We discuss the history, risks, benefits, and logistics of circumcision. We review parental teaching on the care of the uncircumcised and circumcised penis. We are joined by Craig Peters, MD, Professor and Chief of the Division of Pediatric Urology at the University of Texas Southwestern Medical Center.
Dr. Neeta Goli:
Welcome to Newborn News, a podcast where we discuss educational topics for medical professionals who care for newborns. I'm your host, Dr. Neeta Goli, a pediatrician in the UT Southwestern Newborn Nursery. Welcome back to the podcast. In today's episode, we'll be discussing circumcisions. We are recording remotely due to the ongoing COVID pandemic. We are joined today by Dr. Craig Peters, Professor and Chief of the Division of Pediatric Urology at UT Southwestern.
Dr. Craig Peters:
Hello.
Dr. Neeta Goli:
Hi, Dr. Peters, thanks for joining us today.
Dr. Craig Peters:
Well, thanks very much for the invitation. Always appreciate a chance to discuss these issues for pediatricians.
Dr. Neeta Goli:
So let's get started. Male circumcision is a procedure in which the foreskin of the penis is removed. If parents choose to have their baby circumcised, the procedure is typically performed in the nursery prior to discharge. Today, we'll learn a little bit more about the history, logistics, and some potential controversies regarding the procedures. To start off with, Dr. Peters, please can you tell us a little bit about the history of circumcisions in the United States?
Dr. Craig Peters:
Sure. Obviously, people know circumcision has been done for thousands of years and was largely practiced as a religious ritual for most of that time. Probably starting in the middle of the 1800s, there began to be an interest in its possible hygienic benefit in terms of sexually transmitted disease, albeit without a lot of data. And then also in the Victorian era, it was felt to potentially limit masturbation and this was felt to be a major health problem. Obviously, I think we've evolved out of that phase. But combined, the two elements seem to push the development of circumcision largely in the English-speaking community. And similarly, both in Britain and in the United States, it started to evolve. And then in the 20th century, it took off rapidly and it's a little hard to know exactly why. And it was estimated that at the turn of the century, between about 1900, maybe 5% of Americans were circumcised. And that rapidly increased through the 20th century until about 70% were circumcised in the late 1970s, 80s, and 90s.
Dr. Craig Peters:
And some of this was pushed by hygiene. There was clearly a simplification of care with it, and yet there was very little real data as to supporting that contention. Starting in the latter quarter of the 20th century, I think people started to question its true value. People looked at issues of cost and potential complications, and there was a drifting of the use, except for ritual circumcision, which of course has continued. I think as the US has become much more culturally diverse, the incidence of routine circumcision has declined. But at the same time, there has been some of the more objective evidence that there is a reduction in the risk of urinary tract infection in boys and the risk of sexually transmitted infections in adolescence and adulthood. So there is, to some degree, still some pressure to say there's a value to it medically. And that's where we are today.
Dr. Neeta Goli:
And you just alluded to this, so as pediatricians, the American Academy of Pediatrics or the AAP did publish a policy statement in 2012, proposing some health benefits of circumcisions, including what you mentioned in terms of being reduction of risk of UTI in the first year of life, some sexually transmitted infections later in life and penile cancer. And we as pediatricians and clinicians, we don't make a recommendation either for or against circumcision. Eventually, ultimately stating to the parents that they should be the ones to make the decision in the context of their own personal beliefs and practices. Actually, could you give us some more information about the risks and benefits themselves? And if parents ask you what you recommend for circumcision, can you tell us how you counsel families?
Dr. Craig Peters:
Right. Well, I think the AAP's position is appropriate. It's a balanced position because the risks and the benefits are not coordinate, if you will, in that you can prevent a urinary infection, certainly within the first year of life, probably by 10 fold. And yet, the incidence in boys, even who are not circumcised, is relatively low. The consequences can be significant, but so can the consequences of a complication of circumcision. Again, very rare, but they can occur. So it's a little tough to draw a direct comparison to say that the benefits outweigh the risks. So there's balance. And I think there's a balance in the AAP's position, even though some people considered it wishy-washy.
