Why Circumcision?

Since the subject of this presentation is a query, let us follow with other questions. Why has controversy developed among educated peoples when discussing a procedure which has been performed for centuries? Why has circumcision become a "hot issue"? One reason, we know, is that health insurance carriers have asked the American Academy of Pediatrics, the American Urologic Association and, we are sure, other concerned groups or associations to determine whether or not neonatal circumcisions should be covered. They have proposed an economic question; and we, as concerned physicians, must review the procedure from its inception and offer reasonable recommendations.

Is circumcision economically and medically indicated in the neonatal period, or should it be reserved for the "problem prepuce"? Review of the literature brings no formalized recommendations with regard to neonatal circumcision. We shall attempt to do so.

The historical background of this procedure is quite interesting. In ancient Egypt captured warriors were often mutilated. At first an extremity was amputated; but if the prisoner survived, he was not usually fit for full labor. An alternative procedure, castration, was tried. With total castration of testicles and penis, the morbidity and mortality were extremely high. As a result, orchiectomy, and later circumcision; marked these men as slaves. Eventually, all descendants of these slaves were circumcised. That this custom was not extended to those of royal blood is attested to by inspection of royal male mummies in all of whom the prepuces were found intact. The Phoenicians, and later the Jews who were largely slaves, adopted the practice of circumcision and turned it into a ritual. In time, ritualistic circumcision was incorporated into the Old Testament and considered to be a covenant between God and man. The Moslem religion also advocates circumcision. The male child is operated upon at the age of 12, a rite of puberty not required by any writings in the Koran.[1,2]

During the Roman occupation of Egypt, priests were required to be circumcised; and they alone were allowed to perform these ritualistic procedures. Stone implements were used.

Ritualistic circumcision also sprang independently in other parts of the world. Aboriginal tribes of Australia, Nicaraguan Indians, North and South American Indian tribes, and several of the African tribes practiced neonatal circumcision. In other of the world's peoples, circumcision was often performed as a test of the rnale's ability to withstand pain as he entered puberty and eventual adult life in his community. In some cases, females were also circumcised as a tribal or communal rite.

Now we must evaluate neonatal circumcision in our age and society from both a medical and an economical standpoint. What are the medical considerations?

In 1942 Ravich postulated that circumcision decreased the incidence of cervical and prostatic carcinoma.[3] This postulation was restated in the mid sixties by Aitken-Swan and others, who showed that carcinoma of the cervix had an increased incidence in women whose husbands were not circumcised.[4,5] This malignant disease shown to have an incidence of 2.2 per 100,000 in married Jewish women and as high as 44 per 100,000 in non-Jewish women marriecl to uncircumcised males. Penile hygiene appeared to be a significant factor and correlated with the degree of coverage of the glans penis by the prepuce. The incidence of cervical carcinoma varied with cleanliness, increasing even in the wives of circumcised men to 5.5 per 100,000 where partial preputial covering or poor hygiene was found. From these data, it can be concluded that circumcision promotes cleanliness of the glans penis add thus decreases the incidence of cervical carcinoma in wives or sexual partners.

Carcinoma of the penis has only been reported once when neonatal circumcision was performed. In this case, however, the skin edges separated postoperatively and the glans was still covered. In England there are over 200 deaths from penile carcinoma each year. The United States records over 300 such cases. In Brazil, where the performance of circumcision is low, deaths from penile carcinoma are much higher. When circumcision is delayed until puberty, as in Moslems, the incidence of penile carcinoma is less than in the general population, although it does occur. It seems, then, that prevention of penile cancer requires neonatal, not a later, circumcision.[6]

Medical practitioners -- especially urologists, peatricians, family doctors, dermatologists, and venerologists -- are familiar with the conditions of the penis which occur in the uncircumcised male. Balanitis and balanoposthitis, condylomata, balanitic adhesions, frenular lacerations, phimosis and paraphimosis are not infrequently seen. Mycotic and parasitic infections thrive in hot humid climates; therefore, the moist anaerobic environment under the prepuce favors these complications. They can be avoided with neonatal circumcision.

Most circumcisions are done with a preoperative diagnosis of phimosis. Gairdner states that 96% of newborn males have a physiologic phimosis and that 10% of these become pathologic by of 3.[7] It is impossible to tell which will be in the 10% of true phimotics when the infant is originally seen. He feels, therefore, that circumcision should be delayed until these 10% make themseIves evident. With them, however, hospitalization and general anesthesia will surely be required, adding additional economic and psychological disadvantages.

