home
library
search contact review

Benefits of Newborn Circumcision: is Europe Ignoring Medical Evidence?

E.J. Schoen
Department of Pediatrics and the Department of Genetics, Regional Perinatal Screening Program, Kaiser Permanente Medical Care Program, Oakland, California, USA

Introduction

A major difference between the paediatric care provided in Europe and that provided in the US stems from the attitudes of care providers toward newborn circumcision as a preventive health measure. In the US, the great majority of newborn boys (about 1.4 million annually) are circumcised, whereas in Europe, neonatal circumcision is rarely done. European countries consider newborn circumcision an unnecessary surgical procedure which increases the costs of operating nationalised health systems, whereas in the US, circumcision is generally considered a simple, rapid operation with medical benefits which accrue throughout life.

Local foreskin problems and hygiene

Phimosis, balanoposthitis, and difficulty of ensuring adequate genital hygiene in uncircumcised boys have been best described in the European literature[1-4. US anticircumcision groups claim that genital hygiene can easily be maintained as the foreskin naturally separates, but, in reality, genital hygiene in uncircumcised boys has been shown to be poor, even in British and Scandinavian middle class schoolboys[1-2].

The prevalence of true phimosis (anatomic constriction of the preputial opening, which must be distinguished from adherent foreskin) in published studies varies from 0.3% to 0.9%[5], but true phimosis requires circumcision later in life, when the procedure is more difficult, risky, and expensive[6,7]. Balanoposthitis has been estimated to occur in 4% of uncircumcised boys, and incidence peaks at age 2 to 5 years[3]. Although treatment can be conservative, late circumcision is often necessary for recurrent cases, and medical management requires additional physician visits and treatment.

Cancer of the penis

The evidence that circumcision protects against penile cancer is overwhelming. In the US, incidence of penile cancer in circumcised men is essentially zero (about one reported case every five years), but it is 2.2 per 100 000 in uncircumcised men (about 1000 cases are reported annually). On the basis of life table analysis, Kochen and McCurdy estimated that an uncircumcised man in the US has a lifetime risk of penile cancer of one in 600[8].

During the last 50 years in the US, six major series of cancer of the penis encompassing more than 1600 cases have been reported; none of these cancer patients was circumcised in infancy[9]. Human papilloma virus and smegma have been implicated in the aetiology of penile cancer[10]. Of the approximately 50 000 cases of cancer of the penis that have occurred in the US since the 1930s (and which resulted in about 10 000 deaths), only 10 were reported in circumcised men[9]. Newborn circumcision virtually eliminates this devastating threat.

Urinary tract infection (UTI)

When the American Academy of Pediatrics Task Force on Circumcision report was issued,5 data from Wiswell et al suggested that uncircumcised male infants had an increased risk of clinically significant UTI[11]. Since then, the evidence has become definitive, indicating a greater than 10-fold increased risk of UTI in uncircumcised boys compared with their circumcised counterparts in the first year of life[12-14]. Uncircumcised preschool boys and men are also at increased risk for UTI[15,16]. UTI in infants can lead to permanent renal parenchymal damage[17]. The pathophysiological basis of UTI in uncircumcised males was convincingly demonstrated by Fussell et al in electron photomicrographs showing preferential binding of uropathic fimbriated bacteria, mainly Escherichia coli, to the sticky mucosa of the foreskin, from which point they migrate up the urethra[18]. A meta-analysis of the nine major studies relating UTI to circumcision showed a mean 12-fold increased risk of UTI in uncircumcised boys[14]. These worldwide studies indicated that between 0.9% and 4.2% of uncircumcised infant boys have a symptomatic UTI in the first year of life[14].

UTI is particularly dangerous in the first months of life, during which 36% of uncircumcised boys with UTI were found to have bacteraemia, 3% to have meningitis, and 2% acute renal failure; moreover, 2% died[19]. Further, most uncircumcised boys with UTI in the first six months of life show renal parenchymal damage[17], and in 10% to 15% of those aged less than 1 year, renal scarring develops, which can result in systemic hypertension.

