Early Circumcision Research Articles

CDC's Male Circumcision Recommendations Represent a Key Public Health Measure.

CDC's Male Circumcision Recommendations Represent a Key Public Health Measure.

Timing of Circumcision and Breastfeeding Initiation Among Newborn Boys.

Newborn circumcision, particularly in the first 24 hours of life, has been thought to adversely affect breastfeeding initiation. However, no studies specifically support an association between early circumcision and difficulty with breastfeeding initiation or maintenance. This study was designed to determine whether timing of newborn circumcision affects rates of exclusive breastfeeding during the first 2 weeks of life. A retrospective study of 797 newborn boys and their mothers was conducted at a large military hospital. Exclusion criteria included gestational age <38 weeks, multiple delivery, NICU admission, and absence of maternal intention to breastfeed. Multivariable logistic regression models examined the relationship between time of elective circumcision and exclusive breastfeeding at 3 time points: hospital discharge and the newborn and 2-week outpatient visits. Mean infant age at circumcision was 29.7 hours. Thirty-one percent were circumcised at <24 hours of age. Rates of exclusive breastfeeding were 66.8%, 64.1%, and 63.7% at hospital discharge and the newborn and 2-week outpatient visits, respectively. In the multivariable model, time of circumcision was not significantly associated with exclusive breastfeeding at hospital discharge (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.99-1.00; P = .54), the newborn outpatient visit (OR, 1.00; 95% CI, 0.99-1.02; P = .84), or the 2-week outpatient visit (OR, 0.99; 95% CI 0.98-1.01; P = .44). There was no significant association between timing of elective newborn circumcision and exclusive breastfeeding in the first 2 weeks of life. In this setting, early circumcision of otherwise healthy, term boys had no deleterious effects on breastfeeding initiation or maintenance.

Randomised trial of early infant circumcision performed by clinical officers and registered nurse midwives using the Mogen clamp in Rakai, Uganda.

To assess the safety and acceptability of early infant circumcision (EIC) provided by trained clinical officers (COs) and registered nurse midwives (RNMWs) in rural Uganda. We conducted a randomised trial of EIC using the Mogen clamp provided by newly trained COs and RNMWs in four health centres in rural Rakai, Uganda. The trial was registered with clinicaltrials.gov # NCT02596282. In all, 501 healthy neonates aged 1-28 days with normal birth weight and gestational age were randomised to COs (n = 256) and RNMWs (n = 245) for EIC, and were followed-up at 1, 7 and 28 days. In all, 701 mothers were directly invited to participate in the trial, 525 consented to circumcision (74.9%) and 23 were found ineligible on screening (4.4%). The procedure took an average of 10.5 min. Adherence to follow-up was >90% at all scheduled visits. The rates of moderate/severe adverse events were 2.4% for COs and 1.6% for RNMWs (P = 0.9). All wounds were healed by 28 days after circumcision. Maternal satisfaction with the procedure was 99.6% for infants circumcised by COs and 100% among infants circumcised by RNMWs. EIC was acceptable in this rural Ugandan population and can be safely performed by RNMWs who have direct contact with the mothers during pregnancy and delivery. EIC services should be made available to parents who are interested in the service.

P195 Should male circumcision be considered curative treatment for lichen sclerosus?

<h3></h3> Lichen Sclerosus is a chronic inflammatory skin disorder. In men it presents mainly on the prepuce, coronal sulcus and glans penis. The cause of lichen sclerosus is not fully understood, but genetic and autoimmune factors are thought to be important. Infections have been investigated as a cause, but with no clear evidence of a potential causative agent. In men the association with autoimmune diseases is weaker; however studies have shown a family history of diabetes mellitus, and thyroid disease are possible risk factors. Other suggested potential causes are chronic intermittent damage by urine, as early circumcision seems to be preventative in those who do not have congenital anomalies such as hypospadias. Recommended treatments include circumcision and potent topical steroid ointments. Taking this into consideration we reviewed notes of patients that presented to the monthly Joint Dermatology clinic with a diagnosis of lichen sclerosus to ascertain the number of recurrences post circumcision. We found four cases of recurrence of lichen sclerosus in patients attending the clinic over a four month period. Ages varied between 39–81 years old. One patient had diabetes mellitus, and another had been circumcised twice. All patients needed treatment with potent topical steroid ointment. Lipscombe <i><i>et al</i></i>. stated that 50% of patients who had a circumcision had a recurrence. It is important when discussing management with patients to remember that lichen sclerosus can recur after circumcision. From our observations, the presence of folds of skin still covering the glans penis best predicts recurrence.

