September 1997.

The above paper by Schoen reflects the influence of culture and habit on the interpretation of medical practice. The practice of neonatal circumcision, so rare in Europe and ubquitous in the USA, has been discussed. The author credits Europe with avoiding neonatal circumcision on cost grounds. I think this is a basic misconception. The practice of medicine in Europe is far less invasive than in the US and medical intervention, particularly irreversible mutilating surgery, is avoided unless there is a proved medical benefit. The morbidity of neonatal circumcision is occasionally significant, and recent evidence demonstrating evidence of altered pain responses after neonatal circumcision suggests that the unperceived morbidity may be significantly higher.1

Balanitis xerotica obliterans is usually considered an absolute indication of childhood circumcision, but has an incidence significantly under 1%, with a peak incidence at 6-10 years. Balanoposthitis occurs in up to 4% of uncircumcised boys but fewer than 1 percent go on to three episodes or more of this minor local infection. Where these justify intervention we have learnt from our European colleagues of the value of preputioplasty, which saves the prepuce and has much less morbidity than circumcision. It is rare that physiological phimosis fails to resolve spontaneously and also is treatable by preputioplasty.

Circumcision as an alternative to hygiene in prevention of penile carcinoma, is an oft voiced argument. The author has quoted figures based on the 1971 national cancer survey (US) and extrapolated from the unsupported assumptions that all penile carcinoma occurred in uncircumcised males.2 More recent data calculates the relative risk in the US to be 3.2 times greater in the intact male.3 Using the author's own source, the quoted incidence of penile cancer is the US was one per 100,000 (1969-71). This a comparable incidence with that in Finland4 at the same time, where the circumcision rate is less than 1%, of 0.5 per 100 000 (1970) with a 78% relative 20 year survival rate. Thus, I find Marshall's argument at a meeting of the Society for Paediatric Urology, that one would have to perform 140 circumcisions a week for 25 years, to prevent one case of carcinoma of the penis, enough to prevent me from setting out on such a course.5

The strongest argument in favour of neonatal circumcision is the recognition that circumcision removes a reservoir of bacteria, associated with urinary tract infection, and indeed, in the child with an abnormal urinary tract where prophylaxis has failed to prevent urinary tract infection, I also practice circumcision. The author identifies, however, a paper that reports a pattern of male urinary tract infection in the first month, unassociated with renal tract anomaly, which we rarely see in the UK, and perhaps is linked to the practice of forcible preputial retraction (Rushton et al6, discussion). The protection of vulnerable infants with abnormal urinary tracts, possible pre-existing renal dysplasia, and a risk of new scar formation, would be better assured by renal ultrasound and family history screening.

The authors extrapolation of knowledge that circumcision reduces the transmission rate of HIV within the unprotected population of developing countries, to a belief that this has a role within the European population, is I feel, irrelevant where barrier contraceptives are readily available and considerably more efficacious.

Finally, there are now strong pressure groups (NOCIRC and INTACT), largely in North America, protesting against the perceived assault of circumcision. Duckett estimates a million adult males in the US would pay significant fees for a preputial reconstruction when it is possible.5

In countries where neonatal circumcision is rarely practiced, and appropriate non-aggressive management of the normal foreskin, with non-forcible retraction and regular cleaning after spontaneous relaxation of the physiological phimosis, there is no population demand for neonatal circumcision. This supports the conclusion that neonatal circumcision is a social ritual with a grain of medical origin, and aligns with the recent guidelines of the Canadian Paediatric Society, that `circumcision of newborns should not be routinely performed.'7

Department of Paediatric Surgery,
John Radcliffe Hospital,
Headley Way, Headington,
Oxford, OX3 9DU

1 Taddio A, Goldbach M, Ipp M, Stevens B, Koren G, Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet (North American edition) 1995;345:291-2.

2 Kochen M, McCurdy S. Circumcision and the risk of cancer of the penis. Am J Dis Child 1980;134:486-6. [Abstract]

3 Maden C, Sherman KJ, Beckma AM, et al. History of circumcision, medical conditions and sexual activity and risk of penile cancer. J Natl Cancer Inst 1993;85:19-24.

4 Maiche AG. Epidemological aspect of cancer of the penis in Finland. Eur J Cancer Prev 1992;1:153-8.

5 Duckett JW. A temporate approach to neonatal circumcision Urology 1995;46:771-2.

6 Rushton HG, Majd M. Pyelonephritis in male infants: how important is the foreskin? J Urol 1992;148(2 pr 2):733-6.

7 Fetus and Newborn Committee. Canadian Paediatric Society. Neonatal circumcision revisited. Can Med Assoc J 1996;154:769-80.

(File revised 1 October 2006)