Neonatal circumcision: Risks and benefits
- Laurence S Baskin, MD, FAAP
Laurence S Baskin, MD, FAAP
- Section Editor — Pediatric Urology
- Frank Hinman, Jr, MD, Distinguished Professorship in Pediatric Urology
- Chief Pediatric Urology
- Professor of Urology and Pediatrics
- UCSF Benioff Children's Hospital
- Section Editors
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- John G Bartlett, MD
John G Bartlett, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — HIV; Pulmonary Infections
- Professor Emeritus
- Johns Hopkins University School of Medicine
- Duncan Wilcox, MD
Duncan Wilcox, MD
- Section Editor — Pediatric Urology
- Professor of Urology, The Ponzio Family Chair in Pediatric Urology
- University of Colorado
Circumcision in the male refers to the surgical removal of the prepuce (ie, foreskin) of the penis. The procedure is centuries old and continues to be performed for a variety of religious, cultural, and medical reasons.
Parents of newborn males often have questions about circumcision: Is it necessary? What are its benefits? What are its risks? In addition to these medical issues, other factors that influence parental decision-making include the father's circumcision status, opinions of family members and friends, a desire for conformity in their son's appearance, and the belief that the circumcised penis is easier to keep clean [1-3].
The risks and benefits of circumcision will be reviewed here, with the focus on circumcision of neonates. Procedures for neonatal circumcision are discussed separately. (See "Techniques for neonatal circumcision".)
Normal penile development and anatomy — (See "Techniques for neonatal circumcision", section on 'Development and anatomy'.)
Prevalence and epidemiology — The United States is the only country in the developed world where the majority of male infants are circumcised for nonreligious reasons. Circumcision rates in the United States vary according to geographic area, socioeconomic status, religious affiliation, insurance coverage, hospital type, and racial and ethnic group. The overall prevalence is estimated to be about 80 percent for males aged 14 to 59 years, with most of these procedures performed in newborns . Circumcision rates are highest in the Midwestern states (74 percent), followed by the Northeastern states (67 percent) and Southern states (61 percent), and are lowest in the Western states (30 percent) . The rate is higher in non-Hispanic whites (91 percent) than in non-Hispanic blacks (76 percent) and Mexican Americans (44 percent) .To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Neonatal circumcision. Report 10 of the Council on Scientific Affairs (I-99). www.ama-assn.org/ama/pub/category/13585.html (Accessed on September 14, 2006).
- Waldeck SE. Social norm theory and male circumcision: why parents circumcise. Am J Bioeth 2003; 3:56.
- Xu B, Goldman H. Newborn circumcision in Victoria, Australia: reasons and parental attitudes. ANZ J Surg 2008; 78:1019.
- Morris BJ, Bailis SA, Wiswell TE. Circumcision rates in the United States: rising or falling? What effect might the new affirmative pediatric policy statement have? Mayo Clin Proc 2014; 89:677.
- Blank S, Brady M, Buerk E, et al. Male circumcision. Pediatrics 2012; 130:e756.
- Halperin DT, Timberg C. Update of chart in 'Male Circumcision and HIV Prevention: 10 Years and Counting' Circs.org. 2012. www.circs.org/library/HalperinTimberg (Accessed on December 14, 2006).
- Badger, J. Circumcision. What you think. Australian Forum 1989; 2:10.
- Badger, J. The great circumcision report part 2. Australian Forum 1989; 2:4.
- Binner SL, Mastrobattista JM, Day MC, et al. Effect of parental education on decision-making about neonatal circumcision. South Med J 2002; 95:457.
- Wang ML, Macklin EA, Tracy E, et al. Updated parental viewpoints on male neonatal circumcision in the United States. Clin Pediatr (Phila) 2010; 49:130.
- Adler R, Ottaway MS, Gould S. Circumcision: we have heard from the experts; now let's hear from the parents. Pediatrics 2001; 107:E20.
- Tiemstra JD. Factors affecting the circumcision decision. J Am Board Fam Pract 1999; 12:16.
- Walton RE, Ostbye T, Campbell MK. Neonatal male circumcision after delisting in Ontario. Survey of new parents. Can Fam Physician 1997; 43:1241.
- Turini GA 3rd, Reinert SE, McQuiston LD, Caldamone AA. Circumcision: a study of current parental decision-making. Med Health R I 2006; 89:365.
