Osama ALOmar MD FEBU FACS Assistant Professor of Surgery West Virginia University WVU West Virginia Chapter on AAP 4152016 Chad Morley MD Chief Resident of urology West Virginia University WVU ID: 670886
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Slide1
Circumcision:Cut It or Leave It.!
Osama AL-Omar, MD. FEBU. FACS.Assistant Professor of SurgeryWest Virginia University (WVU)
West Virginia Chapter on AAP, 4/15/2016
Chad Morley, MD
Chief Resident of urology
West Virginia University (WVU)Slide2
Introduction:
Medical organizations’ position on circumcision.Advantages.Disadvantages/Complications.Costs.
Closing statement.Slide3
Disclosure:
Both presenters have neutral position for circumcision, and neither one is pro or against routine neonatal circumcision.
This presentation is an attempt to provide evidence based for two side of long standing argument about circumcision
.The balance of this presentation is mainly tilted toward neonatal circumcision (NC), as non-neonatal circumcision is mostly done as treatment for underlying conditions, which is beyond the scope of this presentation.Dr. George Kaplan:“There
probably is no procedure that has produced as much emotion and rhetoric as
circumcision”Slide4
Medical Organizations
’ Position:
American Academy of Pediatric (AAP):On August 27, 2012, the AAP released its most recent Policy
Statement on Circumcision:*“
New scientific evidence shows the health benefits of newborn male circumcision outweigh the risks of the procedure, but the benefits are not great enough to recommend routine circumcision for all newborn
boys”
*
AAP
: August 27/2012Slide5
Medical Organizations
’ Position: Continue…1
American Academy of Family Medicine (AAFM):
The American Academy of Family Physicians (AAFP) position of 2001, and reaffirmed in 2012, is similar in context and tone to the AAP
statement
:
*
“The
potential health benefits from circumcision justify it being a covered medical service by third-party payers, and it should be an available service for those who desire
it”
*http
://
www.aafp.org
/about/policies/all/neonatal-
circumcision.htmlSlide6
Medical Organizations
’ Position: Continue…2
American
College of Obstetricians and Gynecologists (ACOG):ACOG endorsed the policy statement that was issued by AAP in 2012:*
“We
support the idea that parents choosing circumcision should have access to the
procedure”
said
Sabrina
Craigo
, MD, the College’s liaison to the AAP task force on circumcision.
*http://
www.acog.org
/About-ACOG/AnnouncementsSlide7
Medical Organizations
’ Position: Continue…3
American Urological Association (AUA):
The (AUA) policy statement of 1989 with a final revision in 2012, is in favor of non-routine neonatal circumcision after proper counseling, and states
that:*
“AUA
believes that neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks. Neonatal circumcision is generally a safe procedure when performed by an experienced
operator
…
.
Nevertheless, when performed on healthy newborn infants as an elective procedure, the incidence of serious complications is extremely
low”
*https
://
www.auanet.org
/education/policy-statements/
circumcision.cfmSlide8
Medical organizations’ position:
Continue…4World Health Organization (WHO):
WHO took a
neutral position on this subject in its published report “Neonatal and child male circumcision: Global review”, 2010:*“Our
review of the published literature shows that there is relatively little literature on this very common surgical procedure, but that neonatal, infant and child circumcision is generally a safe procedure when conducted by trained and experienced providers in hygienic
conditions”
However, WHO is
recommending adult male
circumcision in areas with HIV epidemic, especially the region of
sub-Saharan
Africa:**
*http
://
www.who.int
/
hiv
/pub/
malecircumcision
/
neonatal_child_MC_UNAIDS.pdf
**
World Health Organization. Global health sector
strat
-
egy
on HIV/AIDS 2011–2015. 2011. Slide9Slide10
Medical Organizations’ Position:
2010 The Royal Australasian College of Physicians1"After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision
, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand."
2015 The Canadian Paediatric Society2“The CPS does not recommend the routine circumcision of every newborn male.”2003 Central Union for Child Welfare in Finland
3
“Circumcision
of boys
violates
the personal integrity of the boys is not acceptable unless it is done for medical reasons to treat an illness
.”
