A. Egyptian artifacts date circumcision to 6,000 years ago.

B. Four thousand years ago the Old Testament references ritual circumcisions to be performed on the eighth day of birth with a flint knife.

C. Both the Old and New Testaments make numerous references to circumcision without any relationship to health benefits.

D. Widespread practice of circumcision originated in the 19th century, allegedly as a prophylaxis against disease.

E. The present incidence of circumcision in the United States is estimated to be between 30% and 90% of newborn males with a much lower incidence in Europe. Geographic variations exist, with the Midwest having a greater incidence of circumcision compared to the East and West coasts.

F. Circumcision is the most common operation performed in the United States.

In 1975 and 1983, the American Academy of Pediatrics stated that “there is no absolute medical indication for circumcision in the neonatal period.” This was revised in 2012 and the outcome leaned toward the benefits of circumcision stating, “Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it.” Those benefits included prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV.

When circumcision is being considered, the benefits and risks should be explained to the parents and informed consent obtained.

A. Prevent phimosis.

B. Repair phimosis.

C. Prevent balanoposthitis (superficial infection of the glans penis [balano] and foreskin [posthitis]).

D. Eliminate the risk of penile cancer.

E. May decrease the incidence of some sexually transmitted diseases (HPV and HIV), and thereby cervical cancer.

F. Reduces the incidence of urinary tract infection in neonatal males (newborns to 12 months of age) by approximately 10 fold.

A. Transient behavioral and physiologic changes that the infant experiences.

B. Pain.

C. Potential complications of circumcision.

D. Irreversible removal of the prepuce.

All males born with penile anomalies (hypospadias, epispadias, megalourethra).

A. Bleeding diathesis.

B. Prematurity.

C. Severe medical problems.

A. Emotional.

B. Cultural.

C. Religious.

D. Father’s foreskin status.

A. Development

1. The foreskin begins to develop in the third month of intrauterine life with normal completion by 4 to 4½ months.

2. It is normal for the newborn’s foreskin to be adhered to the glans.

3. Separation of the foreskin from the glans penis occurs late in gestation with only 4% of newborn males having a completely retractable foreskin. In 50% of newborn males, the foreskin cannot be retracted far enough to visualize the urethral meatus.

4. By the age of 6 months, 20% of boys have a completely retractable foreskin, and by the age of 3 years that number increases to 90%. By the teenage years, complete separation of the foreskin occurs in virtually all males.

B. Foreskin Care

1. The uncircumcised penis needs no special care other than the same attention given to the rest of the body.

2. Genital hygiene in little boys does not require retraction of the foreskin.

3. For undetermined reasons, possibly folklore or tradition, many physicians, parents, and grandparents remain convinced that the foreskin must be retracted at an early age.

4. Painful early foreskin manipulation can lead to bleeding, scarring, phimosis, and psychological trauma for the child and parent.

A. Phimosis is defined as a narrowing of the opening of the prepuce, preventing it from being drawn back over the glans penis (typically from scarring and/or recurrent infection). Treatment in severe cases is by surgical release of the scarred tissue, which may be referred to as a cicatrix. In less severe cases, the phimosis will respond to local treatment with topical steroids. Betamethosone 0.05% ointment applied to the tip of the penis at the area of the phimosis for 6 to 8 weeks twice a day has a 50% to 90% success rate. After one week the patient or parent should gently stretch the foreskin to facilitate release of the phimosis.

B. Penile adhesions in children with and without circumcision will typically resolve over time without the need for formal treatment. If concerning to
parents they may also be treated with topical steroids in the same fashion as described for phimosis. Recalcitrant adhesions after circumcision may require surgical release. Simple adhesions can be lysed with the use of EMLA (eutectic mixture of local anesthetics) cream and a sharp iris scissors in the office. More dense adhesions or multiple adhesions may require general anesthesia.

C. Paraphimosis is defined as a painful constriction of the glans penis by the foreskin, which has been retracted behind the corona of the glans penis. Prolonged retraction of the foreskin leads to a relative obstruction of the lymphatics. This may cause lymphedema distally. Treatment requires reducing the foreskin after manual compression of the edematous glans penis. In severe cases, the constricting foreskin may need to be surgically released via a dorsal slit (see below).