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Male Circumcision Indications and Complications

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					      Male Circumcision:
Indications and Complications

           David Galvin
        Mr. Dennis Murphy
             23.1.06
                Introduction
• 1 in 6 men worldwide is circumcised
• In the US, 62% of male neonates are
  circumcised (1.2 million)
• Uncircumcised males are at an increased risk
  of UTI especially in first 6 to 12 months 1
  – 1 in 120 risk. 1 in 195 risk of hospitilisation.
  – Protection is x6 - 10
  – Mandatory circumcision if at high risk of UTI or if a
    UTI would have serious consequences
• Neither recommended nor condemned by AAP
                                        1 Wisell TE. Paediatrics 1985
      Foreskin Embryology
• Development of prepuce between week 8
  and 16 in utero
• Prepuce mucosa and glans are
  contiguous
• Exfoliation of underlying epithelium in a
  proximal direction leads to resolution of
  the physiological adhesions and
  formation of a preputial sac
• Usually complete by 3 - 5 years but may
  continue until puberty
           Natural History

• Work by Gairdner
  1949 and Oster
  1968

• Less than 1% of
  boys require a
  circumcision
       Introduction

• Controversial Issues

  –   Risk of UTI
  –   Anaesthesia
  –   Sexual function
  –   Malignancy
  –   STDs
                    Risk of UTI
• Risk is Low
   – 1 in 120 - 140 of UTI in a male < 1 year
• Many studies did not examine other factors
  that may also have lowered the risk
• Mandatory circumcision is not warranted
• May be recommended if a UTI would risk renal
  injury e.g congenital anomalies
• Risk of UTI is 10% (1:11) for those with
  recurrent UTIs and 30% (1:4) for those with
  VUR 1                            1 Arch Dis Child. Craig J. Aug 2005
    Anaesthesia - Neonates
• Studies mainly in neonates in USA
  – Only used by 45% of doctors
• Options
  – Eutectic mixture of local anaesthetics
    (EMLA)
  – Dorsal penile nerve block
  – Ring block
  – Sucking on pacifier / blanket (Religious)
             Sexual Function
• Prepuce is filled with nerve endings similar to lips
  or fingers (much more so than the glans)
• Circumcision permanently inhibits sexual
  function ? Mutilation ?
• Function
   – Produce a gliding mechanism during intercourse
   – Prevents the loss of vaginal secretions
   – Smegma may release pheremones
• Glandular skin undergoes hyperkeritinisation
• Tactile sensation would appear to be unchanged
• One study showed women preferred
             Malignancy
• SCC penis is rare and also depends on
  smoking and phimosis.
• Neonatal circumcision is protective
  whereas adult circumcision is not.
• Incidence of penile cancer is higher in
  circumcised men but overall the
  incidence is very low.
• Probably related more so to poor
  hygiene 1
                1 Pediatr Clin North Am. 2001 Neonatal circumcision. Liao
                JC
      Sexually Transmitted
           Diseases
• Jewish men had lower levels of syphilis
  in 19th century
• Meta-analysis: no clear evidence that
  circumcision prevents STDs 1
• Studies on risk of HIV risk are
  conflicting and no conclusion can be
  made 2
                             1 Van Howe RS. BJU Int 1999
                             2 East Afr Med J. 2005 Jan. Nyindo
                             M.
                    Indications
• Medical                                             Religious
  – Pathological Phimosis
     • White, scarred prepuce (BXO - absolute)
     • May cause ballooning, bleeding, dysuria or retention
     • Alternatives are preputioplasty / steroid cream

  – Recurrent Balanitis
     • Exclude diabetes


  – Urinary Tract Infection Prophylaxis
     • Protects against UTI in infants with VUR, PUJ, posterior
       valves and hydronephrosis 1
     • In VUR: 63% v 19% of circumcised boys suffered UTIs
                                                          1 Herden CDA. J Urol
         Contraindications
• Premature Infants

• Congenital Penile Abnormalities
  – Hypospadias, episapdias, chordee, penile
    webbing or concealed penis


• Blood Dyscrasias
             Complications
• Death                 • Chordee
• Bleeding (2-5%)       • Urethrocutaneous
• Suture sinus tracts     fistula
• Infection (2%)        • Necrosis
• Phimosis and          • Amputation
  concealed penis       • Hypospadias
• Adhesions             • Meatitis
• Meatal stenosis
             Complications
• Death
  – Canada 2002: 5 year old died 48 hours after non-
    therapeutic circumcision
• Bleeding
  – Usually from frenulum or dorsal fascial vessel
  – Should be explored if large haematoma / deep (2-
    5%)
• Concealed penis
  – Conservative circumcision or excess dorsal skin
    may lead to phimosis again. Suprapubic fat pad
    may lead to a concealed penis.
             Complications
• Chordee
  – Secondary to circumcision is related to excess skin
    removal
• Urethrocutaneous Fistula
  – Urethral injury during excision of prepuce
• Necrosis
  – May occur secondary to surgery or infection
  – Only use bipolar electrocautery sparingly and never
    with a ‘clamp’ device
• Amputation of Glans
  – May occur using a ‘clamp’ device
 Current Status in N. America
• Medicaid no longer cover routine
  neonatal circumcision in 11 states
• Legally, routine circumcison may be
     considered battery - as parents are
  consenting to invasive non-therapeutic
  surgery for their son
• www.doctorsopposingcircumcision.org

				
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