1. Circumcision of Male Infants. Sydney: Royal Australasian College of Physicians, 2010
2. S Todd
Sorokan
et al.
Canadian
Paediatric
Society,
Paediatr
Child Health
2015
3. Position Statement on the Circumcision of Boys. Helsinki: Central Union for Child Welfare.
2003Slide11
Medical Organizations’ Position:
2010 Royal Dutch Medical Society4“There is no convincing evidence that circumcision is useful or necessary in terms of prevention or hygiene. Partly in the light of the complications which can arise during or after circumcision, circumcision is not justifiable except on medical/therapeutic grounds
. Insofar as there are medical benefits, such as a possibly reduced risk of HIV infection,
it is reasonable to put off circumcision until the age at which such a risk is relevant and the boy himself can decide about the intervention, or can opt for any available alternatives.”2006 British Medical Association “The BMA does not believe that parental preference alone constitutes sufficient grounds for performing a surgical procedure on a child unable to express his own view
. Parental preference must be weighed in terms of the child's interests. . . . The BMA considers that the evidence concerning health benefit from non-therapeutic circumcision is insufficient for this alone to be a justification for doing it. . . . Some doctors may wish to not perform circumcisions for reasons of conscience.
Doctors are under no obligation to comply with a request to circumcise a child
.”
4. Non-therapeutic circumcision of male minors. Utrecht, Royal Dutch Medical Association, 2010.Slide12
Medical Organizations’ Position:
American Academy of Pediatrics (AAP) in 2012Although health benefits are NOT great enough to recommend routine circumcision for all male newborns,
the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns.
Parents ultimately should decide whether circumcision is in the best interests of their male childAAP policy statement. 2012Slide13
Medical Organizations’ Position:The American Academy of Family Physicians recommends physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn
son.5The American College of Obstetricians and Gynecologists (ACOG)6
ACOG cannot and does not recommend elective non-therapeutic circumcision of infant boys for medical reasons or for any other reason.
American Medical Assocation (AMA)7 In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child.
5. AAFP Commission on Science. Position Paper on Neonatal Circumcision.
Leawood
, Kansas: American Academy of Family Physicians, 2002.
6. The American College of Obstetricians and Gynecologists (ACOG), 2012
7. Council on Scientific Affairs. Report 10: Neonatal circumcision. Chicago: American Medical Association, 1999Slide14
Advantages of CircumcisionSlide15
Advantages:
Indication:No
absolute indication for circumcision, especially in the newborn period…………
”ELECTIVE”Surgical indications for circumcision are either:
P
reventive (HIV)
T
herapeutic (
balanitis
xerotica obliterans
BXO).Majority of cases are done
for:
religious, ritual, cultural and cosmetic reasons.Slide16
Advantages:
Continue…1
AAP Task Force Recommendation:
“Evaluation of the current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it.”
AAP circumcision policy statement 2012 Slide17
Advantages: Continue
…2
Hygiene:
Prevent collection of microorganism behind foreskin.Eliminate Smegma.
Protect against BXOSlide18
Advantages: Continue
…3UTI:
Lowers the risk of urinary tract infections in the
first year of life.1
A meta-analysis in 2005
noted that
circumcision reduced UTI
7.7 fold
(infants)
2
In the “
Pediatric Research in Office Settings Febrile Infant Study
”: being
uncircumcised was the
strongest multivariate predictor
of UTI, with an
odds ratio of 11.6
(95% CI 5.9–22.6
)
3
In
Seattle study
: The
protective effect of circumcision against UTIs continues into adulthood, with a
5.6-fold higher
rate of UTI in the
uncircumcised (average of men was
32
years)
4
1.AAP policy statement. 2012
2.Singh
-Grewal D,
et al.
Arch Dis Child. 2005;90:853–8
.
3.Newman
TB,
et al.
Arch
Pediatr
Adolesc
Med. 2002; 156:44–54
.
4.
Spach
DH, et al.
J Am Med Assoc. 1992;267:679–81. Slide19
Advantages: Continue…4
STIs:
Lower risk for:*
Genital herpes (type2) (34%
decreased risk),
H
uman
papilloma virus (
HPV) (
30
%
decreased risk
).
