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Circumcision

Circumcision. Dr. Grahame Smith The Childrens Hospital at Westmead. History. Undertaken for many thousands of years. Why. Originally a hygiene measure A ritual, religious Enhance/decrease sexual performance Prevent masturbation (Brigman). Current position statements. RACP/RACS 2010

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Circumcision

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  1. Circumcision Dr. Grahame Smith The Childrens Hospital at Westmead

  2. History Undertaken for many thousands of years

  3. Why Originally a hygiene measure A ritual, religious Enhance/decrease sexual performance Prevent masturbation (Brigman)

  4. Current position statements • RACP/RACS 2010 • Not recommended routinely • American Academy of Pediatrics 2012 • Not recommended routinely • Justified for families that choose it • Canadian Pediatric Society 1989 • Not recommended None recommend routine circumcision

  5. Strongly opposed • Finland • In February 2010, a Jewish couple were fined for causing bodily harm to their then infant son who was circumcised in 2008 by a mohel brought in from the UK. Normal procedure for persons of Jewish faith in Finland is to have a locally certified mohel who works in Finnish healthcare perform the operation. In the 2008 case, the infant was not anesthetized and developed complications that required immediate hospital care. The parents were ordered to pay 1500 euros in damages to their child • Netherlands • Germany • Dec 2012; law passed explicitly permitting non-therapeutic circumcision to be performed under certain conditions (religious)

  6. Risk & cognitive error 1

  7. Risk & cognitive error 2

  8. Risk & cognitive error summary • We fear snakes and not cars • We fear spectacular, unlikely events • Plane crash versus car crash • We underestimate our risk of disease • We don’t interpret statistics well

  9. Thought processes • Thought Hats • Religious - faith • * Science* - evidence

  10. Arguments for • Religious, social, “cultural freedom” • Prevent • Penile cancer • HIV • Other STDs • UTIs

  11. Medical indications • Recurrent UTIs – 1% children • Foreskin increases UTI risk 5 – 10 times • Phimosis (pathological) – 1% children • Recurrent balanitis – 1% children

  12. Invalid reasons • Reduced sexually transmitted disease • HIV, Herpes, HPV etc. • Safe sex practices cheaper & more effective • May be valid in areas with high HIV incidence • HPV vaccine a better alternative • Penile cancer (1: 100,000) • too rare to worry about • UTIs – example to follow

  13. Risk benefit analysis for UTIs • Assume complication rate 2% (1% - 10%) • 1000 well children circumcised • => 8 less UTIs, 20 complications • 1000 Children with UTIs • => 250 UTIs prevented, 20 complications

  14. And further risk Circumcision may decrease female pleasure during intercourse O’Hara & O’Hara - surveyed 138 women. Of that group 20 (14.5%) preferred non-intact circumcised sexual partners while 118 or (85.5%) preferred intact non-circumcised sexual partners. This means that about 6 out of 7 women preferred intact non-circumcised partners while about 1 out of seven preferred non-intact circumcised partners

  15. Contra indications • Abnormal penis • Hypospadias • Epispadias • Buried penis • Systemic • Coagulopathy • Increased anesthetic risk

  16. Risks • Early • Pain • Infection • Bleeding • Fistula • Glans amputation • Loss of penis • Death

  17. Risks • Late • Meatal stenosis • Poor cosmetic result • Skin tags, suture sinuses • Buried penis

  18. Risks • Theoretical • Sued or prosecuted • Legally, parents may not consent for an operation for a child when such a decision is not in the child’s best interest.

  19. Care of the normal foreskin

  20. Infancy and childhood Nothing required Forceful retraction may cause injury and phimosis

  21. After puberty Retract and clean each day

  22. Phimosis - physiological Treatment not needed Responds well to Betnovate ½ cream

  23. Phimosis – pathological • Responds to Betnovate ½ cream – rarely • Tacrolimus • May be carcinogenic • Circumcision usually curative

  24. Phimosis and buried penis Megaprepuce

  25. Paraphimosis

  26. Tight frenulum

  27. Foreskin adhesions

  28. Foreskin lumps

  29. Smegma

  30. Smegma - more

  31. Circumcision complications Multiple Happen even in the best of hands Incidence = 5 to 10%

  32. Buried penis

  33. Shaft to glans adhesions

  34. Meatal stenosis

  35. Shortage of skin

  36. Amputation glans

  37. Conclusion Don’t circumcise unless there is a medical indication (benefits outweigh the risk) If there is an indication, it’s a good operation

  38. References • https://www.racp.edu.au/page/paed-policy • http://www.cps.ca/documents/position/circumcision • http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1989 • http://www.cirp.org/library/legal/brigman/ • http://www.circumcision.org/ (against) • http://www.circinfo.net/ (pro) • O’Hara K, O’Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int 1999;83 Suppl 1:79–84.

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