy circumcision was associated with increased risks of penile problems but after infancy with a reduction in these risks. However, the comparisons given in Table 2 do not take into account the potentially confounding social or perinatal factors that may have influenced both the child's neonatal circumcision status and risks of penile problems. To account for these factors the data were reanalyzed using logistic regression methods14
Table 2 Penile Problems in Boys by Age and Circumcision Status*
Age (yr)
<1 2 3 4 5 6 7 8
Circumcised 5.5 3.5 2.1 0 0 0 0 0
(146) (141) (138) (137) (137) (137) (137) (137)
Uncircumcised 1.1 3.7 4.2 2.3 2.3 2.3 1.5 1.4
(445) (436) (433) (430) (425) (425) (417) (415)
Total 2.2 3.6 3.7 1.8 1.8 1.8 1.1 1.1
(591) (577) (571) (567) (562) (559) (554) (553)
* Results are numbers of problems per 100 boys at risk. The number of
children studied are in parentheses.
Table 3 Unadjusted and Adjusted Rates of Penile Problems
Infants Children 1-8 yr of Age
Unadjusted Adjusted Unadjusted Adjusted
Circumcised 5.5 5.2 5.6 6.5
Uncircumcised 1.1 1.2 17.7 17.2
P Value <.01 <.05 <.01 <.01
|
The findings of this 8-year longitudinal study suggest the presence of an interactive relationship among the child's neonatal circumcision status, age, and risks of penile problems. During infancy circumcised children had a significantly higher risk of penile problems, whereas after infancy these problems were significantly higher among the uncircumcised boys. The net effects of these trends were that by 8 years of age the uncircumcised boys had experienced more than 1.5 times the rate of penile problems. The apparent correlations between the child's neonatal circumcision status and risks of penile problems could not be explained by the confounding effects of a range of social and perinatal factors.
The higher rate of problems among circumcised children during infancy may reflect the effects of exposure of the glans to irritation by wet diapers. This has been noted previously and Kaplan15,16 argues that meatitis and meatal ulcers occur almost exclusively in circumcised boys for this reason.
The higher rate of problems in uncircumcised children after infancy is consistent with the findings of Herzog and Alvarez5 who reported a higher rate of problems among uncircumcised boys in a sample of boys 4 months to 12 years of age. These authors did not report higher rates of problems among circumcised infants younger than 1 year of age. However, this difference may be explained by the fact that Herzog and Alvarez's data were collected cross-sectionally and on a sample of children aged 4 months to 12 years and thus may have failed to provide adequate longitudinal data concerning the prevalence of penile problems during infancy. In common with Herzog and Alvarez's findings, the great majority of penile problems occurring in our sample were relatively minor and most (64%) wereresolved after a single medical consulation.
These findings and recent evidence2-4 suggesting a link between urinary tract infection during infancy and circumcision status inevitably resurrect the controversy about whether neonatal circumcision is a justifiable procedure. On the one hand, it may be argued that the possible link between urinary tract infection and circumcision and the greater rates of penile problems among uncircumcised boys after infancy justify circumcision. On the other hand, it may be suggested that the higher rates of penile problems among circumcised children during infancy coupled with the complications of circumcision including the small risks of death and mutilation do not justify the alleged benefits of circumcision.1,17-19
This issue has been complicated by the suggestions that circumcision reduces risks of penile cancer and genital herpes.19-21 However, it has also been argued that the apparent correlations between circumcision status and these conditions could be due to confounding genetic or environmental factors.17,22 Additionally, it is unclear whether good hygiene can offer the alleged benefits of neonatal circumcision.1, 22-25
Received for publication April 6, 1987; accepted July 1, 1987.
Reprint requests to D.M.F. Christchurch Development Study, Dept. of Pediatrics, Christchurch Public Hospital, Christchurch, New Zealand.
Note:
This report by Fergusson et al. has received considerable attention as it has been cited by several medical societies in their position statements on male circumcision. It is, therefore, worthy of careful examination.
Note:
Fergusson et al. find that circumcised boys have 1) more penile problems in the first year of life, while 2) uncircumcised boys have more penile problems in the span from 1 to 8 year of age. The first finding is well supported by the medical literature. The foreskin is protective1 and the removal of the foreskin is well documented to cause meatitis, meatal ulcers, and meatal stenosis.2,3
Note:
The second finding, however, is worthy of careful examination as it is counterintuitive. Fergusson et al. reported more inflammation, more phimosis, and, most curiously, an equal amount of post-circumcision infection in uncircumcised boys.
Note:
The reported increase in inflammation in uncircumcised boys is especially problematical. It is not clear whether the inflammation is inherent in the prepuce or is caused by confounding environmental factors for which Fergusson et al. did not control. For example, forcible premature retraction of the prepuce or excesive washing4 is known to cause inflammation. The authors do not tell us what sort of hygenic care was practiced in New Zealand in those years. The prepuce of prepubertal boys should be left alone and only the outside should be washed.5 Improper hygienic care may have caused the reported high rates of inflammation in uncircumcised boys.
Note:
The reported high rates of phimosis are also deserving of some scrutiny. Most boys are born with non-retractile foreskins,6 which only gradually become retractable over a period of many years. Most boys in the 1-8 year-age-range have normal, healthy, non-retractile foreskins.7,8. Confusion by medical doctors of the normal non-retractile developing prepuce with the pathological condition of phimosis has been and remains a problem.9,10 In many cases, pathological phimosis cannot properly be diagnosed until after puberty. Fergusson et al. do not report the diagnostic standards used to diagnose phimosis among the boys in the New Zealand birth cohort. Therefore, it is unclear whether the reported incidence of phimosis was truly phimosis or misdiagnosis of a normal condition.
Note:
A later study of boys from birth to age 18 by Van Howe found substantially more penile problems in circumcised boys.11
Note:
The authors' failure to control for confounding environmental factors leave unclear whether the reported problems with the foreskin actually were caused by the simple presence of the foreskin or were the result of environmental problems such as improper hygenic care and the misdiagnosis of phimosis. In any case, the reported problems (inflammation and phimosis) were minor and so are easily and effectively treated with conservative therapy.12,13 They do not support non-therapeutic circumcision of the newborn.
Note:
For further comment on this study see Van Howe RS. Variability in Penile appearance and penile findings: a prospective study. Brit J Urol 1997;80(5):776-82.
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