Syphilis (
39%
).**
No
decreased risk on Gonorrhea or Chlamydia.
*AAP policy statement 2012
**Meta-analysis, 2006. Weiss HA, et al.
Sex
Transm
Infect
. 2006;82:101–9.
Slide20
Advantages: Continue
…5
Penile Cancer:
Circumcision also lowers the risk of penile cancer over a lifetime:The predicted lifetime risk of penile cancer for an uncircumcised man in the U.S. (
1:600
).
2 case
-
control studies: showed that the
absence of circumcision confers an increased
risk of penile cancer
(
OR
1.5
,
CI
of 1.1–
2.2)
1
.
Kochen
M, et al.
Am
J Dis Child. 1980;134:484–6
.
2.
Daling
JR, et al.
Int J Cancer. 2005;116(4):606–616 Slide21
Advantages: Continue
…6
Cervical Cancer:
Circumcision reduces the risk of cervical cancer in sexual partners.(AAP statement)
HPV
infection with
oncogenic types
(
HPV types 16, 18,
31
)
is the main prerequisite to developing cervical squamous
carcinoma
.
1
There was a lower incidence of HPV detection in circumcised men
compared
with uncircumcised men (
5.5%
and
19.6%
, respectively
).
2
A meta-analysis in 2009
of
14 studies (
5.5X
risk of cervical cancer in women
whose male
partners are uncircumcised).
3
1. AAP policy statement. 2012.
2.
Castellsague
́ X,
et al.
N Engl J Med. 2002;346(15):1105–1112
3.
Bosch FX,
et al.
J
Fam
Plann
Reprod
Health Care. 2009;35:5–7. Slide22
Advantages:
Continue…7
HIV:
Lower risks of acquiring HIV: Several RCTs has shown circumcision reduces risk of risk of heterosexually acquired HIV infection in men by 50–60
%
in areas with high HIV prevalence (
ie
, Africa).
1,2
South Africa
(published
in
2005)
Kenya (published in 2007)
Uganda (published
in
2007)
1. AAP policy statement. 2012.
2. http://
www.who.int
/
hiv
/pub/
malecircumcision
/
neonatal_child_MC_UNAIDS.pdfSlide23
Advantages: Continue
…8
Prostate Cancer:
1 in 7 men will be diagnosed with prostate cancer during his lifetime.
1
Prostate cancer is
the
2ed
leading cause
of cancer death in American
men
(
lung
cancer is 1
st
).
1
Risk of prostate cancer has been found to
correlate
with a history of
STIs.
2
Uncircumcised men have a
1.6- to 2.0-fold
higher incidence of
prostate cancer (due to higher risk for STIs).
2
1. ACS
http://
www.cancer.org
2. Ross RK, et al.
J
Natl
Cancer
Inst
. 1987;78:869–74
.Slide24Slide25
“Mythical” Advantages Hygiene –
In 1999, the AAP said, "there is little evidence to affirm the association between circumcision status and optimal penile hygiene.“AAP states there is no difference in cleaning of uncircumcised and circumcised penis Wash with soap and waterSeveral studies do show more bacteria flora under foreskin and periurethral
in uncircumcised boys, but…“the long-term significance of the findings is unclear”
AAP policy statement. 2012Slide26
“Mythical” Advantages UTI
Boys with real risk of UTI are those with other GU anomalies, like vesicoureteral reflux Lack of data for those over 2 years old Incidence in boys under 2 years old1 Uncircumcised 1-2 %Circumcised 0.2-0.4%
Therefore, the NNT is ~ 100, so you must circumcise 99 boys to prevent 1 UTI!2
1. http://www.circumcision.org/aap.htm2. AAP Policy statement. 2012Slide27
“Mythical” Advantages STDs, including HIV
Condoms show a better reduction than circumcision 98-99% effective against transmission of HIV when used correctly1Reduces the risk of transmission of STDs such as gonorrhea, chlamydia, and trichomoniasis.