Dr. Craig Peters:
The other thing that the AAP does say that I think is important to emphasize is they feel and have contended that insurance companies should provide the opportunity to families to have the procedure done, and that is not always the case. And I would agree with that. I think it then comes down to very much a familial discussion and decision. And that's what I tell parents is that this is less a medical decision than a personal, social, cultural thing, and I'm not going to be the one to tell them what they feel comfortable with. And I think we as physicians need to be careful about being too prescriptive of saying that this is right or wrong. The things that we do know is that in the first 9-12 months of life, the circumcised male will have about 1/10th the incidence of a UTI. Generally, that's not a high incidence, but it's not zero. If someone has specific risk factors for UTI, such as an abnormality in the genitourinary system, well then that could be a big deal. So we would recommend circumcision in those cases.
Dr. Craig Peters:
Going further down in the age progression, sexually transmitted infections are definitely reduced. There is still controversy in areas where there's a high prevalence of HIV/AIDS, as to whether this is truly a significant reduction. But most of the data leans pretty heavily in favor of it and there are a number of programs for young adult circumcision in areas where that is a particular risk. There's no question, I think the data show clearly that the incidence of penile cancer, which is a very aggressive type of cancer that is difficult to cure, is reduced in men who have had early circumcision. It can probably be equally prevented with good hygiene, but that's not always available in some parts of the world.
Dr. Craig Peters:
There's also some emerging evidence of transmission of papillomavirus with the secondary issues of cervical cancer in women. And there's maybe a reduction in transmission in men who are circumcised, although that's still, I think, a bit of a controversy. It's a little tough to talk about those issues with expectant parents who are parents of a newborn, because it's more abstract. And so what I really deal with is that if this is something that the family feels is part of their custom and culture, then I say, “I'm perfectly willing to do this and my obligation is to do it safely and properly.” I don't try to say that you should do it or shouldn't do it, I do go through the risks and benefits and try to lay that out as the balance. Sometimes it's a little difficult to convey that to someone who is less familiar with medical issues. But most come to me, I think, with an idea.
Dr. Craig Peters:
I do also tell them very clearly that it is not medically essential. There are some families that come with the notion that, "Oh, yes, we have to do a circumcision or this child will be ruined or at risk for terrible diseases." And that's just not true. And so, I try to make sure that they hear both sides and try to really empower them, if you will, to make their own decision based on their consideration of both the medical information and their own social and cultural traditions.
Dr. Neeta Goli:
You did mention that if there was a baby with severe urinary tract dilation, you might actually lean towards recommending circumcision. Are there any other specific cases in which you either would or would not recommend circumcision?
Dr. Craig Peters:
I think any case where there is an increased risk of a urinary tract infection, many of us would say yes, if you're sitting on the fence, go ahead and do the circumcision. If they did not want to do the circumcision, I don't say that you should. Some people do. Now, if the child in the first few months of life develops urinary infections and they're complicated because of their underlying anatomic or functional problem, then we encourage circumcision and most parents would agree. There is another difficult group. Although, these are typically older kids that we have to make this decision, those who may not be able to care for themselves through their lifespan. A lot of parents will come to me and say, "We think he should have a circumcision because he's not going to be able to care for himself. And we don't know what kind of care he might have years down the road." And in that situation, sometimes that is actually easier to do for the child in the long term.
Dr. Neeta Goli:
And in recent years, we've seen circumcision has become slightly controversial with the growth of many vocal anti-circumcision groups. Some of our listeners may have seen these groups at some point, since they will typically gather during the annual AAP conference. Why is it in your view that circumcision has become so controversial?
