Circumcision

Introduction

Male circumcision is one of the oldest and most common surgical procedures worldwide, and is undertaken for many reasons: religious, cultural, social and medical. There is conclusive evidence from observational data and three randomized controlled trials that circumcised men have a significantly lower risk of becoming infected with the human immunodeficiency virus (HIV)[i] among many other medical conditions. Medical research has also determined that male circumcision reduces the incidence of penile cancer, prostate cancer and STI’s such as human papillomavirus (HPV), syphilis, chancroid, HSV-2 and others as outlined below.

"1 in 3 uncircumcised men will require medical attention

due to a condition stemming from their uncircumcised state"

Global Prevalence of Male Circumcision

Worldwide 30-32% of males are circumcised[ii] according to the World Health Organisation. Due to the almost universal coverage of circumcision among Muslim and Jewish men, prevalence in the Middle East and North Africa is high as can be seen in the figure below.

Figure 1: Global map of prevalance of male circumcision as at December 2006 ii

The total number of circumcised men aged 15 years and older can be estimated to be between 661.5 million and 727.65 million or 30% - 33% of men globally.

Today in the USA, over 1.2 million newborn males are circumcised annually and this figure is rising[iii]. For Australian born men the rate is 69% although it is only 32% for men aged 16-20. In the Middle East 10 million Muslim and 100,000 Jewish circumcisions are performed annually and in Africa the number is 9 million.

 

"the benefits exceed the risks by a factor of more than 100 to 1"

 

Physiology of the Foreskin

Circumcision removes some or all of the foreskin from the penis. The foreskin is a continuation of skin from the shaft of the penis that covers the glans penis and the urethral meatus. The role of the foreskin is debatable although sources suggest it has a function in keeping the glans moist, whereas others suggest the foreskin protects the developing penis in utero.

The foreskin develops during the third month of intra-uterine development (about 65 mm

stage), when a fold of skin develops at the base of the glans penis and beings to grow distally. This free fold of skin will become the prepuce. The dorsal aspect grows more rapidly than the ventral, so that initially only the dorsum is covered. As the glanular urethra closes, so does the ventral prepuce, and the resultant fusion is marked by the frenulum. This process is completed by the fifth month, and fusion then occurs between the inner epithelium of the prepuce and the epithelium of the glans penis, both of which are made of stratified squamous cells. The squamous cells arrange themselves in whorls as they keratinize and then degenerate so that clefts appear. These clefts increase in size and fuse with each other so that eventually the inner preputial epithelium and epithelium of the glans are separated from each other. This separation is usually incomplete at birth, and consequently, the foreskin is not usually retractable in newborn males. The phenomenon of incomplete separation is commonly referred to as ‘adhesions’, which need to be broken with a blunt probe during paediatric circumcision. By the age of three years, about 10% of males still have an unretractable foreskin, and by the age of 17, the foreskin is completely retractable in almost all males.

 (Taken from source i)

 Medical Indications for Male Circumcision

The most frequent medical condition which requires circumcision is:

·         Phimosis, a condition in which is characterized by a constriction of the preputial orifice so that the prepuce cannot be retracted back over the glans.

Several other conditions exist such as:

·         Untreatable paraphimosis: a retraction of phimotic foreskin proximally past the corona, causing a painful swelling of the glans and foreskin. Severe cases may cause dry gangrene

·         Balanoposthitis: inflammation of the foreskin and glans

·         Balanitis Xerotica Obliterans: a chronic sclerosis and atrophic process of the glans of the penis and foreskin. This is a risk factor for penile cancer.

Benefits of Male Circumcision

Male circumcision provides an immediate ten-fold protection against urinary tract infections (UTI) and thus kidney damage in male infants[iv]. It also prevents balanoposthitis and phimosis, a common cause of sexual problems in adolescent males and men and also a major risk factor for penile cancer. Prostate cancer is 1.6-2.0 times higher in uncircumcised men[v] [vi], and penile cancer is over 22 times higher in men that are uncircumcised[vii] [viii] [ix] . The probability of uncircumcised men developing penile cancer in developed countries is 1 in 600-900, whereas for circumcised men it is 1 in 50,000-12,000,000[x] [xi] Male circumcision also protects against certain sexually transmissible infections (STI’s) and most notably human papillomavirus (HPV), the pathogen responsible for most cervical cancers in women and a proportion of penile cancers in men[xii]. Male circumcision reduces the incidence of ulcerative STI’s including syphilis, chancroid, thrichomonas vaginalis and herpes simplex virus type 2 (HSV-2)[xiii]. As a result of this, circumcised men have a lower incidence of genital ulcer disease and experience a reduction in penile injury arising from tearing of the foreskin and frenulum during sexual activity. The table below shows that circumcised men are at significantly lower risk of developing urinary tract infections, HIV, syphilis, and chancroidii.