2The African studies did not seek to determine the source of the HIV infections. Most HIV infections in Africa are transmitted by contaminated injections and surgical procedures3
In Europe, where circumcision is rare, there is no increase in the incidence of HIV transmission.3
Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database Systematic Review. 2002;(1):CD003255.
http://www.cdc.gov/condomeffectiveness/docs/condoms_and_stds.pdf
http://www.circumcision.org/aap.htmSlide28
“Mythical” Advantages
Penile CancerThe incidence of penile cancer is 0.58 cases in 100,000 in the United States, where circumcision is commonThe incidence of penile cancer is 0.82 case in 100,000 in Denmark, where circumcision is rare.
Rates are declining in both countries It is thought that socioeconomic and economic development factors (including effects on hygiene habits) may have an important role (NOT Circumcision)
According to studies cited in the report, between 909 and 322,000 circumcisions would be required to prevent one case of penile cancer Slide29
“Mythical” Advantages Cervical Cancer
More Condoms!Reduces HPV transmission by approximately 70%1Gardasil and Cervarix HPV vaccination has been found to prevent nearly 100 percent of the precancerous cervical cell changes that would have been caused by HPV 16/18
2
“Thus, the contribution of male circumcision to prevention of cervical cancer is likely to be small.” (2012 AAP Policy Statement)Winer, R et al. (2006). "Condom use and the risk of genital human papillomavirus infection in young women". N Engl
J Med
"Human Papillomavirus (HPV) Vaccines"
.
National Cancer Institute
(NCI).
2009Slide30
“Mythical” Advantages Prostate Cancer
Condoms, again!!IF…the “association” is due to an increased risk of STDsSeveral studies shows real benefit is if circumcision occurs before sexually active, therefore the patient could decide to be circumcised Ross et al paper in 1987 did not take into account family history, which is a known risk factor
1“It’s still premature to say go ahead with circumcision to prevent prostate cancer,” said lead author Marie-Elise Parent1
1. Wright, J. L., Lin, D. W. and Stanford, J. L. (2012), Circumcision and the risk of prostate cancer . Cancer, 1182. Spence, A. R., Rousseau, M.-C., Karakiewicz
, P. I. and Parent, M.-É. (2014), Circumcision and prostate cancer: a population-based case-control study in Montréal, Canada. BJU International, 114Slide31
Disadvantages of CircumcisionSlide32
Disadvantages – Pain Circumcisions are
Painful!!Slide33
“In less than 30 seconds, a nurse can immobilize the struggling infant
securely in the correct position with Circumstraint. The immobilizer works on a proven principle of positive 4-point restraint. Soft wide Velcro straps encircle the infant's elbows and knees, depriving him/her of leverage. The child is held safely and securely without danger of escape.
Circumstraint's comfortable contoured shape positions the infant, hips elevated, perfectly presenting the genitalia. The platform between the infant's legs provides support for a circumcision clamp. Without pins, towels, plastic shells or the threat of strangulation,
Circumstraint snugly and securely immobilizes the infant with their entire torso visible.”http://www.quickmedical.com/olympicmedical/circumstraint/immobolizer.htmlSlide34
Disadvantages Circumcisions are Painful!!
