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Circumcision
From Medscape Education Clinical Briefs
AAP Issues Recommendations on Male Newborn Circumcision CME/CE
News Author: Yael Waknine
CME Author: Charles P. Vega, MD, FAAFP Faculty and Disclosures
CME/CE Released: 09/05/2012; Valid for credit through 09/05/2013
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Clinical Context
Circumcision is one of the oldest procedures in medicine, and data from the US Centers for Disease Control and Prevention (CDC) suggest that more than half of male newborn infants in the United States receive circumcision in the hospital. The most common reason that parents cite for choosing circumcision is health and medical benefits, followed by social concerns. Religious concerns are less important in the overall practice of circumcision in the United States.
The current policy statement from the American Academy of Pediatrics (AAP) updates the group's previous recommendations from 1999. The principal recommendations along with their rationale are presented in the Study Highlights section.
Study Synopsis and Perspective
New scientific evidence shows that benefits of male circumcision (MC) outweigh its small risks and justify access to the procedure for families who choose it, according to an updated policy statement published online August 27 in Pediatrics by the AAP.
Benefits cited in the accompanying technical report compiled by the AAP Task Force include the prevention of urinary tract infections and decreased transmission of some sexually transmitted infections such as HIV/AIDS, herpes, and human papillomavirus (HPV), which has been linked to the development of cancer in men and their female partners.
The report also states that the procedure is "well tolerated when performed by trained professionals under sterile conditions with appropriate pain management," and that complications such as bleeding and infection are rare.
Although the procedure remains elective, prospective parents should be routinely educated regarding the procedure to make an informed decision.
"Ultimately, this is a decision that parents will have to make," said Susan Blank, MD, FAAP, in an AAP news release. "Parents are entitled to medically accurate and non-biased information about circumcision, and they should weigh this medical information in the context of their own religious, ethical and cultural beliefs."
"It's a good idea to have this conversation during pregnancy, and to learn whether your insurance will cover the procedure, so you have time to make the decision," Dr. Blank added, noting that MC should be performed during the newborn period to maximize both safety and health benefits.
Dr. Blank is chair of the task force that authored the AAP policy statement and technical report.
The AAP also supports third-party coverage of MC, the cost of which would be offset by significant long-term health savings.
Cuts in Coverage Could Cost $1 Billion
As previously reported by Medscape Medical News, cuts in state coverage during the last 20 years have had a major effect on MC rates, which have decreased from 79% to 54.7%.
Mathematical modeling suggests that continued decreases leading to the European MC rate (10%) could inflate healthcare costs by nearly $916 million for every birth cohort because of potentially preventable cases of HIV/AIDS, sexually transmitted infections, and cancer.
The updated policy confirms the "potential benefits" cited in the 1999 and 2005 AAP statements and has been endorsed by the American College of Obstetricians and Gynecologists.
"This information will be helpful for obstetricians who are often the medical providers who counsel parents about circumcision," Sabrina Craigo, MD, the college's liaison to the AAP task force on circumcision, said in the news release. "We support the idea that parents choosing circumcision should have access to the procedure."
The majority of male urinary tract infections occur during the first year of life and may involve the possibility of an invasive procedure and hospitalization.
Literature analysis suggests that MC significantly decreases the incidence rate of urinary tract infections to 0.1% or 0.2% during this period compared with 0.7% to 1.4% for uncircumcised infants.
Plausible explanations for the effect include the decreased presence of uropathogenic bacteria around the urethral meatus of circumcised infants and a decreased bacterial adherence to the keratinized surface of the circumcised foreskin.
A review of the literature revealed a consistently reported protective effect of 40% to 60% for MC in reducing the risk for HIV acquisition among heterosexual men in areas with high disease prevalence, such as Africa.
CDC modeling based on these data suggests that circumcising all currently uncircumcised heterosexual US males would yield a 15.7% reduction in lifetime HIV risk for all men, given that heterosexual men account for 27% of new infections and 61% occur in men who have sex with men, for whom MC has not shown a protective effect.
According to the authors, the uncircumcised foreskin contains a high density of HIV target cells, has an easily abraded inner surface that can serve as a port of entry for pathogens, and "traps" pathogens in an incubation-friendly environment.
Two randomized African trials have yielded good evidence that MC confers a 32% to 35% decrease in risk for oncogenic and nononcogenic HPV in men; 1 study showed a 28% decrease in risk for male-to-female transmission of high-risk HPV from HIV-negative men.