- Morris BJ, Waskett JH, Banerjee J, et al. A 'snip' in time: what is the best age to circumcise? BMC Pediatr 2012; 12:20.
- Mallon E, Hawkins D, Dinneen M, et al. Circumcision and genital dermatoses. Arch Dermatol 2000; 136:350.
- Shaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of urinary tract infection in childhood: a meta-analysis. Pediatr Infect Dis J 2008; 27:302.
- Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Arch Dis Child 2005; 90:853.
- Larke NL, Thomas SL, dos Santos Silva I, Weiss HA. Male circumcision and penile cancer: a systematic review and meta-analysis. Cancer Causes Control 2011; 22:1097.
- Fergusson DM, Lawton JM, Shannon FT. Neonatal circumcision and penile problems: an 8-year longitudinal study. Pediatrics 1988; 81:537.
- Jagannath VA, Fedorowicz Z, Sud V, et al. Routine neonatal circumcision for the prevention of urinary tract infections in infancy. Cochrane Database Syst Rev 2012; 11:CD009129.
- Günşar C, Kurutepe S, Alparslan O, et al. The effect of circumcision status on periurethral and glanular bacterial flora. Urol Int 2004; 72:212.
- Aridogan IA, Ilkit M, Izol V, et al. Glans penis and prepuce colonisation of yeast fungi in a paediatric population: pre- and postcircumcision results. Mycoses 2009; 52:49.
- Wiswell TE, Miller GM, Gelston HM Jr, et al. Effect of circumcision status on periurethral bacterial flora during the first year of life. J Pediatr 1988; 113:442.
- Circumcision policy statement. American Academy of Pediatrics. Task Force on Circumcision. Pediatrics 1999; 103:686.
- Pisacane A, Graziano L, Mazzarella G, et al. Breast-feeding and urinary tract infection. J Pediatr 1992; 120:87.
- Morris BJ, Wiswell TE. Circumcision and lifetime risk of urinary tract infection: a systematic review and meta-analysis. J Urol 2013; 189:2118.
- Spach DH, Stapleton AE, Stamm WE. Lack of circumcision increases the risk of urinary tract infection in young men. JAMA 1992; 267:679.
- Fakjian N, Hunter S, Cole GW, Miller J. An argument for circumcision. Prevention of balanitis in the adult. Arch Dermatol 1990; 126:1046.
- Barnholtz-Sloan JS, Maldonado JL, Pow-sang J, Giuliano AR. Incidence trends in primary malignant penile cancer. Urol Oncol 2007; 25:361.
- Frisch M, Friis S, Kjaer SK, Melbye M. Falling incidence of penis cancer in an uncircumcised population (Denmark 1943-90). BMJ 1995; 311:1471.
- Krueger H, Osborn L. Effects of hygiene among the uncircumcised. J Fam Pract 1986; 22:353.
- Wiswell TE, Geschke DW. Risks from circumcision during the first month of life compared with those for uncircumcised boys. Pediatrics 1989; 83:1011.
- Christakis DA, Harvey E, Zerr DM, et al. A trade-off analysis of routine newborn circumcision. Pediatrics 2000; 105:246.
- Learman LA. Neonatal circumcision: a dispassionate analysis. Clin Obstet Gynecol 1999; 42:849.
- Albero G, Castellsagué X, Giuliano AR, Bosch FX. Male circumcision and genital human papillomavirus: a systematic review and meta-analysis. Sex Transm Dis 2012; 39:104.
- Aynaud O, Piron D, Bijaoui G, Casanova JM. Developmental factors of urethral human papillomavirus lesions: correlation with circumcision. BJU Int 1999; 84:57.
- Davis MA, Gray RH, Grabowski MK, et al. Male circumcision decreases high-risk human papillomavirus viral load in female partners: a randomized trial in Rakai, Uganda. Int J Cancer 2013; 133:1247.
- Castellsagué X, Bosch FX, Muñoz N, et al. Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. N Engl J Med 2002; 346:1105.
- Herzog LW, Alvarez SR. The frequency of foreskin problems in uncircumcised children. Am J Dis Child 1986; 140:254.
- Kaplan GW. Complications of circumcision. Urol Clin North Am 1983; 10:543.
- DeVries CR, Miller AK, Packer MG. Reduction of paraphimosis with hyaluronidase. Urology 1996; 48:464.
- Wright JE. The treatment of childhood phimosis with topical steroid. Aust N Z J Surg 1994; 64:327.