AAP update in Feb 2016 – “Preventing or minimizing pain in neonates should be the goal of pediatricians and other health care professionals who care for neonates.”Exposure to repeated painful stimuli early in life is known to have short- and long-term adverse sequelae. Physiologic instability,
Altered brain developmentAbnormal neurodevelopment, somatosensory, and stress response systems
Anand
KJ,
Aranda
JV,
Berde
CB, et al
. Summary proceedings from the neonatal pain-control group. Pediatrics. 2006;117(3
Suppl
1):S9–S22pmid:16777824Slide35
http://www.circumstitions.com/Pain.htmlSlide36
Disadvantages Other acute complications
Bleeding HematomaInfectionPenile amputation Urinary retention Slide37
Disadvantages
Too much skin removed Tissue epithelizes causing unacceptable cosmesis Increases likelihood of concealed penis May require skin grafting Too little skin removed Increases likelihood for penile adhesions
Requires circumcision revision under general anesthesia Dr. AL-Omar has revised 106 circumcisions since March 2013
Hundreds of other outpatient visits Slide38
Disadvantages – Meatal Stenosis
Thought to be secondary to glans irritation causing meatitis or ischemia from damage to frenular artery during circumcision IncidenceAllen et all in 1973 reported an incidence of 32%1
Joudi et al in 2011 found the rate to be 20.4% after neonatal circumcision2
SymptomsSpraying urine stream Dysuria, frequency and gross hematuria UTIsDr. AL-Omar has performed 91 meatoplasties since March 2013
1. Allen
SJ, Summers JL, Wilkerson JE:
Meatal calibration of
newborn boys. I
Urol
107:498, 1972
.2. Joudi. J Pediatric Urology. 2011 Slide39
Disadvantages – Erectile Dysfunction
Circumcised men have a 4.5 times greater chance of suffering from erectile dysfunction (ED) than intact menReduced glans sensitivity due to keratization and excision of perineal nerve endings in the frenulum Reduced penile sensation by 75%1
Inability of achieve an erection 5x increase in premature ejaculation2
1. Sorrells, M. L., Snyder, J. L., Reiss, M. D., Eden, C., Milos, M. F., Wilcox, N. and Van Howe, R. S. (2007), Fine-touch pressure thresholds in the adult penis. BJU International, 99: 864–869.
2. Tang
WS and
Khoo
EM. Prevalence and correlates of premature ejaculation in a primary care setting: A preliminary cross-sectional study. J Sex Med 2011;8:2071–2078Slide40
Disadvantages Other late complications
Abnormal healing Epidermal inclusion cysts Penile curvature (chordee)PhimosisNecrosis of the penis DEATHSlide41Slide42
CIRCUMCISION CAUSES AUTISM!!!Slide43
Disadvantages – Autism
Analyzed 340,000 boys born in Denmark between 1994 and 2003. The overall risk of developing autism before age 10 was almost 50 percent higher for circumcised boys than uncircumcised boysWhy?“...painful experiences in neonates have been shown in animal and human studies to be associated with long-term alterations in pain perception, a characteristic often encountered among children with ASD... The present study was carried out to address the hypothesis that ASD might be a rare adverse outcome in boys undergoing ritual circumcision during a vulnerable period in life.” – Dr. Morten FrischSlide44Slide45
Disadvantage….?!!.Slide46
Disadvantage: Continue
…1
AUA statement:
“The incidence of serious complications is extremely low. The minor complications are reported to be (3%)
”.
AAP statement:
“
Significant acute complications are rare. In general, untrained providers who perform circumcisions have more complications than well-trained providers who perform the procedure
”.Slide47
Disadvantage: Continue
…2
Pain:
Anyone who has performed circumcisions, knows that newborn babies respond appropriately to painful stimuli.
AAP statement:
“Analgesia
is safe and effective in reducing the procedural pain associated with newborn
circumcision”
Pain management (Safe and effective)*
Dorsal penile nerve block (DPNB
).
R
ing Block.
Topical Anesthesia (EMLA,
Tetracaine
gel).
Sucrose pacifier:
is insufficient as a sole agent, but may use in adjacent to local agents.
*
Lenhart
JG,
et al.
J Am Board
Fam
Pract
. 1997;10:310–1
.
Lander J, et al.
JAMA. 1997;278:2157–62. Slide48
Disadvantage:
Continue…3
Acute Complications
(Bleeding, hematoma, infection…etc.)
Wiswell
et al. (1989):*
Reviewed
the records of more than
100,000 circumcisions
in U.S. Army hospitals.
O
verall
complication rate was
(
0.29%
):
B
leeding
was
(0.08%)
Infection
(0.06%)
T
oo
much or too little skin
removed
(
0.01
%)
No
deaths.
Christakis, et al. (2000):**
R
eviewed
the hospital discharge records of
over
130,000 circumcisions
from Washington
State
.
Overall complication rate was
(0.22%)
:
B
leeding
was the most common with an incidence of
0.18%
.
A
penile injury occurred in
0.04%
,
I
nfection
was identified in
0.0008%
.
*
Wiswell
TE, et al.
Pediatrics
. 1989;83(6):1011–5.
