The incidence of adverse events related to circumcision varies according to the age of the patient, increasing substantially in boys and adolescent males, compared with infants, according to a report published online May 12 in JAMA Pediatrics.
In the largest study by far of circumcisions in the United States, the rate of associated adverse events was 20-fold higher among boys who underwent the procedure between 1 and 9 years of age, and 10-fold higher among boys who had it after 10 years of age, than among boys who were circumcised during infancy, said Charbel El Bcheraoui, Ph.D., of the office of surveillance epidemiology and laboratory services at the Centers for Disease Control & Prevention, and associates.
Until now, studies of circumcision-related adverse events "were based on small samples, a single clinical site or state, cross-sectional data, or nonrepresentative cohorts," the investigators said. Their study, which included approximately 1.4 million circumcisions across the country, is the first to compare rates of adverse events across all age groups from neonates to adults, said Dr. El Bcheraoui, who is also of the Institute for Health Metrics and Evaluation at the University of Washington, Seattle, and colleagues.
To determine the risks associated with circumcision, the investigators analyzed information in a database representing 120 million inpatient hospitalizations at urban and rural, academic and nonacademic, medical centers of all sizes in every region of the country, as well as representing 870,000 outpatient medical providers. They reviewed 1,400,920 reimbursement claims for circumcisions to males of all ages during a 10-year period.
Of these, 95.3% procedures were done during infancy, 2.0% were done at ages 1-9 years, and 2.7% were done at ages 10 years and older.
The researchers identified ICD codes for adverse events that were likely related to circumcision, namely, partial or complete amputation of the penis; open wound on the penis; suturing of a penile laceration; reconstruction of the penis; replantation of the penis; division of penile adhesions; lysis or excision of postcircumcision penile adhesions; repair of incomplete circumcision; vascular disorder of the penis, including death or decay of tissue caused by insufficient blood supply; penile inflammation or edema; urethral or other penile strictures; and suturing of an incised penile artery.
The incidence of adverse events was 0.4% among boys circumcised during infancy, 9.06% among those circumcised at ages 1-9 years, and 5.31% among boys, adolescents, and adults circumcised at age 10 years or older, the investigators reported (JAMA Ped. 2014 May 12 [doi:10.1001/jamapediatrics.2013.5414]).
The most common adverse events were related to correctional procedures and bleeding.
The incidence of the most severe adverse event – penile amputation – was highest, at 0.17%, in the 10-and-older group. The total number of amputations was 71. The database doesn’t distinguish between partial and complete amputations, so the exact number of each type is not known.
It is possible that this analysis was affected by some confounding by indication, because older males in the United States are more likely to undergo circumcision for medical indications (infections or adhesions) than for cultural or religious reasons. "Future studies will need to carefully adjust for this potential source of confounding," Dr. El Bcheraoui and associates noted.
Dr. El Bcheraoui and associates reported no financial conflicts of interest.