- Ashfield JE, Nickel KR, Siemens DR, et al. Treatment of phimosis with topical steroids in 194 children. J Urol 2003; 169:1106.
- Stenram A, Malmfors G, Okmian L. Circumcision for phimosis--indications and results. Acta Paediatr Scand 1986; 75:321.
- Oster J. Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child 1968; 43:200.
- Kalcev, B. Circumcision and personal hygiene in school boys. Med Officer 1964; 122:171.
- Weiss HA, Larke N, Halperin D, Schenker I. Complications of circumcision in male neonates, infants and children: a systematic review. BMC Urol 2010; 10:2.
- Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996; 77:291.
- Boyle GJ, Bensley GA. Adverse sexual and psychological effects of male infant circumcision. Psychol Rep 2001; 88:1105.
- Morris BJ, Krieger JN. Does male circumcision affect sexual function, sensitivity, or satisfaction?--a systematic review. J Sex Med 2013; 10:2644.
- Schoen EJ, Wiswell TE, Moses S. Reply to Carole M. Lannon and the task force on circumcision. Pediatrics 2001; 108:211.
- Howard CR, Howard FM, Weitzman ML. Acetaminophen analgesia in neonatal circumcision: the effect on pain. Pediatrics 1994; 93:641.
- Marshall RE, Porter FL, Rogers AG, et al. Circumcision: II. Effects upon mother-infant interaction. Early Hum Dev 1982; 7:367.
- Brady-Fryer B, Wiebe N, Lander JA. Pain relief for neonatal circumcision. Cochrane Database Syst Rev 2004; :CD004217.
- Dixon S, Snyder J, Holve R, Bromberger P. Behavioral effects of circumcision with and without anesthesia. J Dev Behav Pediatr 1984; 5:246.
- Fergusson DM, Boden JM, Horwood LJ. Neonatal circumcision: effects on breastfeeding and outcomes associated with breastfeeding. J Paediatr Child Health 2008; 44:44.
- Weiss GN, Weiss EB. A perspective on controversies over neonatal circumcision. Clin Pediatr (Phila) 1994; 33:726.
- Schoen EJ. The status of circumcision of newborns. N Engl J Med 1990; 322:1308.
- Poland RL. The question of routine neonatal circumcision. N Engl J Med 1990; 322:1312.
- Schoen EJ, Wiswell TE, Moses S. New policy on circumcision--cause for concern. Pediatrics 2000; 105:620.
- Weiss GN. Prophylactic neonatal surgery and infectious diseases. Pediatr Infect Dis J 1997; 16:727.
- Flynn P, Havens P, Brady M, et al. Male circumcision for prevention of HIV and other sexually transmitted diseases. Pediatrics 2007; 119:821.
- Dickerman JD, American Academy of Pediatrics. Circumcision in the time of HIV: when is there enough evidence to revise the American Academy of Pediatrics' policy on circumcision? Pediatrics 2007; 119:1006.
- Neonatal circumcision revisited. Fetus and Newborn Committee, Canadian Paediatric Society. CMAJ 1996; 154:769.
- American Academy of Pediatrics Task Force on Circumcision. Circumcision policy statement. Pediatrics 2012; 130:585.
- The American College of Obstetricians and Gynecologists Endorses AAP Policy Statement on Circumcision. http://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/New-Benefits-Point-to-Greater-Benefits-of-Infant-Circumcision-But-Final-Say-is-Still-Up-to-parents-Says-AAP.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token (Accessed on August 28, 2012).
- American Urological Association. Circumcision http://www.auanet.org/content/aua-policies/policy-statements/c/circumcision.cfm (Accessed on April 15, 2013).
- UNAIDS. Safe, voluntary, informed male circumcision and comprehensive HIV prevention programming. March 2008. (Accessed December 15, 2008).
- World Health Organization. Male circumcision quality assurance: a guide to enhancing the safety and quality of services. 2008.
- Normal penile development and anatomy
- Prevalence and epidemiology
- POTENTIAL BENEFITS
- Reduction in urinary tract infection
- - Infants with congenital uropathy
- Reduction in risk of some cancers
- - Penile cancer
- - Cervical cancer in partners
- Reduction in penile inflammation and retractile disorders
- Reduction in HIV and other sexually transmitted infections
- Easier hygiene
- POTENTIAL DISADVANTAGES
- Procedure related complications
- Sexual dissatisfaction
- OPINIONS OF ORGANIZATIONS AND GROUPS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS