Oliver B. Lao and Stephen C. Raynor

The Prepuce

The prepuce is the anatomical covering of the glans. Contributing to the debate concerning the appropriateness of routine circumcision is a poor understanding of its function. The prepuce is specialized junctional mucocutaneous tissue that has both somatosensory and autonomic innervation. Innervation of the prepuce differs from the glans, which is innervated by free nerve endings with protopathic sensitivity. As a result of these differences, the inner mucosa of the prepuce is felt to be a part of penile erogenous tissue.⁶ Given the possible relationship between the prepuce and sexual satisfaction, studies have looked into outcomes following circumcision.

Problems with sexual dysfunction (inability to ejaculate, lacking interest, premature ejaculation, pain during sex, not enjoying sex) appear to be slightly more prevalent among uncircumcised men.⁷ For sexually active adult males undergoing circumcision, there does not appear to be any adverse, clinically important effects on sexual function or satisfaction.^8–11 Other studies, however, have shown difficulty with sexual enjoyment, erectile function, and a decrease in masturbatory pleasure following circumcision.^11,12 These mixed results hold true for homosexual men as well.¹³ The effects on female partners of adult males who are circumcised are similarly mixed. Some report dyspareunia, orgasm difficulties, and incomplete needs fulfillment, while others report no significant problems at all.^14,15

Medical Indications

The inability to retract the foreskin of a newborn is the result of incomplete keratinization of the glans and is not pathologic. Phimosis is the inability to retract the foreskin. True phimosis is associated with a white, scarred preputial orifice, most common just before puberty, and is an indication for circumcision.¹⁶ Balanitis xerotica obliterans is a ring-like distal sclerosis of the prepuce with whitish discoloration or plaque formation that may involve the prepuce, glans, or urethral meatus, and is also an indication for circumcision.¹⁷ Paraphimosis occurs when the foreskin has been retracted behind the corona and is unable to be brought back over the glans. This is also an indication for circumcision, though ardent opponents of circumcision would offer preputial stretching, plasty, or topical steroid creams as alternative therapy.^18–21 Balanitis is an infection of the glans, and posthitis is an infection of the prepuce. Recurrent infection with scarring of the prepuce is also an indication for circumcision.^5,22

Routine Circumcision at Birth

The appropriateness of routine circumcision of healthy newborn males is an emotional and contentious issue. Underlying the argument is a poor understanding as to the function of the prepuce.²³ Opponents have presented circumcision as a symbol of the ‘therapeutic state’,²⁴ a mutilating procedure,²⁵ and have questioned the ethics and legality of newborn circumcision, especially with respect to human rights considerations and the notion of respect for bodily integrity.^26,27 Opponents have also cited an association between circumcision and subsequently developing poor breastfeeding outcomes, delayed cognitive abilities, and neonatal jaundice. However, these concerns have not been substantiated.^28,29 One urologic study among children without urinary complaints did find a relationship between circumcision and meatal stenosis.³⁰

Circumcision is performed on the eighth day in the Jewish faith, traditionally by a mohel, a member of the faith trained in circumcision. In Islamic countries, circumcision is considered traditional but not obligatory, with a wide variability in age at circumcision.3,31

Proponents for routine newborn circumcision generally cite three advantages: prevention of urinary tract infections,³² prevention of sexually transmitted disease, and prevention of cancer, both penile and prostate.

As rates of circumcision have diminished in the USA, reports have appeared showing an increased rate of urinary tract infections (UTIs) in uncircumcised infants with a male predominance in infants younger than 3 months of age.³³ A disproportionate number were uncircumcised. A large retrospective analysis of infants from military families suggested that uncircumcised infants have a 12-fold increased risk for UTI compared with circumcised infants.^34–36 A prospective study found a reduced incidence of asymptomatic UTI in circumcised children.³⁷ Finally, there is a tenfold increase in the cost of managing UTIs in uncircumcised compared to circumcised infants.³⁸

An increased incidence of infection in uncircumcised children is believed to be secondary to adherence of pathogenic bacteria to the prepuce and may also hold true for young adults.39,40 Proponents point to the 10% incidence of concurrent bacteremias and long-term sequelae of renal scarring after infection.⁴¹ Critics have countered that these studies are retrospective analyses and that other studies associate genitourinary infection with circumcised children.^42–44 Additionally, they argue that colonization of the prepuce by nonmaternal uropathic bacteria could be prevented by strict rooming-in with the mother.⁴⁵

There are many studies examining the relationship between circumcision and sexually transmitted diseases (STDs).⁴⁶ The benefits of circumcision relative to STDs are a strong factor in the support of circumcision in the new AAP statement. Studies have shown that uncircumcised individuals have an increased risk of acquiring Human immunodeficiency virus (HIV), human papillomavirus (HPV), and genital herpes.^47–50 However, other studies have found little support for or have refuted these findings altogether.^7,51,52 There is also evidence that circumcision is associated with a decreased risk of cervical cancer in women.⁴⁸ It is possible that the protective effect of circumcision against STDs may differ between developed and developing nations with poor hygiene.⁵¹ Possible mechanisms for differing rates of STDs in relation to circumcision status include a more easily traumatized mucosa and epithelium of the uncircumcised phallus, the foreskin environment being more conducive to pathogens, or nonspecific balanitis in uncircumcised men predisposing to certain STDs. Behavior and sexual practice still represent the greatest risk factors in STD transmission.⁴⁸

Epidemiological studies of HIV and acquired immune deficiency syndrome (AIDS) have raised another argument for prophylactic circumcision. There is a substantial amount of evidence linking uncircumcised men with an increased risk of HIV infection that is independent of the increased risk of genital ulcers in uncircumcised men.⁵³ In Africa, there is an increased rate of HIV/AIDS observed in areas with low circumcision rates.⁵⁴ A meta-analysis from Africa concluded that there was enough evidence that circumcision was associated with reduced HIV infection rates to consider male circumcision as a strategy to reduce HIV transmission.⁴⁵ Three randomized trials in Africa showed an estimated 50–60% reduction in the relative risk of HIV infection with circumcision.^54,55 Similar findings have been noted in the USA, with uncircumcised homosexual men having a twofold increase in the risk of HIV infection.^56,57 An uncircumcised male partner also appears to be associated with an increased risk of transmission of HIV to heterosexual contacts.⁵⁸ The most recent Cochrane reviews cite a protective association between circumcision and HIV acquisition, and recommend routine circumcision among heterosexual men while stopping short of recommending the same in homosexual men.^59,60

Circumcision may act as a protective measure against cancer, both prostate and invasive penile. It is believed that these cancers have infectious etiologies and that rationale underlies the reasoning that circumcision before first sexual intercourse may be associated with a decreased risk of prostate cancer.⁶¹ The uncircumcised state has been strongly associated with invasive penile cancer in multiple case series, especially given its strong association with HPV.^53,62 The incidence of penile cancer in the USA is approximately one case per 100,000, with nearly all cases occurring in uncircumcised men.^63,64 The protective effect against penile cancer is diminished or lost when circumcision is performed after the newborn period.^5,64,65 Other factors associated with invasive penile cancer include smoking, a history of genital warts, penile rash or tears, multiple sexual partners, and poor penile hygiene.^53,65 Critics cite equally low rates of penile cancer in developed countries with low circumcision rates and feel that the incidence of penile cancer does not justify routine neonatal circumcision.^43,62

There is no definitive answer to the question of the appropriateness of routine newborn circumcision. Current studies do not provide conclusive evidence definitively for or against routine newborn circumcision. Males not circumcised at birth have between a 2–10% likelihood of needing circumcision.21,25