The effect of circumcision on the frequency of urinary tract infection, growth and nutrition status in infants with antenatal hydronephrosis

The objective of this study was to determine the effect of circumcision on the frequency of urinary tract infection (UTI), growth development, and the nutrition status in infants with antenatal hydronephrosis (AH). The data were collected prospectively between 1998 and 2010. Infants with a fetal pelvis diameter of >5 mm identified with antenatal ultrasound were followed-up. Body height and weight were expressed as HZ scores (observed height − median height/standard deviation) and WZ scores (observed weight − median weight/Standard deviation). The nutritional status was evaluated and the body weight was transformed to a weight-for-height index (WHI = weight/median weight for the height age × 100). The HZ and WZ scores or WHI were calculated for each patient at the first and last visits. The chi-square and Student’s t tests were used for statistical analysis. A p value <0.05 was considered significant. The study included 178 (134 males, 44 females) patients. Of these, 29 were diagnosed by vesicoureteral reflux (VUR), 87 by obstructive uropathy, and 54 by normal. Of 134 males, 111 infants were circumcised. The mean monitoring time was 45±24.9 months and the mean age of circumcision was 14 ± 16.06 months. The pre-circumcision UTI frequency (2.97 ± 1.14/y) was significantly higher than post-circumcision period (0.25 ± 0.67/y) (p < 0.05). Also, pre-circumcision UTI frequency (2.97 ± 1.14/y) was significantly higher than the UTI frequency observed in female cases (0.85 ± 0.91/y) and in the overall study group (0.73 ± 0.79/y) (p < 0.05). In all patients, the HZ of the circumcised subjects (0.18 ± 1.01) was statistically higher than uncircumcised subjects (−0.26 ± 0.92) (p < 0.05). Although statistically insignificant, the HZ of the circumcised males (0.13 ± 1.24) with VUR was higher than the uncircumcised patients (0.03 ± 0.55) (p > 0.05). In obstructive uropathy groups, the HZ of the circumcised males (−0.13 ± 0.54) was also found to be higher than uncircumcised males (−0.49 ± 0.66) (p < 0.05). Although nutrition scores were found to be better in circumcised males, no statistically significant effect of circumcision on the nutrition status was detected. In conclusion, postnatal early circumcision of infants with AH seems to prevent frequent UTIs and nutritional disturbances enabling normal growth.

Repair-oriented categorization of circumcision urethral injury in Benin city, Nigeria

BackgroundThe wide spectrum of circumcision urethral injury/fistula makes selection of appropriate repair methods challenging in sub-Saharan Africa. This paper reports on the outcome of repair-oriented categorization in a Nigerian center. MethodsConsecutive children presenting with circumcision urethral injury/fistula at the University of Benin Teaching Hospital were categorized into six repair-oriented groups in 2009–2011. Results21 children were treated. Except in 2 cases, early neonatal circumcision at an average age of 8 days (range 4–14 days) had been performed, the majority (52%) by paramedics at home. Categories of injury/fistula based on severity ranged from isolated fistula (38%) which required fistula excision and repair (category A) to severe ventral urethral/coronal/glanular avulsion (29%) which required urethral plate tubularization/ventral penile reconstruction (category F). Overall, successful first-stage repair was achieved in 19 (91%) children. Meatal stenosis (2), urethral stricture (1), which responded to serial dilatation, and minor urinary leakage (2), which was closed at second stage, were the post-repair complications. Adequate penile size and straight penis on erection were achieved in all cases. Cosmetic outcome was excellent in 16 (76%) cases, good in 4 (19%) and fair in 1 (5%). ConclusionRepair-oriented categorization, which could be useful to practitioners in similar settings, was satisfactory in managing urethral injury/urethrocutaneous fistula.