Dr. Craig Peters:
Well, first of all, I think you're understating it very nicely that it has been controversial for years. I think we clearly see more vocal expression of resistance to circumcision, is largely what you see. Although, in my 35 years in practice, it's been there all along. I think today there seems to almost be a more radicalization perhaps. And I think it's a combination of things. First of all, there is ambiguity as to the medical necessity. Secondly, there is a much greater development of the concept of autonomy for children in terms of any medical decisions. Because in essence, if we say that this is a medically optional or unnecessary procedure, then there are legal questions about whether a parent can consent to that. That's never been established in the law that I'm aware of in the United States, but there was an interesting article from Germany. It was both a physician and a lawyer, and the physician was a good friend of mine, where they argued that under German medical consent that, no, a parent cannot give consent to have their child circumcised because it is unnecessary and invasive.
Dr. Craig Peters:
There is to some degree, a possible parallel drawn with female, what is called female circumcision, which is not a good term, but female genital mutilation that is a long established cultural tradition in some parts of Africa. And that is roundly criticized and considered to be a terrible thing by most modern societies. Yet, some people say, "Well, why is that different than male circumcision?" You could start arguing nitty gritty points, but you can understand the line of logic. I don't agree with that, but I think that we have to at least acknowledge those arguments and think about them and potentially present them to parents.
Dr. Craig Peters:
There is now a growing discussion and controversy regarding pediatric genital reconstruction in children who do not have what we would typically call normal. I hate saying abnormal because even that is being questioned today, but those children who have alternate patterns of development of the genitalia. And one of these for instance, might be considered hypospadias, which all of us would have always considered appropriate to repair. But some people are even now saying, "Well, you should wait until this child grows up and can make their own decision." And similarly, they draw an analogy to circumcision, why do it early on?
Dr. Craig Peters:
So I think these are some of the themes that have emerged that have fueled the controversy. I don't see it going away quickly. There is still a large part of our culture and several very established religious groups that feel circumcision is part of their underlying culture. And if we are going to allow it, then why not let someone choose as an individual? That's my perspective, obviously that would not be agreed to by everyone.
Dr. Neeta Goli:
And if a family, like you mentioned, due to their own cultural practices and preference, does want their baby to be circumcised, why do we recommend that it's done in the newborn nursery rather than later in life?
Dr. Craig Peters:
Well, that's an important point and I think it is true that it is much easier on the child to do it very young. It does not require a general anesthetic and I truly think that with good local anesthesia, and that is now the recommendation of the AAP, this has not been done universally for sure, and still is not done universally. But definitely a local anesthetic administered by someone who knows how to do it to limit or eliminate any significant procedural pain. And this is a procedure, it can be done with a variety of methods that we can talk about, that has a very good result, a very low complication rate, and you don't require a general anesthesia, which has both risks and cost, and you have a very good outcome. I think it's preferable.
Dr. Craig Peters:
Doing a circumcision in an older, very aware child, even with anesthesia has a definite psychological impact. Doing it in a teenager is not easy nor fun for that teenager. So I think if the family wants, feels that they want to do the circumcision, I do recommend trying to get it done early if it's medically suitable. Some kids, either because of size or medical comorbidities, should not be done in the nursery. And that's fine, they can be done later or simply live with their foreskin.
Dr. Neeta Goli:
And you mentioned if it can't be done in the nursery due to size or other limitations it might be able to be postponed slightly. What is the age typically where you would say that newborns need to go under general anesthesia, rather than local?
Dr. Craig Peters:
Right. Well, we will do a newborn circumcision in our practice up to about 12 pounds, and this is typically two to three months, depending upon the child. And that's largely because of bleeding complications, but if you interact with kids at that age, they're very aware. And just personally, I feel it's not fair to the child to strap them down and administer local anesthetic and do the procedure after they're developing that kind of awareness. We would then typically wait until they're at least six months of age, because that's recommended by the anesthesiology group, as to the time for elective general anesthetic with relatively minimal risk. And then we try to get it done between six months and 12 months of age. The kids recover quickly, they heal well, they don't remember it as best we can tell, and it's an easier procedure on them if they have to do it under a general anesthesia. But of course we can do it at any age.
