Neonatal circumcision in the United States in 1982

Note:

Dr. Lowell King served on the ad hoc task force that wrote the historic 1975 policy statement regarding neonatal circumcision that started the trend toward genital integrity in the United States. Later, in 1982 he set forth some of the considerations of that committee. This paper, therefore, is of some historic interest.

This paper is dated in many ways. Some of the medical information in this paper is not current. For example, we now know that, for most boys, the foreskin typically becomes retractable at an older age than given in this paper. Also, there is absolutely no concern expressed for the pain of circumcision and there is no real consideration of the ethical issues raised by performing a non-therapeutic, irreversible, injurious, amputative operation on a non-consenting minor child.

COMMENTARY

In 1972 a committee on the fetus and the newborn asked their parent body, the American Academy of Pediatrics, to study the desirability of neonatal circumcision. The reasons for this request were 2-fold: 1) a concern about needless surgery causing pain and suffering, and 2) the thought that the insurance dollars spent on neonatal circumcision would cover the costs of neonatal intensive care. At the time family healthy insurance policies commonly excluded newborns for the first 15 days after birth.

Successive ad hoc committees struggled with the issue. American parents and physicians had adopted an uncritical attitude to neonatal circumcision and about 92 percent of the boys born in Illinois in 1975 were being circumcised as neonates. This rate was thought to be typical of the United States asa whole.

After careful review of the literature then available the ad hoc committee reached various conclusions.¹

1) Circumcision prevents carcinoma of the penis but this is such a rare malignancy that routine circumcision is an inefficient means of prevention. Retraction of the foreskin and simply washing the glans during baths also are effective means of preventing future carcinoma.

2) There was no compelling evidence that noncircumcision increased the the incidence of carcinoma of the cervix in sexual partners. Cervical carcinoma rates are low in Israel, where most boys are circumcised, but also are low in Finland, where circumcision is unusual. Genetic resistance to cancer of the cervix is a tempting alternative explanation.

4) Neonatal circumcision disposes to meatitis and meatal stenosis. Such stenosis is a common reason for subsequent meatomy or other operation. Circumcision injuries are not really rare.

5) Circumcision should not be performed on sick or premature neonates, especially those with blood dyscrasia, hypospadias or related penile anomalies.

6) Circumcision does make later instruction in special penile hygiene necessary but such hygiene consists of simple clearliness and assurance that the child washes under foreskins during baths that he later does himself after the foreskin has become retractable.

The report concluded that “there is no absolute medical indication for routine circumcision of the newborn” and advised informed consent, suggesting that prospective parents decide at leisure before birth whether they wanted a boy circumcised. This report received a mixed reception. In general, pediatricians have become aware that neonatal circumcision is unnecessary. Debate has centered on when and how to retract the prepuce. The view that since the prepuce and glans develop from the same block of tissue painless retraction without breaking up synechaie should not be expected until the child is 3 to 6 years old and only now is becoming accepted. Obstetricians continue to account for the circumcision of a large majority of male newborns in the United States. Slotkowski and King recently sampled Illinois hospitals and found that the neonatal circumcision rate to be 88 percent in the wake of considerable efforts at parental education.² One hospital continues to have a high circumcision rate even though the noncircumcision option has been incorporated into the operative consent form. The circumcision rate had decreased precipitously in only 2 responding hospitals.

Recently, the question of whether neonatal circumcision protects male newborns from urinary tract infection has arisen. Most male neonates that get urinary tract infections from underlying anatomical abnormalities of the urinary tract and they are often severe in degree. However, in one series only 5 percent of the male infants with such urinary tract infections had been circumcised. The significance of this observation is unclear. However, urinary tract infections in infants are so uncommon that it would seem like carcinoma of the penis, inefficient to try to protect male infants from urinary tract infection by circumcision.

Parents faced with the decision on an informal basis probably are given more information than they desire. A common response on learning that circumcision is medically unnecessary is, “but doctor, we want our boy to look like this brother(s).” In short, Americans have come to regard neonatal circumcision as inherently desirable and difficult to guess how long this attitude will prevail. If neonatal circumcision is not elected parents will seek out someone to perform the circumcision when the child is several months or even years old.

