A Temperate Approach to Neonatal Circumcision

Reprint requests: John W. Duckett, M.D.,
Pediatric Ambulatory Care Center,
34th St and Civic Center Blvd.
Philadelphia, PA 191O4-4399

Submitted September 28, 1995, accepted September 28, 1995.

Unfortunately the rhetoric and emotion that engenders spirited debate over circumcision today will not likely be resolved with the facts. The controversy seems to polarize a pro/con intransigence, the foundations of which are untenable for either position. There is a good review in an AUA Update Series,¹ which supports neonatal circumcision from the urologist's point of view. The avoidance of cancer of the penis and cancer of the cervix are always strongly argued positions. It has been pointed out that the moist glans is more susceptible to venereal disease and HIV infections. Devine has said, If the decision is made not to circumcise a male infant, there must be a lifetime commitment to genital hygiene. This is the rub - penile hygiene is the key to penile health, circumcised or uncircumcised. Most opponents of circumcision must feel that every uncircumcised individual will take meticulous care of his penis as they seem to compare the benefits of circumcision with this ideal. He then sardonically implies that parents should have to sign an AAP medical alert. The decision not to circumcise a male infant must be accompanied by a lifetime commitment to genital hygiene to minimize the risk of developing penile cancer.

Although penile cancer occurs in the uncircumcised, it is so rare in the United States that Marshall argued convincingly in 1960 (at a meeting of the Society for Pediatric Urology in Philadelphia) that someone would have to do 140 circumcisions a week for 25 years to prevent one case of carcinoma of the penis. Good hygiene and health awareness may serve the same goal.

Blandy has pointed out that in 1949 16 deaths occurred in the United Kingdom in 1 year associated with neonatal circumcision from unrecognized clotting disorders or infection, prompting the United Kingdom to reverse its circumcision policy. He also noted a humane provision in the Talmud, excusing a third son from circumcision if two previous sons have died from it.¹ A proper informed consent might include a list of complications of circumcision: excessive bleeding, necrosis of the glans, removal of the penile skin, urethral fistula, lymphedema, laceration of the scrotum, staphylococcal septicemia, penile necrosis, and even hematogenous osteomyelitis. Aspiration complications in babies without anesthesia are also reported. At a recent meeting of the American Academy of Pediatrics, Horowitz and Glassberg² reported on Circumcision: Successful Glanular Reconstruction and Survival Following Traumatic Amputation. There were 7 cases in 8-day-old infants all done by a different mohel in New York City. A straw poll of the pediatric urologists in the audience indicated at least half had similar cases.

Those advocating circumcision point out the 10% incidence of the uncircumcised population, who develop phimosis, trauma, paraphimosis, and recurrent balanoposthitis, come to circumcision at a later date requiring anesthetics and anxiety to the patient. The difficulties in diabetics with an intact foreskin are well known and are another indication for neonatal circumcision. The incidence of these complications, however, in Scandinavia is less than 1% in a culture that manages the uncircumcised penis more appropriately.

The new data on urinary tract infections in baby boys has caused the American Academy of Pediatric Task Force on Circumcision to revise its statement in 1984 from one of no medical indications to the 1989 statement, newborn circumcision has potential medical benefits and advantages as well as disadvantages and risks.³ Ginsberg and McCracken, in 1982,⁴ were the first to point out that 95% of boys with urinary tract infections were uncircumcised, data similar to that found in Scandinavia. Wiswell and associates, in 1985,⁵ in a large military survey found an overall incidence of 0.43% urinary tract infections in infants; 1.12% were uncircumcised males while 0.11% were circumcised males and the females comprised 0.57%. These data have been used recently by the circumcisers to support neonatal circumcision, while neonatologists and pediatricians are now more aware of this likely diagnosis.

We are, nevertheless, impacted by the activities of lay groups such as  NOCIRC and INTACT as well as the feminist movement. These groups have defended the right of the mother to refute the American trend toward neonatal circumcision even though this carries with it enormous guilt and the difficulty of informed consent. When advocates for intactness discuss the sexual benefits, they rhapsodically describe the dynamic transformability of the intact penis as one of the most unique and striking features of sexuality. The mobility of the skin and the forefold retraction with erection is the preservation of this sensitivity. They describe the sensitivity and pleasure of the erogenous penis as being chronically altered by the dastardly deed of circumcision. There are well over a million men estimated in America that would pay good money to have their foreskins restored were there aneffective procedure.

The need exists today for a good book for parents regarding the facts of infant circumcision. In addition, a major effort should be made in instructing the health care providers, from mid-wives and nurses to pediatricians and urologists, on how to manage the uncircumcised penis. Unfortunately the need for cleanliness has been pervasive and the forceful retraction of the infant's foreskin is still a ritual taught by some of the most respected pediatricians. This is absolutely contraindicated and leads to the complications of phimosis, balanoposthitis, and other problems that will require circumcision.

The American Academy of Pediatrics has a pamphlet available entitled,  How to Care for the Un-circumcised Penis. It can be obtained by sending a self-addressed envelope with your request to AAP, Dept. C, 141 Northwest Point Blvd., Elk Grove Village, IL 60007. The pamphlet describes the natural adhesion of the inner preputial skin to the glans and emphasizes avoiding the forceful retraction before the natural separation process occurs to the inner preputial layer adherent to the glans. Parents should be instructed to cleanse the external skin and not to permit others to retract the child's fore skin. It is at puberty that cleansing beneath the foreskin becomes a routine part of the healthy life-style. Natural retraction may not occur for many years. It is likely that a significant part of the population will choose to remain uncircumcised. We urologists should make them comfortable with this choice instead of laying a guilt trip. On the other hand, the positive cultural connotation of neonatal circumcision in our country is so well ingrained that those families wishing to maintain this position should be encouraged to make this choice forthrightly. The neonate should, however, be afforded the benefit of local anesthesia or a penile block and an experienced circumciser. Hopefully a balanced informed consent will make the parents' decision easier, whichever side is chosen.

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