Dr. Neeta Goli:
And then in terms of technique, there are generally speaking three different methods which can be used, the Gomco clamp, the Mogen clamp, and the Plastibell technique. At Parkland, the primary method that's used is the Gomco clamp. Could you just speak briefly to the differences between the techniques in terms of logistics, in terms of how long it takes to do them, potentially risks or benefits or differences in cosmetic outcome?
Dr. Craig Peters:
Right. The Gomco is a more complex device developed in the 1930s, but it's the safest of the procedures, but you do have to know how to use it. And once you're experienced, it's a very good method. That's what I would recommend and what I use. And if you know how to apply the bell on the inside of the foreskin and release the skin adequately, you very often get a very nice result. Minimal risk of inadvertent injury to the head of the penis, the glans.
Dr. Craig Peters:
The Mogen clamp is a very old-fashioned traditional, and there are a couple of different versions of it, and this is the traditional Hebrew method. And this involves placing a clamp and crushing the foreskin, all layers of it. And you pull it just beyond the head of the penis, clamp it, and then cut it, and that pressure will seal it and limit the bleeding. The problem with the Mogen is that if you're not careful and you don't get the glans of the penis completely underneath and below the clamp, you can cut the tip of the glans off. And the most of the major circumcision injuries such as that come from the Mogen clamp. And those are the ones that I've had to reattach the tip of the glans to the penis after it's been cut off. And that's a bit of a disaster. They heal, but that's obviously not what you want to do.
Dr. Craig Peters:
A Plastibell is probably the safest for a relatively less experienced surgical practitioner. And that is a plastic device that puts a ring around on the inside of the foreskin, and you tie a suture around it tightly and then trim the extra. And as the tissue heals and eventually slough the ring, the Plastibell ring will fall off. I've seen a variety of problems with these. Sometimes they just don't fall off in time. They can get infected. They sometimes have to be trimmed off. Sometimes they get stuck behind the head of the penis. So we're pretty experienced in dealing with various Plastibell issues, but they're relatively minor. Very limited risk of bleeding, limited risk of injury to the glans. So it's a reasonable technique for someone who's not as comfortable with surgical manipulation. By and large, all of these are fine in the hands of someone who has appropriate learning and is careful. They probably take a similar amount of time. I've seen people do Gomco circumcisions in five minutes. I'm not that fast, I don't try to be. And I think a moderate degree of efficiency is good, but trying to be speedy is probably risky.
Dr. Craig Peters:
Again, almost all of these should be done with a local anesthetic, I think for the kid's comfort. And they all have the limitation that if you have not removed enough of the inner foreskin, and this is one of the complications of circumcision, and by any method, that inner foreskin will go back to its normal position, which is over the head of the penis, and that will pull the now circular scar. And if it contracts as it heals and traps the head of the penis then you create a secondary phimosis, and that may require surgical revision. And those are often the types of revisions that we have to do. Some of them are medically essential, some of them are cosmetic, but usually it's because too much of the inner foreskin has been left in place.
Dr. Neeta Goli:
What are signs that either we as clinicians or the parents can look out for to make sure that doesn't happen?
Dr. Craig Peters:
So what we counsel our parents on is that, after the first day is they should be able to see the whole head of the penis, and if not, to gently push alongside of the penis, to pull the skin back a bit and make sure that the head of the penis will pop out. There are some little boys who have a very generous pre-pubic fat pad that pushes the skin over the penis, and that's not a problem, that will go away as they lose that baby fat. But if you let the circumcision scar, which is really a circle, close and trap the head of the penis, then you have a secondary phimosis. And we encourage parents to check that, if they start seeing it develop to let us know. We sometimes will more vigorously pop that open and then use a little bit of steroid cream to keep it open until the rest of the healing completes.
Dr. Neeta Goli:
And then what else should families do to care for a freshly circumcised penis?