There are several reasons why neonatal circumcision should not be practiced routinely on the newborn. It should never occur without a complete physical examination by a competent physician. The procedure is contraindicated when the infant shows evidence of exstrophy, epispadias, or hypospadias. There is contraindicatiori when there is any question of ambiguous genitalia, a poor Apgar rating, or premature birth. We recommend that it not be done in any infant less than 24 of age since this lapse gives the physician another chance to examine the child after the heat of delivery room and provides the child an opportunity to cope with his new, hostile environment. We feel it is contraindicated when there is any umbilical artery anomaly which might indicate further urologic evaluation. Such an anomaly is associated with a high degree of urologic congenital problems. Urologic anomalies also occur when other teratogenic defects are noted at birth. We also feel that surgery is contraindicated when is evidence of blood dyscrasia. When such infants are excluded, appropriate candidates for circumcision remain.

Like any other surgical procedure, circumcision is not without complications; and the question arises as to whether or not the complications and even deaths outweigh the benefits. Most complications have been shown to be the result of inexperienced, incompetent, or careless surgeons. It is our feeling that every safeguard should be observed to prevent any but the experienced, trained and skillful surgeon from performing this operation so important to the developing male. Cautery burns, bivalving or amputation of the glans, urethral fistula, concealed penis, exploded penis or erysipeloid infections have been reported and, although few in number, are inexcusable.[8-12]

When a large series of circumcisions is looked at, the complication rate is extremely low. Spreet reported one death in 500,000 cases in New York City. This death occurred after a circumcision at home by a noncertified moel. Miller and Snyder's 24,000 cases had no serious complications and no deaths. In all studies, neonatal circumcision has been reported to have a lower morbidity and mortality than the general complications of general anesthesia and delayed procedures.[6,10]

Meatal ulceration leading to meatal stenosis is the most frequent complication seen in neonatal circumcision. It is not related to iatrogenic incompetence but is due to exposure of the uncovered glans and meatus to the diaper wet with urine. Occasionally, this ulceration can be prevented by frequent diaper changes or applications of ointments to the glans until keratinization protection develops. In those cases where meatal stenosis develops, a simple office procedure is all that is required for correction.

Published articles have decried circumcision because of a reported diminution in glandular sensitivity after preputial excision. We do not argue with this assertion but theorize that such diminished sensation might reduce the incidence of premature ejaculations. Also, if one considers that tactile stimulus is diminished and is of such significance to the very large number of males who have been circumcised, then one must ask why these men are not lining up to have skin grafts or prepuce plasties to replace this lost vestige?

Economically, the case for neonatal circumcision seems to be a reasonable one. The usual procedure is performed during the neonatal hospital stay and does not require additional hospitalization. The surgical fee is minimal compared to that of a delayed childhood or adult procedure. It is, therefore, not unreasonable to recommend coverage by insurance carriers.

In summary, the following recommendations are made:

1. Circumcision should never be referred to as routine or simple and should be performed only by a well-trained and experienced physician.
2. This procedure should only be performed on a healthy male neonate older than 24 hours of age with a good Apgar rating and without congenital or endocrine abnormalities.
3. Insurance carriers should cover this procedure as any other elective surgical procedure.

We conclude that the medical and economic advantages of neonatal circumcision far outweigh the disadvantages.

References

1. Bitschai, J., and Brodney, M. L.: A History of Urology in Egypt. Cambridge, Mass.: Riverside Press, 1956.
2. Wershub, L. P.: Urology From Antiquity to the 20th Century. St. Louis: Warren H. Green, 1970.
3. Ravich, A.: The relationship of circumcision to cancer of the prostate. J. Urol., 48:298, 1942.
4. Aitken-Swan, J., and Baird, D.: Circumcision and carcinoma of the cervix. Brit. J. Cancer, 19:217, 1965.
5. Bolande, R. P.: Ritualistic surgery. New Eng. J. Med., 280:591, 1968.
6. Miller, R. L., Snyder, D. C.: Immediate circumcision of the newborn male. Amer. J. Obstet. Gynec., 65:1, 1953.
7. Gairdner, D.: The fate of the foreskin. Brit. Med. J., 2:1433, 1949.
8. Lackey, J. T., Mannion, R. A., and Kerr, J. F.: Subglandular urethral fistula from infant circumcision. Indiana State Med. Assoc. J., 62:1305, 1969.
9. McGowan, A. J., Jr.: Complications of circumcision-Bivalve penis. JAMA, 207:2104, 1969.
10. Spreet, H.: Circumcision of the newborn: An appraisal of present status. Obstet. Gynec., 2:164, 1953.
11. Trier, W. C., and Drach, G. W.: Concealed penis. Amer. J. Dis. Child.; 125:276, 1973.
12. Yellen, H. S.: Bloodless circumcision of the newborn. Amer. J. Obstet. Gynec., 30:146, 1935.