Sexually transmitted disease (STD)

A link between the foreskin and STD has long been proposed[20-24]. In his classic, turn-of-the-century work on circumcision, Remondino described the protective effect of circumcision against syphilis, genital herpes, and urethritis[20]. STD agents that disrupt the epithelium (syphilis, chancroid, herpes, and papilloma virus) are believed to enter through miniabrasions of the foreskin, and the warm, moist environment under the foreskin permits growth of organisms causing urethritis[25]. In almost all published series, these forms of STD were more common in uncircumcised men; reports of the converse are rare. Reports from Africa beginning in the late 1980s indicated that uncircumcised, heterosexual men were from four to eight times more likely than circumcised men to contract HIV upon exposure to infected women[26-29]. Multiple reports since then were summarised in 1994 by Moses et al who found that, in 22 of 30 studies, a statistically significant increase in HIV infection occurred in uncircumcised men (a mean of four times the risk of circumcised men)[30]. The authors felt strongly enough about these findings to recommend adult circumcision of African men to halt the raging AIDS epidemic on that continent.

Recently Caldwell and Caldwell studied the AIDS epidemic in sub-Saharan Africa where nearly 25% of the population is HIV positive as a result of heterosexual viral transmission[31]. The authors concluded that lack of male circumcision was the only factor that seemed to correlate with the exceptionally high susceptibility to HIV infection.

Discussion and conclusions

The decision to discourage newborn circumcision in the UK and the resultant decrease in the number of circumcised males occurred before the accumulation of this evidence about the protective effect of circumcision against UTI and HIV infection. Particularly in the face of an expanding worldwide AIDS epidemic, these benefits are a powerful argument in favour of encouraging universal newborn circumcision. In an editorial comment on the epidemic spread of HIV-1 in Asia, Weniger and Brown pointed out that in those countries in which circumcision is practiced (Bangladesh, Indonesia, and the Philippines) rapid sexual transmission of HIV-1 is less likely[32]. When properly done, newborn circumcision is a quick, simple procedure with a low complication rate. Morbidity and costs of circumcision are much lower for newborns than they are for older patients[6,7].

Moreover, about 70 million circumcised US males currently attest to the lack of effect of circumcision on either emotional health or sexual performance, and no objective studies indicate otherwise. As a matter of fact, evidence indicates that women in Middle America have a sexual preference for circumcised men, mainly from the standpoint of aesthetics and hygiene[33].

The multiple benefits of newborn circumcision are additive over a lifetime and include prevention of cancer of the penis, of balanoposthitis, and protection against the effects of phimosis and poor hygiene as well as prevention of UTI and STD, particularly of HIV. Protection against these diseases constitutes a substantial public health advantage and provides a strong argument in favour of instituting universal newborn circumcision in Europe. With AIDS spreading rapidly in developed Western countries in persons who practice heterosexual behaviour as well as in men who practice homosexual behaviour, implementation of universal circumcision beginning with Europe is prudent and timely.

Acknowledgments

The Medical Editing Department, Kaiser Foundation Research Institute, provided editorial assistance.

