TO DO or NOT TO DO?

1. TO DO or NOT TO DO?

2. CIRCUMCISION Rabbi Zia, M.D. PGY-1 Resident UNSOM Department of Pediatrics

3. Definition • From Latin circumcisio, meaning to “cut around” • In males, it is the surgical removal of some or all of the foreskin (prepuce) from the penis.

4. Epidemiology • Uncommon in Asia, South America, Central America, and most of Europe • In Canada, 48% of males are circumcised • In the US during 1995, 64.1% males were circumcised • Circumcision rate varies among racial and ethnic groups

5. Which racial group has the highest circumcision rate? • Blacks • Hispanics • Whites

6. 2009/10 Circumcision Statistics

7. Embryology • Penis glans -> genital tubercle (develops by 4-6 wks) • Primitive urethral folds fuse to form the penile urethra • Genital swellings ultimately become the scrotum • The skin of the body of the penis begins growing forward at about 8 weeks gestation and covers the glan eventually • Initially, no separation between the glans and the foreskin, and separation may be partially complete at birth.

8. At about what age is the foreskin fully retractable? a. 1 year b. 2 years c. 3 years d. 4 years e. 5 years

9. Why? Not known with certainty. Various theories have been proposed: • Religious sacrifice • Rite of passage marking a boy's entrance into adulthood • Enhancing sexual pleasure / removing “excess” pleasure • Aid to hygiene where regular bathing was impractical • Higher social status • Differentiating a circumcising group from their non-circumcising neighbors • Discouraging masturbation or other socially proscribed sexual behaviors • As a means of increasing a man's attractiveness to women • As a demonstration of one's ability to endure pain

10. Medical Reasons to say “YES” • Markedly reduces risk of HIV • Significantly reduces risk of acquiring a number of STIs, including genital herpes (HSV), human papilloma virus (HPV), and syphilis • Reduces risk of UTIs in the first year of life • Reduces risk of penile cancer • Reduces the risk of cervical cancer in sexual partners • Prevention of foreskin infections • Prevention of phimosis • Easier genital hygiene

11. Recent Studies Supporting Health Benefits • Circumcision has reduced the incidence of heterosexually transmitted HIV by 40% to 60% in Africa • Cases of HSV type 2 were 28% to 34% lower • 30% to 40% reduction in risk of HPV infection • Circumcised males has a much lower risk of UTIs in the first year of life

12. Religious/Cultural Reasons to say “YES” • Some groups, such as followers of the Jewish and Islamic faiths, practice circumcision for religious and cultural reasons.

13. Social Reasons to say “YES” • Why not? All the other men in the family had it done, and they did not want their son to feel left out. Thank you for having me circumcised

14. Why one MIGHT lean towards “NO” • Fear of the risks • Belief that the foreskin is needed • Belief it can affect sexual experience • Belief that proper hygiene can reduce health risks • Religious beliefs

15. Can I still enjoy my sexual encounters? • One survey of adult males using self-report suggests more varied sexual practice and less sexual dysfunction in circumcised adult men • There are anecdotal reports that penile sensation and sexual satisfaction are decreased for circumcised males • An investigation of the exteroceptive and light tactile discrimination of the glans of circumcised and uncircumcised men found no difference on comparison

16. Methods • Three methods: • The Gomco clamp • The Plastibell device • The Mogen clamp

17. The Gomco Clamp • Inserted between the head of the penis and the foreskin. The device is clamped over the foreskin, cutting off circulation. After about five minutes, the blood around the clamp will begin to clot, and a scalpel is used to cut away the foreskin. This method sometimes leaves a distinctive light brown scar on the head of the penis.

18. The Plastibell Device • A plastic device is placed over the head of the penis, under the foreskin. A string is tied around the foreskin, cutting off circulation. The string may be used as a guide for the surgical removal of the foreskin, or the Plastibell may be left on for a week or so, after which the dead foreskin will fall off on its own.

19. The Mogen Clamp • A scissorlike device consisting of two flat blades used that are clamped over the foreskin, cutting off blood flow. A scalpel is then used to slice away the tip of the foreskin.

20. Different Devices, Same Principle • Estimates the amount of external skin to be removed • Dilation of the preputial orifice so that the glans can be visualized to ensure that the glans itself is normal • Bluntly frees the inner preputial epithelium from the epithelium of the glans

21. Complications of the Circumcision Procedure • Reports of two large series have suggested that the complication rate is between 0.2% - 0.6% • Most common, bleeding, which is 0.1% of circumcisions • Second most common, infection • Isolated case reports, such as recurrent phimosis, wound separation, unsatisfactory cosmesis because of excess skin, etc

22. Optimal Timing When is the best time to perform neonatal circumcision? • Within the first 12 hours of life • Within the second week of life • Within the 1st week of life • No preference

23. Contraindications • Hyperbilirubinemia • Infection • Congenital penile abnormalities • Prematurity • Bleeding disorder • Medical problem • No informed parental consent

24. Is it painful? • According to the American Academy of Pediatrics 2012 Circumcision Policy Statement, "There is considerable evidence that newborns who are circumcised without analgesia experience pain and physiologic stress.” • One of the supporting studies found a correlation between circumcision and intensity of pain response during vaccination months later. • Therefore, it is recommended to use pain relief for circumcision

25. Analgesia • Eutectic Mixture of Local Anesthetics (EMLA Cream) • Dorsal Penile Nerve Block (DPNB) • Subcutaneous Ring Block • Others: • sucrose on a pacifier has showed to be more effective than water for decreasing cries during circumcision. • Acetaminophen – immediate postoperative period • Neither one should be used as the only method

26. Anatomy of the Penis

27. Dorsal Penile Block • 27 gauge needle or TB syringe is used to inject 0.4 cc of 1% lidocaine at 10- and 2 o’clock positions at the base of the penis. • Needle directed posteromedially 3 to 5mm until Buck’s fascia is entered at base of penis. • Allow 3 to 5 min before proceeding. • Anesthesia lasts 1-2 hours • Bruising is the most common complication.

28. Subcutaneous Ring Block • 0.8 to 1.0 cc of 0.5-1.0% lidocaine without epinephrine. • Inject SQ along shaft at 2,10 and ventral surface (very superficially). • Alternatively inject a small ring immediately adjacent to the corona.

29. 2012 AAP CIRCUMCISION POLICY STATEMENT • “Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it. Specific benefits identified included prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV.” • “Parents ultimately should decide whether circumcision is in the best interests of their male child. They will need to weigh medical information in the context of their own religious, ethical, and cultural beliefs and practices. The medical benefits alone may not outweigh these other considerations for individual families.”

30. Information for Parents • http://www.healthychildren.org/ • http://www.circumcision.org/ • http://www.malecircumcision.org/ • http://www.nocirc.org/

31. References • Pediatrics Vol. 130 No. 3 September 1, 2012 pp. 585 -586 • Srinivasan S, Middleton DB. Chapter 1. Well Child Care. In: South-Paul JE, Matheny SC, Lewis EL, eds. CURRENT Diagnosis & Treatment in Family Medicine. 3rd ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=8148901. • http://www.aafp.org/online/en/home/clinical/clinicalrecs/children/circumcision.html • Pappas S, “5 Things You Didn’t Know About Circumcision” 27 Aug. 2012. http://www.sciencebuddies.org/science-fair-projects/project_mla_format_examples.shtml • http://mgmbill.org/statistics.htm

32. Conclusion