Dr. Craig Peters:
In the newborn period, we don't put a dressing on and we just use some Vaseline to keep it moisturized and keep it from sticking to the diaper. You don't have to do any special cleaning, obviously just rinse it off if there's stool on it. And then once it's healed, which is usually about five to seven days, you don't need to use the Vaseline, but we do want them to watch for the secondary phimosis or entrapment of the head of the penis. Occasionally we'll see some bleeding. Usually it's not a big deal, a few bits of blood the size of quarters on a diaper is normal. But if it persists, what I typically tell the parents to do is snug up the diaper and then hold the baby with your hand between the legs, use the palm of your hand to gently push the penis against, really the pubic bone, and with a little gentle pressure, cradle the child for 15 or 20 minutes and that will often slow it down.
Dr. Craig Peters:
If it does persist, we have the kids come back and we can put a gentle compression dressing on and usually take care of it. But bleeding is certainly a reported complication and can be severe. The other thing to watch out for is obviously infection. Quite rare, but does happen, and you'd see sort of vigorous redness spreading down the shaft of the penis and away from the base of the penis, you may see some drainage, beyond the normal little white and yellowish exudate that you see on the glans in the first few days. But if you're seeing real drainage and redness spreading and a cranky baby, that may be a wound infection, and those need to be treated. It's really rare, but it has happened. And these can be very aggressive infections with staph and need prompt treatment.
Dr. Neeta Goli:
And then I did want to make sure we cover this briefly. If a family chooses not to have their baby circumcised, how do you recommend parents care for an uncircumcised penis?
Dr. Craig Peters:
Pretty much leave it alone in the first few years. You do not need to retract the foreskin. Some babies have a very retractable foreskin, that's fine. It should be cared for like an older child, where you retract it for cleaning. You don't want to be aggressive with scrubbing; that'll irritate the skin. You will sometimes see accumulations of smegma, which is just the dead skin cells and oil. And it looks like a little whitish or yellowish bleb under the foreskin. And I've had those children send to me because people think it's a tumor or an infection, and it's just the normal sloughing of the skin cells, and that actually facilitates separation of the foreskin from the glans. And so it's not a problem, you don't need to drain those or dig that stuff out, just let it come out on its own and that'll facilitate ultimate separation.
Dr. Craig Peters:
Long-term, most boys have at least a partially retractable foreskin between four and eight years of age. Some don't retract until they're approaching puberty. But if it's not partially retractable as kids are hitting eight, nine or 10, we may want to treat it a little bit to help it open up before puberty. Because we are seeing, at least I've seen here in Texas, more than elsewhere, a larger number of kids with real scarring of the foreskin and even the glans and even the urethral meatus, because they haven't ever retracted the foreskin and they've gotten an irritated situation. And this can be a very difficult to treat condition called balanitis xerotica obliterans or lichen sclerosis, and it's not a good thing. So we want pediatricians to make sure that they're checking the kids and they don't have to be fully retractable, but at least reasonably open. And if not, we're more than happy to see the boys and prescribe and give them instructions on medical treatment of this.
Dr. Neeta Goli:
And then to end the episode today, do you have any advice for our listeners while they take care of newborns?
Dr. Craig Peters:
Well, I think we've covered a lot of different things and if the family wants to do the circumcision, we want to be sure it's done carefully, safely and properly, so that it's over and done with. If the family does not want to do it, then great. Support them and give them information and education on caring for that child. Lots of the world survives with the foreskin intact and they do great, but it really does come down to a family choice. And I think that's what we should support, rather than trying to dictate how families live their lives.
Dr. Neeta Goli:
Dr. Peters, thanks again for joining us today.
Dr. Craig Peters:
My pleasure. Thanks very much.
Dr. Neeta Goli:
Thanks for listening to Newborn News. We hope you join us next time. If you like what you hear, make sure to subscribe and leave us a review. If you have questions, comments, feedback, or suggestions for future episodes, please email me at NewbornNews@utsouthwestern.edu. As a reminder, this content is educational and is not meant to be used as medical advice. Views or opinions expressed in this podcast are those of myself and my guests and do not necessarily reflect the views of the university.