Urologists who do neonatal circumcisions are affected by the latter trend and generally are the physicians who evaluate questionable meatal stenosis and treat circumcision injuries.

The impact of the latter is considerable. Circumcision can be safe. During one period 500,000 consecutive circumcisions were performed in New York City without fatality. This is feasible if the circumcision is deferred until the infant is at least 1 day old and is tested for bleeding tendencies. Obviously, circumcision should be deferred in boys with a family history of excessive bleeding.

On the other hand, circumcisions do lead to complications. The common problems usually are not serious. 1) Asymetrical removal of the foreskin may require recircumcision for cosmetic purposes. 2) Bleeding from an artery or vein may require secondary ligation. 3) the suture line may become infected and although usually responsive to local treatment, the staphylococcal-scalded skin syndrome may result.³ 4) Meatal stenosis probably is the most common potentially adverse result of neonatal circumcision. Loss of the covering foreskin predisposes to meatitis. Healing narrows the meatus, sometimes to a pinpoint that may diminish the or angulate the urinary stream. Meatotomy may be required but often is performed just because the meatus looks narrow. However, like any stricture a small meatus may continue to narrow or fail to enlarge with growth to a degree that decreases the stream and reduces the flow rate. In extreme instances bladder decompensation or ulrinary retention may result. 5) Phimosis in male infants is caused by incomplete circumcision. The reapproximation line between the skin and deep preputial layer heals by scar. When the scar contracts the remaining foreskin cannot be retracted and re-circumcision is necessary. If excessive skin has been removed a concealed penis resultsuntil re-circumcision liberates the shaft.

Taken in aggregate these relative minor complications of neonatal circumcision are relatively common, perhaps 1 in 15 to 20 boys. Unfortunately, there is worse to come. Serious complications of neonatal circumcision are unusual but not rare. 1) Removal of excessive skin of the penile shaft may result in a concealed penis, alluded to previously, or a denuded penis. The skin edges must be mobilized and re-sutured or the shaft should be buried in the scrotum to pick up new, eventually hair-bearing, skin. 2) If the urethra is caught in a circumcision clamp the injury usually is a fistula at the corona, where closure may be difficult and 2 operations often are needed. 3) The glans or even penis itself may be amputated. Reanastomosis should be attempted using microsurgical techniques, which have been successful. 4) Cautery, applied to the bell of a Gomco clamp, has resulted in glanular slough. Cautery also has burned the penis completely when applied to circumcision clamps. These complications can be terrible and usually are the result of the use of a circumcision clamp by inexperienced operators. Free hand techniques are much preferred by the occasional operator, although circumcision clamps are safe and effective when usedby trained personnel.

Fortunately, new microsurgical techniques allow construction of a missing penis from revascularized and reinnervated grafts. These patients eventually can be fitted with a penile prosthesis for erection, permitting intercourse. However the nerve endings of the glans cannot be replaced. Obviously boys who lose the penis in infancy should continue to be reared and reconstructed as girls.

Routine infant circumcision continues to be uniquely popular in the United States. However, a noncircumcision trend may be gathering momentum slowly. Success of this movement will depend on the realization and acceptance of the fact that the noncircumcised penis does not require any treatment. Our population must learn that full retraction of the prepuce should not be expected until the child is 3 to 6 years old, although occasional foreskins are readily retractable at birth and that penile hygiene consists of learning to wash under the foreskin after it becomes retractile, just as a child learns to wash behind and in the ears. Meanwhile, complications of neonatal circumcision continue. Some, such as meatal stenosis, bleeding and infection, are inherent risks of the procedure. Others, such excessive or inadequate skin removal, urethral fistula and damage to the glans or penile shaft, probably would diminish, if not disappear, if occasional practitioners of the art of circumcision would eschew blind or semi-blind clamps and use a free-hand open surgical technique.

REFERENCES

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