CPS: Benefits and risks of circumcision: Another view
BENEFITS AND RISKS OF CIRCUMCISION: ANOTHER VIEW
Platform of the Fetus and Newborn Committee of the Canadian
Paediatric Society
The review by Warner and Strashin(1) clearly presented the
arguments for and against circumcision and the contraindications.
However, the most important reason for favouring circumcision -
that is, preventing carcinoma of the penis - is not completely
established. In addition, Warner and Strashin overly minimized
the risks of circumcision. They also did not include the cost of
complications of neonatal circumcision in their cost benefit
analysis.
While the literature suggests that circumcision may protect
against carcinoma of the penis, the case is not entirely proven.
There are, for example, wide differences in the incidence of
penile carcinoma among African tribes that do not practise
circumcision.(2) In Sweden, where circumcision is rare, the
incidence of penile carcinoma is low.(3) It is possible that
there are genetic or environmental factors that influence the
incidence of this carcinoma and, by coincidence, are associated
with circumcision. Warner and Strashin do recognize that the
protective role of circumcision is not completely established.
In their conclusions they stated that "cancer of the penis may be
prevented by circumcision", but in the abstract of the article
the crucial word "may" is omitted.
Warner and Strashin discussed the literature on the incidence of
early complications, including the report by Gee and Ansell(4),
which noted one life-threatening hemorrhage, four cases of
septicemia and one case of complete penile denudation, as well as
circumcision in eight cases of hypospadias among 5000 circumcised
boys. Then they concluded that "hemorrhage, infection and other
immediate complications..... are easily treated; those that are
not are very rare". The potential for meningeal spread from
septicemia and the hospital costs for these complications were
ignored. Neither did they discuss problems resulting from
inappropriate management of the prepuce that can result in the
need for later circumcision. Phimosis commonly follows infantile
balanitis, which occurs when premature and energetic attempts are
made to break down the incorrectly named "preputial adhesions"
the epithelial tissue that has not yet separated into planes. This
lack of separation is normal in newborns and may not be completed
until the age of 16 or 17 years.(5) Oster(5) reported that among
1968 schoolboys examined annually for 8 years the incidence of
phimosis was 8% at age 6 to 7 years but only 1% by the age of 16
to 17 years. How many physicians recommending and carrying out
circumcision in schoolboys know this? A survey of 60
pediatricians in the United States revealed that 78% did not know
at what age the prepuce might normally be retracted.(6) Oster(5)
found that only 3 (0.15%) of the 1968 boys required circumcision.
Thus, the true need for later circumcision may be greatly
exaggerated.
McKim's editorial on circumcision also minimized the risks of
this operation in the newborn period.(7) The risks should indeed
be minimal; however, because circumcision is not always carried
out by "experienced, skilful surgeons", surgical complications
are regularly seen and are not "extremely rare", as McKim stated.
Certainly the good teaching and supervision of neonatal
circumcision McKim pleaded for are vital.
In the past we made many errors when therapeutic approaches were
developed in the absence of adequate proof of efficacy.(8)
Silverman(8) has emphasized our need not only to learn from past
experiences but also to ensure that we use the correct methods to
evaluate our interventions.
Several years ago the fetus and newborn committee of the Canadian
Paediatric Society carefully reviewed the pros and cons of
circumcision; the conclusions were published in a statement in
1975.(9) The intentions of this statement was to reduce the
number of unnecessary circumcisions and the complications that
might result. (Incidentally, Warner and Strashin did not refer to
this review.) The present fetus and newborn committee sees no
reason for modifying the statement of the previous committee and
is concerned that a completely balanced view be available to the
physician asked to decide upon the necessity for circumcision.
References:
1. Warner E. Strashin E: Benefits and risks of circumcision.
Can Med Assoc J 1981; 125: 967-976, 992
2. Burkitt DP: Distribution of cancer in Africa. Proc R Soc
Med 1973; 66: 312-314
3. Klauber GT: Circumcision and phallic fallacies or the case
against routine circumcision. Conn Med 1973; 37: 445-448
4. Gee WF, Ansell JS: Neonatal circumcision: a ten-year
overview: with comparison of the Gomco clamp and the
Plastibell device. Pediatrics 1976; 58: 824-827
5. Oster J: Further fate of the foreskin: incidence of
preputial adhesions, phimosis and smegma among Danish boys.
Arch Dis Child 1968; 43: 200-203
6. Osborn LM, Metcalf TJ, Mariani EM: Hygienic care in
uncircumcised infants. Pediatrics 1981; 67: 365-367
7. McKim JS: Neonatal circumcision (E). Can Med Assoc J 1981;
125: 955
8. Silverman W: Retrolental Fibroplasia--A Modern Parable.
Grune, New York, 1980
9. Canadian Paediatric Society, fetus and newborn committee:
Circumcision in the newborn period. CPS News Bull Suppl
1975; 8(2)
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Courtesy of:
Canadian Paediatric Society
c/o Children's Hospital of Eastern Ontario
Smythe Road
Ottawa, Ontario