 After analysing the above information, it can be deduced that 1 in 3 uncircumcised men will require medical attention due to a condition stemming from their uncircumcised state[xiv]. It can also be deduced that the benefits exceed the risks by a factor of more than 100 to 1 without considering the severity of the consequences including mortality, morbidity and the effects on the sexual partners in adulthood.

Male circumcision provides a public health benefit to women by mitigating the risk of various STI’s including:

·         High risk HPV types causing cervical cancer

·         HSV-2

·         Chlamydia Trachomatis which can cause pelvic inflammatory disease

·         Ectopic pregnancy and infertility

·         Reduces risk of bacterial vaginosis

 

The World Health Organisation and Circumcision

In 2007 male circumcision was formally endorsed by the World Health Organisation (WHO) and the Joint United Nations Programme on HIV/AIDS[xv] as being an important and proven strategy for the prevention of heterosexually-transmitted HIV in high prevalence settings. The endorsement was the result of more than 20 years of research which culminated in the findings of three large randomized controlled trials in different parts of sub-Saharan Africa[xvi] [xvii] [xviii].


[i] http://www.who.int/hiv/pub/malecircumcision/neonatal_mc/en/index.html

 [ii] http://www.who.int/reproductivehealth/publications/rtis/9789241596169/en/

[iii] Nelson CP, Dunn R, Wan J, Wei JT. 2005. The increasing incidence of newborn circumcision: data from the nationwide inpatient sample. J Urol 173:978–981.

[iv] Brian J. Morris, Chris Eley. Male Circumcision: An Appraisal of Current Instrumentation. Biomedical Engineering – From Theory to Applications 14 315-354

[v] Morris BJ. 2007. Benefits of circumcision: medical, health and sexual. [Review] http://www.circinfo.net (over 400 refs).

[vi] Morris BJ, Waskett J, Bailis SA. 2007. Case number and financial impact of circumcision in prostate cancer reduction. BJU Int 100:5–6.

[vii] Micali G, Nasca MR, Innocenzi D, Schwartz RA. 2006. Penile cancer. J Am Acad Dermatol 54:369–391.

[viii] Schoen EJ, Oehrli M, Colby CJ, Machin G. 2000. The highly protective effect of newborn circumcision against invasive penile cancer. Pediatrics 105: http://www.pediatrics.org/sgi/content/full/105/3/e36.

[ix] Schoen EJ. 1991. The relationship between circumcision and cancer of the penis. CA Cancer J Clin 41:306–309.

[x] Wiswell TE. 1995. Neonatal circumcision: a current appraisal. Focus Opin Pediat 1:93–99.

[xi] Wiswell TE. 1997. Circumcision circumspection. N Engl J Med 36: 1244–1245.

[xii] B.J. & Castellsague, X. (2011). The role of circumcision in the prevention of sexually transmitted infections. Sexually Transmitted Diseases. Gross, G.E. & Tyring, S. Heidelberg, Springer: 715-739

[xiii] Weiss, H.A., Thomas, S.L., Munabi, S.K. & Hayes, R.J. (2006). Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Infect 82, 101-109.

[xiv] Morris, B.J., Castellsague, X. & Bailis, S.A. (2006). Re: Cost analysis of neonatal circumcision in a large health maintenance organization. E. J. Schoen, C. J. Colby and T. T. To. J Urol, 175: 1111-1115, 2006. J Urol 176, 2315-2316.

[xv] http://www.who.int/mediacentre/news/releases/2007/pr10/en/

 [xvi] Auvert, B., Taljaard, D., Lagarde, E., Sobngwi-Tambekou, J., Sitta, R. & Puren, A. (2005). Randomized, controlled intervention trial of male Circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Med 2 (e298), 1112-1122.

[xvii] Bailey, R.C., Moses, S., Parker, C.B., Agot, K., Maclean, I., Krieger, J.N., Williams, C.F., Campbell, R.T. & Ndinya-Achola, J.O. (2007). Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 369, 643-656.

[xviii] Gray, R.H., Kigozi, G., Serwadda, D., Makumbi, F., Watya, S., Nalugoda, F., Kiwanuka, N., Moulton, L.H., Chaudhary, M.A., Chen, M.Z., Sewankambo, N.K., Wabwire- Mangen, F., Bacon, M.C., Williams, C.F., Opendi, P., Reynolds, S.J., Laeyendecker, O., Quinn, T.C. & Wawer, M.J. (2007). Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 369, 657-666.