Does circumcision alter the periurethral uropathogenic bacterial flora

The aim of this study was to assess the pattern of periurethral bacterial flora in uncircumcised boys and to evaluate the effect of circumcision on alteration of periurethral uropathogenic bacterial flora. Pattern of periurethral bacterial flora before and after circumcision was studied prospectively in 124 boys. The results were analysed to compare change in bacterial colonisation before and after circumcision. The age range was 6 weeks to 96 months. Most (94.3%) of the boys had religious indication and 5.7% had medical indication for circumcision. E. coli, Proteus and Klebsiella were most common periurethral bacterial flora in uncircumcised subjects. Coagulase-negative staphylococcus and Staphylococcus aureus was most common periurethral bacterial flora in circumcised subjects. In 66.1% of circumcised subjects, no bacteria were grown from periurethral region. We conclude that presence of prepuce is associated with great quantity of periurethral bacteria, greater likelihood of the presence of high concentration of uropathogens and high incidence of urinary tract infection (UTI). This study provides circumstantial evidence supporting the idea that early circumcision may be beneficial for prevention of UTI.

What is the effect of circumcision on risk of urinary tract infection in boys with posterior urethral valves?

Purpose Boys with posterior urethral valves (PUV) have increased risks of urinary tract infection (UTI) voiding dysfunction and ongoing renal damage. Circumcision has been shown epidemiologically to reduce UTIs, but no trial has yet confirmed this in PUV. Circumcision is not routinely performed in boys with PUV in our unit, but one quarter of our patients are circumcised for religious reasons. It may be hypothesized that circumcision reduces the risk of subsequent urinary tract infection in boys with PUV. This study aims to test this hypothesis by comparing the risk of UTI, and subsequent renal outcome, in PUV in uncircumcised boys with those who were circumcised. Methods A retrospective cross-sectional case note review of boys with PUV was performed, and the following were documented: age at presentation, method of diagnosis, method of treatment, initial renal status, and timing of treatment; use and timing of urinary tract diversion; timing of circumcision; and UTIs—date, organism, and treatment. Results Seventy-eight patients were identified, mean age 6.7 years (range, 1-18). These boys experienced 78 UTIs in the uncircumcised state. Subsequently, 27 were circumcised, experiencing 8 UTIs. Eighteen boys were diverted. The incidence of UTI was reduced from 0.50 ± 0.14 (mean ± SEM) UTIs annually uncircumcised to 0.09 ± 0.02 (mean ± SEM) circumcised ( P < .01, Student's t test). Conclusion In PUV, circumcision reduces the incidence of UTI by 83%, every circumcision prevents 1 UTI on average. Early circumcision in all PUV is beneficial, but a larger randomised control trial should be considered to confirm this.

Circumcision and Risk of Sexually Transmitted Infections in a Birth Cohort

To determine the impact of early childhood circumcision on sexually transmitted infection (STI) acquisition to age 32 years. The circumcision status of a cohort of children born in 1972 and 1973 in Dunedin, New Zealand was sought at age 3 years. Information about STIs was obtained at ages 21, 26, and 32 years. The incidence rates of STI acquisition were calculated, taking into account timing of first sex, and comparisons were made between the circumcised men and uncircumcised men. Adjustments were made for potential socioeconomic and sexual behavior confounding factors where appropriate. Of the 499 men studied, 201 (40.3%) had been circumcised by age 3 years. The circumcised and uncircumcised groups differed little in socioeconomic characteristics and sexual behavior. Overall, up to age 32 years, the incidence rates for all STIs were not statistically significantly different-23.4 and 24.4 per 1000 person-years for the uncircumcised and circumcised men, respectively. This was not affected by adjusting for any of the socioeconomic or sexual behavior characteristics. These findings are consistent with recent population-based cross-sectional studies in developed countries, which found that early childhood circumcision does not markedly reduce the risk of the common STIs in the general population in such countries.

Is Neonatal Circumcision Judicious?

Circumcision is the most frequently performed procedure in male children. The aim of the study was to compare the outcome of circumcision performed in the early neonatal period and circumcision performed at 5 months of age. Setting of the study was the King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia. The study was performed as a prospective cohort study. A total of 350 infants were enrolled. 250 neonates were circumcised at the age of 1 to 4 days (early group) and 100 infants underwent circumcision at the age of 5 months (late group). A bone cutter was used for 50 neonates, a Gomco clamp in another 50 neonates, and a Plastibell in the remaining 250 cases (150 in the early group and 100 in the late group). Complications including meatal deformities, meatal stenosis, adhesions and infection were more frequent and more significant in the neonatal circumcision group. From our study, circumcision at 5 months results in significantly fewer serious complications than circumcision in the neonatal period, irrespective of the method used. Therefore, neonatal circumcision should not be recommended.