References

  1. Kalcev B. Circumcision and personal hygiene in school boys. Medical Officer 1964; 112: 171-173
  2. Oster J. Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child 1968; 43: 200-203
  3. Escala JM, Rickwood AMK. Balanitis. Br J Urol 1989; 63: 196-197
  4. Winberg J, Bollgren I, Gothefors L, Herthelius M, Tullus K. The prepuce: a mistake of nature? Lancet 1989; i: 598-599
  5. American Academy of Pediatrics. Report of the task force on circumcision. Pediatrics 1989; 84: 388-391 [published erratum appears in Pediatrics 1989; 84: 761]
  6. Wiswell TE, Tencer HL, Welch CA, Chamberlain JL. Circumcision in children beyond the neonatal period. Pediatrics 1993; 92: 791-793
  7. Larsen GL, Williams SD. Postneonatal circumcision: population profile. Pediatrics 1990; 85: 808-812
  8. Kochen M, McCurdy S. Circumcision and the risk of cancer of the penis: a life-table analysis. Am J Dis Child 1980; 134: 484-486
  9. Schoen EJ. The relationship between circumcision and cancer of the penis. CA Cancer J Clin 1991; 41: 306-309
  10. McCance DJ, Kalache A, Ashdown K, et al. Human papillomavirus types 16 and 18 in carcinomas of the penis from Brazil. Int J Cancer 1986; 37: 55-59
  11. Wiswell TE, Smith FR, Bass JW. Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1985; 75: 901-903
  12. Wiswell TE, Miller GM, Gelston HM Jr, Jones SK, Clemmings AF. Effect of circumcision status on periurethral bacterial flora during the first year of life. J Pediatr 1988; 113: 442-446
  13. Crain EF, Gershel JC. Urinary tract infections in febrile infants younger than 8 weeks of age. Pediatrics 1990;86:363-367
  14. Wiswell TE, John K. Lattimer lecture. Prepuce presence portends prevalence of potentially perilous periurethral pathogens. J Urol 1992; 148(2 pt 2): 739-742
  15. Spach DH, Stapelton AE, Stamm WE. Lack of circumcision increases the risk of urinary tract infection in young men. JAMA 1992; 267: 679-681
  16. Craig JC, Knight JF, Sureshkumar P, Mantz E, Roy LP. Effect of circumcision on incidence of urinary tract infection in preschool boys. J Pediatr 1996; 128: 23-27
  17. Rushton HG, Majd M. Pyelonephritis in male infants: how important is the foreskin? J Urol 1992; 148(2 pt 2): 733-736; discussion 737-8
  18. Fussell EN, Kaack BM, Cherry R, Roberts JA. Adherence of bacteria to human foreskins. J Urol 1988; 140: 997-1001
  19. Wiswell TE, Geschke DW. Risks from circumcision during the first month of life compared with those for uncircumcised boys. Pediatrics 1989; 83: 1011-1015
  20. Remondino PC. History of circumcision from the earliest times to the present: moral and physical reasons for its performance, with a history of eunuchism, hermaphrodism, etc and of the different operations practiced upon the prepuce. Philadelphia: Davis, 1891, 1900. (Physicians' and students' ready reference series; No 11.)
  21. Wilson RA. Circumcision and venereal disease. Can Med Assoc J 1947; 56: 54-56
  22. Parker SW, Stewart AJ, Wren MN, Gollow MM, Straton JAY. Circumcision and sexually transmissible disease. Med J Aust 1983; ii: 288-290
  23. Taylor PK, Rodin P. Herpes genitalia and circumcision. British Journal of Venereal Diseases 1975; 51: 274-277
  24. Thirumoorthy T, Sng EH, Doraisingham S, Ling AK, Lim KB, Lee CT. Purulent penile ulcers of patients in Singapore. Genitourin Med 1986; 62: 253-255
  25. Fink AJ. A possible explanation for heterosexual male infection with AIDS [letter]. N Engl J Med 1986; 315: 1167
  26. Simonsen JN, Cameron DW, Gakinya MN, et al. Human immunodeficiency virus infection among men with sexually transmitted diseases: experiences from a center in Africa. N Engl J Med 1988; 319: 274-278
  27. Cameron DW, Simonsen JN, D'Costa LJ, et al. Female to male transmission of human immunodeficiency virus type 1: risk factors for seroconversion in men. Lancet 1989; ii: 403-407
  28. Bongaarts J, Reining P, Way P, Conant F. The relationship between male circumcision and HIV infection in African populations. AIDS 1989; 3: 373-377
  29. Moses S, Bradley JE, Nagelkerke MJD, Ronald AR, Ndinya Achola JO, Plummer FA. Geographical patterns of male circumcision practice in Africa: association with HIV seroprevalence. Int J Epidemiol 1990; 19: 693-697
  30. Moses S, Plummer FA, Bradley JE, Ndinya-Achola JO, Nagelkerke NJD, Ronald AR. The association between lack of male circumcision and risk for HIV infection: a review of the epidemiological data. Sex Transm Dis 1994; 21: 201-210
  31. Caldwell JC, Caldwell P. The African AIDS epidemic. Sci Am 1996 Mar; 274(3): 62-68
  32. Weniger BG, Brown T. The march of AIDS through Asia [editorial]. N Engl J Med 1996; 335: 343-345
  33. Williamson ML, Williamson PS. Women's preferences for penile circumcision in sexual partners. Journal of Sex Education and Therapy 1988 Fall/Winter; 14(2): 9-12

Schoen EJ. Benefits of newborn circumcision: is Europe ignoring medical evidence? Arch Dis Child 1997 Sep; 77(3): 258-60

File: www/library/schoen3/index.html. Last updated: 23 Oct 2004.