Warner E. Strashin E. Benefits and risks of circumcision. Canadian Medical Association Journal. 125(9):967-76, 992, 1981 Nov 1. Circumcisions are performed either prophylactically in the neonatal period or therapeutically at a later age. About 10% of males not circumcised at birth will eventually require circumcision. The present neonatal circumcision rate is about 80% in the United States and 40% in Canada. The single most important determinant of whether a newborn male will be circumcised is the attitude of the attending physician. The literature was reviewed to determine the proven benefits of circumcision and to compare these with the known risks. Circumcising the newborn facilitates penile hygiene, prevents cancer of the penis and decreases the incidence of genital herpes in later life. Whether it decreases the incidence of cancer of the cervix is still uncertain. More important, neonatal circumcision is associated with much lower morbidity and mortality and with lower costs than therapeutic circumcision. Thus, prophylactic circumcision is recommended for the male population as a whole. [References: 83] Robson WL. Leung AK. The circumcision question. Postgraduate Medicine. 91(6):237-42, 244, 1992 May 1. Neonatal circumcision continues to be a controversial subject. The American Academy of Pediatrics has revised its earlier policy, stating that newborn circumcision has potential benefits as well as risks and emphasizing the need to explain these issues to parents considering the procedure so that an informed decision can be made. Compared with circumcised males, uncircumcised males are at greater risk for urinary tract infection, sexually transmitted disease, phimosis, paraphimosis, and balanoposthitis. Complications of circumcision include infection, hemorrhage, and meatal stenosis. Analgesia should be prescribed for the substantial pain associated with the procedure. Alternatives to circumcision include retraction of the foreskin with use of local or general anesthesia. Regular foreskin hygiene is important for all males, whether circumcised or not. [Comment. THE FORESKIN SHOULD NEVER BE RETRACTED BY FORCE. It will take usually several years to free itself from the glans. To follow the advice of this article is to invite acquired phimosis, paraphimosis, or other injury to the penis. The ignorance of this fact by the writer of this article casts doubt on his understanding of the issues surrounding circumcision] Lawler FH. Bisonni RS. Holtgrave DR. Circumcision: a decision analysis of its medical value [see comments]. Family Medicine. 23(8):587-93, 1991 Nov-Dec. Routine neonatal circumcision has long been controversial. Presented here is a cost-effectiveness analysis of the consequences of the treatment choices (circumcision versus no circumcision) using a decision tree model. For a simulated 85-year life expectancy, routine neonatal circumcision had an expected lifetime cost of $164.61 per patient circumcised and a quality-adjusted survival of 84.999 years. Conversely, for the noncircumcision approach, the expected average lifetime cost was $139.26 per patient, and the quality-adjusted survival was 84.971 years. The net cost-effectiveness ($919.87 per quality-adjusted life year) is within the range usually considered worthwhile for public health policy. However, because of the minor differences in lifetime cost ($25) and benefit (10 days of life) for an individual and the tenuous values available for disease incidence and surgical risk, we conclude that there is no medical indication for or against circumcision. Additional analyses suggested that reported benefits in preventing penile cancer and infant urinary tract infections are insignificant compared to the surgical risks of post neonatal circumcision. The decision regarding circumcision may most reasonably be made on nonmedical factors such as parent preference or religious convictions. [References: 22] Wiswell TE. Routine neonatal circumcision: a reappraisal. American Family Physician. 41(3):859-63, 1990 Mar. Routine neonatal circumcision has long been a controversial subject. The American Academy of Pediatrics has recently outlined a new position on circumcision that is a marked departure from its previous stance. Neonatal circumcision has many potential advantages: The procedure helps prevent urinary tract infections, penile cancer, sexually transmitted diseases and, perhaps, acquired immunodeficiency syndrome. The risk of complications from the procedure is low. Fewer penile problems occur in circumcised boys than in uncircumcised boys. It is more economical to perform the procedure early in life, rather than later. No evidence shows that penile hygiene alone is as beneficial as circumcision. [References: 33] Anonymous. American Academy of Pediatrics: Report of the Task Force on Circumcision Pediatrics. 84(2):388-91, 1989 Aug. Properly performed newborn circumcision prevents phimosis, paraphimosis, and balanoposthitis and has been shown to decrease the incidence of cancer of the penis among US men. It may result in a decreased incidence of urinary tract infection. However, in the absence of well-designed prospective studies, conclusions regarding the relationship of urinary tract infection to circumcision are tentative. An increased incidence of cancer of the cervix has been found in sexual partners of uncircumcised men infected with human papillomavirus. Evidence concerning the association of sexually transmitted diseases and circumcision is conflicting. Newborn circumcision is a rapid and generally safe procedure when performed by an experienced operator. It is an elective procedure to be performed only if an infant is stable and healthy. Infants respond to the procedure with transient behavioral and physiologic changes. Local anesthesia (dorsal penile nerve block) may reduce the observed physiologic response to newborn circumcision. It also has its own inherent risks. However, reports of extensive experience or follow-up with the technique in newborns are lacking. Newborn circumcision has potential medical benefits and advantages as well as disadvantages and risks. When circumcision is being considered, the benefits and risks should be explained to the parents and informed consent obtained. [References: 56] Grossman EA. Posner NA. The circumcision controversy: an update. Obstetrics & Gynecology Annual. 13:181-95, 1984. One constructive feature has come out of all of the circumcision controversy. It has made us aware that neonatal circumcision is not a simple procedure and that it should not be regarded as "routine." It is a surgical procedure and it should be taught as one. The authors of this article wrote a review article on circumcision in 1981 and Dr. Grossman has recently published a book designed to teach proper circumcision technique, and to familiarize the operator with the common congenital anomalies as well as the prevention and treatment of the complications of circumcision. The advocacy of neonatal circumcision cannot be considered as a cut and dried issue. For some, it has an absolute religious indication, which transcends current medical logic. For others the available facts still allow for a decision based on one's perception of those facts. If one has the perception that there is value in improving local hygiene, or that the loss of the prepuce will allow for an earlier discovery of a penile lesion, or that circumcision actually does cause a decrease in the incidence of penile or cervical cancer, or group conformity is important, then one might well advocate neonatal circumcision. If, however, one sees the potential values as insignificant in light of the lack of hard data relating circumcision to penile or cervical cancer, and that if one is concerned with the "rape of the phallus," then one is against routine neonatal circumcision. But, this individual must be aware that a small percentage of males will need a circumcision at a later time in life, when technical and psychological problems may lead to an increased morbidity. The decision of the physician, and the advice given to the new parents, at present, appears to be more subjective than the advice concerning RhoGAM, or DPT immunization, although it occasionally is given with as much certainty. We are dealing with the art of medicine rather than science. On this basis, rather than deride each other for positions taken, and religious considerations aside, we would do much better to develop better scientific studies to answer the scientific questions. Today's tendency to make decisions on evaluation of the risk:benefit ratio is clearly difficult if both are not adequately quantitated. Until these are available the decision of whether or not to circumcise must result from an objective discussion between the doctor and the parents of newborn males.