Herpes Simplex Virus Type 2 Status at Age 26 Is Not Related to Early Circumcision in a Birth Cohort

The objective of this study was to determine if circumcision in early childhood affects the risk of acquiring herpes simplex virus type 2 (HSV-2) infection. Study members were born in 1972-1973 in Dunedin, New Zealand. Circumcision status was sought at age 3, when the cohort was established. Information about sexual behavior was obtained at ages 21 and 26. Serum was tested for HSV-2 antibodies at age 26 for 435 men (82.9% of the surviving cohort). Of eligible men, 40.2% had been circumcised. The prevalence of HSV-2 antibodies was 7.3% in uncircumcised men and 7.4% in circumcised men. Social and sexual factors were very similar between the 2 groups and adjustment had no effect on the association (odds ratio, 1.1; 95% confidence interval, 0.46-2.5). Seroconversion rates according to years since first sexual intercourse were 0.85 and 0.86 per 100 person-years for uncircumcised and circumcised men. The results support a lack of association between circumcision status and HSV-2 acquisition, although a small effect cannot be ruled out.

A MULTICENTER OUTCOMES ANALYSIS OF PATIENTS WITH NEONATAL REFLUX PRESENTING WITH PRENATAL HYDRONEPHROSIS

Purpose Approximately 10 to 30% of prenatal cases of hydronephrosis result in the postnatal diagnosis of vesicoureteral reflux. Using a new generic prenatal-postnatal data sheet developed by the Society for Fetal Urology the characteristics, natural history and outcome of prenatal hydronephrosis confirmed postnatally to be vesicoureteral reflux were documented at 3 centers. Materials and Methods We performed a retrospective multicenter review of Society for Fetal Urology data sheets completed for each patient in whom prenatal hydronephrosis was proved to be postnatal vesicoureteral reflux from 1993 to 1998. Results In 56 male and 15 female patients with prenatal hydronephrosis a total of 116 refluxing renal units were confirmed postnatally. Of the 116 renal units 112 were hydronephrotic prenatally. During gestation increased hydronephrosis was noted with voiding in 4 cases. Of the 112 hydronephrotic renal units only 26 ureters in 15 patients were seen prenatally. The obstetrician considered the diagnosis of vesicoureteral reflux in only 24% of the cases. Postnatally 116 refluxing renal units were identified. Initial postnatal ultrasound was normal in 25% of the cases. Bilateral reflux was present in 36 male and 9 female patients. In 10 of the 19 uncircumcised patients (53%) urinary tract infection developed despite antibiotic prophylaxis. In 15 of the 74 renal units with grades III to V reflux the condition resolved at an average patient age of 0.9 and 2.1 years in boys and girls, respectively. A total of 27 refluxing renal units were reimplanted. Conclusions The majority of prenatal reflux occurs in boys, and it is high grade and bilateral. The data sheets designed by the Society for Fetal Urology are useful data collection instruments. The presentation and natural history of vesicoureteral reflux are different in male and female individuals. In a significant number of renal units grade reflux resolves spontaneously. Early circumcision may decrease the incidence of breakthrough urinary tract infection in this subpopulation. In addition, the effective management of prenatally detected reflux depends on multispecialty communication.

A multicenter outcomes analysis of patients with neonatal reflux presenting with prenatal hydronephrosis.