**
Christakis
DA, et al.
Pediatrics
. 2000;105(1
Pt
3):246–9
. Slide49
Disadvantage: Continue
…4
Late complications
(Redundant foreskin, excessive skin removal, adhesions, meatal stenosis, concealed penis, and epithelial inclusion cysts):They usually occur late in childhood.
Meatal stenosis:
Van Howe (2006)*: reported
(7.3%)
incidence of meatal stenosis in boys greater than 3 years old.
Circumcision and Sexual function, Sensation, Satisfaction:
The literature review does not support the belief that male circumcision adversely affects penile sexual
function, regardless
of how these factors are
defined:
Two
US
studies in 2002
found
similar or greater
sexual satisfaction in men after circumcision as adults [Collins et al., 2002; Fink et al., 2002
].
Uganda study
:
A randomized controlled trial
of
4,456 sexually-experienced men aged 15-49 found
no difference in sexual satisfaction
or clinically significant function
between circumcised and uncircumcised men
[Kigozi et al., 2008
].
Kenya study:
A
large
randomized controlled trial
,
dispelled the myth that circumcision diminishes penile sensitivity. In fact
64%
of the men in this trial reported an
INCREASE
in their penile sensitivity and 55% reported greater ease in reaching orgasm [Krieger et al., 2008].
Van Howe RS.
Clin
Pediatr
(
Phila
). 2006;45(1):49–54. Slide50
Disadvantage: Continue
…5
CIRCUMCISION CAUSES AUTISM
!!! C’MON MAN!!!....Slide51
Disadvantage: Continue
…6
Dr. Douglas S. Diekema
, one of the authors of the AAP Policy Statement:
Dr. Frisch is
known in Denmark as an outspoken critic of
circumcision (bias concern)
Correlation
does not imply or prove causation
.
While the rate of circumcision decreased in U.S from 80% to 62.5% between 1980 and 1999, the rate of Autism increased from 1/150 to 1/60 between 1992 and 2002.
Diekema
urged
parents who wish to have their child circumcised to insist that adequate pain control be provided both during and after the procedure.
http://
www.huffingtonpost.com
/2015/Slide52
Costs of CircumcisionSlide53
Costs “It is difficult to get a man to understand something when his salary depends on his not understanding it.” – Upton Sinclair Slide54
Costs Neonatal Circumcision = $662
Surgical Circumcision = $585 + ~$400 for anesthesia + Facility fee + OR time
~ $150 for each
PlastibellSlide55
Costs Circumcision Revision = $650
Meatoplasty = $1212 Lysis or Excision of Post-Circumcision Adhesions = $776Foreskin Restoration = at a minimum $7,000Slide56
Costs What’s the cost of keeping your foreskin?
FREESlide57Slide58Slide59
Costs:
Is neonatal circumcision cost effective?AAP Policy Statement:“…..The benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns.”
Indirect cost benefits of circumcision resulted from prevention of infant urinary tract infection,
balanoposthitis, phimosis, HIV infection and penile cancer. I agree with you that Post neonatal circumcision should be avoided as much as possible (unless medically indicated), because it costs 10X more than neonatal circumcision.*
*Schoen
et al
. J
Urol
, 2006. Slide60
Closing Statement:
Except for the region of
sub-Saharan Africa, no call for routine circumcision
has been made by any established medical organizations or governmental bodies. The range of positions is from
“some medical benefit/parental choice”
in the United States, to
“essential no medical benefit/ parental choice”
in Great Britain, to
“no medical benefit/physical and psychological trauma/
parental
choice”
in the Netherlands
.
1
The
preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the
procedure (AAP statement).
Parents should be carefully counseled about advantages and disadvantages of circumcision
.
When circumcision is being performed
on healthy newborn infants as an elective procedure, the incidence of
serious complications is extremely low
. The minor complications are reported to
be
3%
.
Adequate anesthesia
should be provided during circumcision procedure
.
Post neonatal circumcision is not cost effective, as it costs
10X
more than neonatal one.
1
Surgical guide to circumcision.
Bolnick
et al. 2012Slide61
Questions: Thank You!