Although penile cancer is rare and incidence rates seem to be declining in countries with both low and high MC rates (Denmark and the United States, respectively), fair evidence from 2 case-control studies has shown that the absence of circumcision confers a risk for invasive squamous cell carcinoma (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.3 – 4.1), but not carcinoma in situ (OR, 1.1).
According to the authors, the effect is likely derived from a reduced risk for phimosis (which raises the risk for invasive penile cancer by a factor of 11.4) and decreased prevalence of oncogenic HPV in circumcised men.
Persistent infection with oncogenic types of HPV is the main prerequisite to developing cervical squamous cell carcinoma, a leading cause of death for women in developing countries. One study showed a significantly decreased incidence of HPV in circumcised men with multiple female partners (5.5% vs 19.6% for uncircumcised men; OR, 0.37; 95% CI, 0.16 – 0.85), which correlated to a significant decrease in the women's risk for cervical cancer (OR, .42).
Genital ulcers are notable for their association with morbidity and mortality and because their presence increases the risk for HIV transmission.
Genital herpes is a sexually transmitted infection that has been diagnosed at some point in 18.9% of Americans aged 20 to 49 years. Good evidence from 2 randomized controlled African studies shows that MC decreases the risk for herpes simplex type 2 viral infection by from 28% to 34%; fair evidence suggests that MC protects female partners from infection as well.
According to a report by the CDC, the total number of syphilis cases in the United States has increased 2.2% (from 44,830 to 45,834 cases) during 2009 to 2010, with 67% of primary and secondary cases in 2010 being reported in men who have sex with men. The balance of evidence suggests that MC decreases syphilis risk. A meta-analysis reported a relative risk of 0.67 (95% CI, 0.54 – 0.83), but considerable heterogeneity was observed among the studies included.
Bacterial vaginosis is common among pregnant women, affecting more than 1 million annually. Several studies also provide good evidence that MC is protective against bacterial vaginosis in female partners.
Pediatrics. Published online August 27, 2012. Policy statement full text, Technical report full text
Study Highlights
Parents should receive factual and unbiased information on circumcision before conception and early in pregnancy. Currently, most parents decide whether to circumcise during this time and before discussing the subject with a clinician. Parents should understand that circumcision is an elective procedure.
The health benefits of newborn MC outweigh the potential risks, and these benefits justify access to circumcision for families who choose it.
Specifically, circumcision is associated with a lower prevalence of HPV infection and reduced transmission of herpes simplex virus type 2. It is also associated with a lower risk for bacterial vaginosis among female partners.
Circumcision does not appear protective against gonorrhea or chlamydia.
14 studies provide fair evidence that circumcision is protective against heterosexually acquired HIV infection among men. In fact, it is a cost-effective means to reduce the prevalence of HIV infection.
Circumcision is less likely to be protective against HIV infection among men who have sex with men.
Circumcision is associated with a lower risk for urinary tract infection among children younger than 2 years.
Circumcision also reduces the risk for penile cancer, although the number of circumcisions required to prevent 1 additional case of this rare cancer is very high.
2 controlled trials of adult circumcision found improved sexual satisfaction and sensitivity after circumcision. Good evidence exists that sexual function is not impaired among circumcised vs uncircumcised men.
Provider experience and skill in circumcision outweigh the training background of the provider.
Analgesia should be provided during circumcision, and nonpharmacologic techniques such as positioning or sucrose pacifiers are insufficient as the only means to reduce procedural pain. Nerve blocks are more effective than topical lidocaine-prilocaine in reducing pain during and after circumcision.
Significant acute complications of newborn MC occur in approximately 1 in 500 cases. The specific technique of circumcision used does little to influence the risk for adverse events.
In a study by the CDC, the average cost of circumcision ranged between $216 and $601. Circumcision rates are higher in states where Medicaid covers the procedure. The health benefits of circumcision warrant third-party reimbursement of the surgery.
Professional organizations should collaborate to promote better standards for training in circumcision and offering new training opportunities.
Clinical Implications
Circumcision is associated with a lower prevalence of HPV infection and reduced transmission of herpes simplex virus type 2. Circumcision does not appear protective against gonorrhea or chlamydia. Circumcision prevents HIV infection among heterosexual men but not among men who have sex with men.
The current recommendations from the AAP state that the health benefits of newborn MC outweigh the potential risks, and these benefits justify access to circumcision for families who choose it.
Sincerely,
Dr. Benjamin Raskin.
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