I believe one of the greatest challenges facing health care providers is advising parents about circumcision for males. Collectively, we as health care providers and parents want to do the right thing, but what is the right thing? Sure, we may recite the recommendations from the American Academy of Pediatrics, "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision" (Pediatrics 1999:103:686-93, reaffirmed, May 2005).
Should male infants really have an elective circumcision done, and if so, what is the optimal age for it to be performed? We must also factor in medical, cultural, socioeconomic, religious, and ethical considerations.
By Dr. Michael W. Simon
The clinical evidence shows that males who are circumcised have potential benefits. They have a lower risk for urinary tract infections; however, results are confusing because of a variety of variables. Circumcised males have a lower occurrence of squamous cell carcinoma of the penis; a lower risk for sexually transmitted diseases, including HIV; and a lower incidence of balanitis and inflammation, which may be secondary to easier hygiene.
Traditionally, male circumcision is done during the newborn period. Delay in circumcision of several hours up to several days after vitamin K administration appears to have little effect on bleeding complications. A regional anesthetic "block" or topical anesthetic may be used, followed by acetaminophen or sucrose on a pacifier. If circumcision is delayed beyond the neonatal period, hemostasis and sutures are required with general anesthesia.
Neonates may experience episodes of screaming and crying with a circumcision. This is accompanied with an increase in the infant’s heart rate, blood pressure, and cortisol level, and by changes in the oxygen saturation. Screaming and crying are a response to fear, stress, or pain, and may also occur when infants and children have their nails clipped or diaper changed. An infant’s perception, processing, and interpretation of pain may be less acute compared with older children and adults. Keep in mind that after a circumcision, neonates are calmed by sucrose and acetaminophen, while older children and adults require narcotic-containing analgesia.
In many areas of the world, circumcision is viewed as unnecessary and is uncommon. For us, even though circumcision rates are dropping, societal norms may still supersede overwhelming common sense. At the present time, notwithstanding evolving information about HIV acquisition in uncircumcised vs. circumcised males, we may address the advisability and timing of circumcision based on reported information, our individual clinical experience, and empathetic best guess.
Dr. Michael W. Simon is a private practice pediatrician in Nicholasville, Ky., and professor of pediatrics at the University of Kentucky, Lexington. He said he had no relevant financial disclosures.