Approximately 10 to 30% of prenatal cases of hydronephrosis result in the postnatal diagnosis of vesicoureteral reflux. Using a new generic prenatal-postnatal data sheet developed by the Society for Fetal Urology the characteristics, natural history and outcome of prenatal hydronephrosis confirmed postnatally to be vesicoureteral reflux were documented at 3 centers. We performed a retrospective multicenter review of Society for Fetal Urology data sheets completed for each patient in whom prenatal hydronephrosis was proved to be postnatal vesicoureteral reflux from 1993 to 1998. In 56 male and 15 female patients with prenatal hydronephrosis a total of 116 refluxing renal units were confirmed postnatally. Of the 116 renal units 112 were hydronephrotic prenatally. During gestation increased hydronephrosis was noted with voiding in 4 cases. Of the 112 hydronephrotic renal units only 26 ureters in 15 patients were seen prenatally. The obstetrician considered the diagnosis of vesicoureteral reflux in only 24% of the cases. Postnatally 116 refluxing renal units were identified. Initial postnatal ultrasound was normal in 25% of the cases. Bilateral reflux was present in 36 male and 9 female patients. In 10 of the 19 uncircumcised patients (53%) urinary tract infection developed despite antibiotic prophylaxis. In 15 of the 74 renal units with grades III to V reflux the condition resolved at an average patient age of 0.9 and 2.1 years in boys and girls, respectively. A total of 27 refluxing renal units were reimplanted. The majority of prenatal reflux occurs in boys, and it is high grade and bilateral. The data sheets designed by the Society for Fetal Urology are useful data collection instruments. The presentation and natural history of vesicoureteral reflux are different in male and female individuals. In a significant number of renal units high grade reflux resolves spontaneously. Early circumcision may decrease the incidence of breakthrough urinary tract infection in this subpopulation. In addition, the effective management of prenatally detected reflux depends on multispecialty communication.

The prevalence of high insertion of scrotum, hydrocele and mobile testis in the newborn infant (36-42 weeks gestation).

The prevalence of some minor abnormalities of the male genitalia was studied in 271 boys born over a period of 2 months. The scrotal insertion on the ventral side of the penis was determined in an objective manner by measuring the ratio of the ventral and dorsal length of the unstretched penis. A scrotal insertion ratio of less than 0.48 defined high insertion of the scrotum which was found in 2.7% of our newborn infants. This anatomical finding has an important clinical significance for the performance of early circumcision. The prevalence of hydrocele in all male newborn infants was 57.9%. Extravaginal (communicating) type was present in 86% of all infants, intravaginal (noncommunicating) in 9.5%, while both types of hydrocele in the same neonate was observed in 4.5%. The relatively high frequency of mobile testes (22%) is of interest. The natural history of this entity is not fully understood and the question of follow-up remains open.

An NBAS-based intervention with full term LBW infants

Twenty-six newborn infants were randomly assigned to an early (2 day) and delayed (3 week) circumcision group. Each infant was examined three times using the Brazelton Neonatal Behavioral Assessment Scale (NBAS) in which the examiner was blind to the circumcision status of the subject. A reduction scale was derived from the NBAS examination so that infants were assigned to the behavioral categories of average, subdued, or hyperactive. Nearly 90 percent of the early circumcision group changed behavior categories after circumcision for at least four hours compared to 16 percent of the delayed group. The implications of these results and the details of the reduction scale are discussed.

Neonatal Circumcision

Because of an economically motivated study, there has been an attempt to shift insurance dollars from neonatal circumcision to neonatal intensive care. Negative comments regarding the advisability of early circumcision have created confusion for both physicians and parents. Neonatal circumcision is the most common surgical operation in the United States, with probably fewer complications than any other. I believe this valid prophylactic procedure is falling victim to an unwarranted bias.

Circumcision I: Effects upon newborn behavior

Twenty-six newborn infants were randomly assigned to an early (2 day) and delayed (3 week) circumcision group. Each infant was examined three times using the Brazelton Neonatal Behavioral Assessment Scale (NBAS) in which the examiner was blind to the circumcision status of the subject. A reduction scale was derived from the NBAS examination so that infants were assigned to the behavioral categories of average, subdued, or hyperactive. Nearly 90 percent of the early circumcision group changed behavior categories after circumcision for at least four hours compared to 16 percent of the delayed group. The implications of these results and the details of the reduction scale are discussed.

Urethral meatal caliber in circumcised and uncircumcised males.

Congenital or acquired stenosis of the external urethral meatus is recognized as an important cause of serious urinary-tract obstruction. When the literature is reviewed on this subject, one of the aspects often discussed is the possible influence of early routine circumcision on the integrity of the urethral meatus during infancy and early childhood in allowing development of ulcerative meatitis and its sequel, secondary stenosis. The ideas pertaining to this aspect of the subject will be briefly summarized as a background for this study. Gairdner, in his study of circumcision, emphasizes the following points to support his belief that the prepuce should not be considered a vestigial structure that is devoid of function: 1. The prepuce is not fully retractable in 96% of male infants at birth but becomes so in all but 10% of cases by three years of age. Nonretract-ability at birth is not due to so-called adhesions or