Male circumcision provides some medical benefits but also carries risks. While the risk of urinary tract infections is lower in circumcised infants, routine circumcision is not mandatory. Complications can include bleeding, infection, adhesions, and in rare cases, death. The impact on sexual function is controversial as the foreskin contains nerve endings removed by circumcision but sensation appears unchanged. Circumcision is generally not recommended or condemned, with medical indications including phimosis, balanitis, and UTI risk in specific cases like VUR. Non-medical circumcision is declining in the US with some states no longer covering it under Medicaid.

1. Male Circumcision:
Indications and Complications
David Galvin
Mr. Dennis Murphy
23.1.06

2. 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

3. 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

4. Natural History
• Work by Gairdner
1949 and Oster 1968
• Less than 1% of boys
require a circumcision

5. Introduction
• Controversial Issues
– Risk of UTI
– Anaesthesia
– Sexual function
– Malignancy
– STDs

6. 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

7. 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)

8. 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 uncircumcised !

9. 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

10. 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.

11. Indications
• Medical
– 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 1999
Religious

12. Contraindications
• Premature Infants
• Congenital Penile Abnormalities
– Hypospadias, episapdias, chordee, penile
webbing or concealed penis
• Blood Dyscrasias

13. Complications
• Death
• Bleeding (2-5%)
• Suture sinus tracts
• Infection (2%)
• Phimosis and
concealed penis
• Adhesions
• Meatal stenosis
• Chordee
• Urethrocutaneous
fistula
• Necrosis
• Amputation
• Hypospadias
• Meatitis

14. 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.

15. 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

16. 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