recommend routine neonatal circumcision.” As a consequence, parents should be appropriately counseled so that they can make an informed choice and decide whether a circumcision is in the best interest of their child.

•Worldwide, most legal jurisdictions do not have specific laws concerning the circumcision of males.

•Infant circumcision is considered legal under the existing laws in countries such as Australia, Canada, New Zealand, the United Kingdom, and the United States.

•A few countries have passed legislation on the procedure: Germany allows non-therapeutic circumcision under certain conditions, while routine neonatal circumcision is illegal in Finland, non-religious routine circumcision is illegal in South Africa and Sweden.

•In the 9th edition of the Encyclopedia Britannica published in 1876, discusses the practice of circumcision as a religious rite among Jews, Muslims, the ancient Egyptians and tribal peoples in various parts of the world.

•In 1910 the Encyclopedia Britannica changed the statement regarding circumcision: “This surgical operation, which is commonly prescribed for purely medical reasons, is also an initiation or religious ceremony among Jews and Muslims”.

•An association between circumcision and reduced heterosexual HIV infection rates was suggested in 1986. To establish this, trials took place in South Africa, Kenya and Uganda and showed the circumcised group had a lower rate of HIV contraction than the control group.

•Subsequently, the World Health Organization promoted circumcision in high-risk populations as part of an overall program to reduce the spread of HIV.

•The Male Circumcision Clearinghouse website was formed in 2009 by WHO, UNAIDS, FHI and AVAC to provide current evidencebased guidance, information and resources to support the delivery of safe male circumcision services in countries that choose to scale up the procedure as one component of comprehensive HIV prevention services.

22.4Pain Management

•It is well known that circumcision causes pain, and for neonates this pain may interfere with mother-infant interaction or cause other behavioral changes.

•To avoid this, pre and post circumcision analgesia is advocated.

•There are several methods to achieve this.

–Paracetamol orally or suppository

–Topical analgesic creams (EMLA cream which is a mixture of prilocaine and lidocaine)

–Localized or regional nerve blocks (ring block and dorsal penile nerve block)

–The ring block and dorsal penile nerve block (DPNB) are the most effective at reducing pain.

–The ring block may be more effective than the DPNB.

–The ring block and dorsal penile nerve block are more effective than EMLA cream.

•Non-pharmacological methods to reduce circumcision pain include:

–The use of a comfortable, padded chair

–The use of a sucrose or non-sucrose pacifier

•The American Academy of Pediatrics (AAP) states that such methods are insufficient alone and should be used to supplement more effective techniques.

•A quicker procedure to do circumcision reduces duration of pain.

•The use of the Mogen clamp was found to result in a shorter procedure time and less pain-induced stress than the use of the Gomco clamp or the Plastibel.

•Formal surgical circumcision in older children is done under general anesthesia. This can be supplemented with a caudal block to reduce postoperative pain.

22.5Indications for Circumcision

•Circumcision is commonly performed for cultural, religious, or hygienic reasons.

•Medical indications for circumcision include:

–Phimosis

–Paraphimosis

–Balanitis and posthitis

–Recurrent urinary tract infection

–Children who require clean, intermittent catheterization

–Part of the repair of hypospadias, epispadias and ambiguous genitalia

•Phimosis:

–Phimosis is a condition in which the distal prepuce cannot be retracted over the glans penis.

–Severe phimosis can be demonstrated by bulging of the foreskin during micturition.

–Phimosis causes chronic skin irritations, yeast infections, balanitis, posthitis, and the forceful retraction of the foreskin may result in paraphimosis.

–Phimosis may cause pain and difficulty during micturition and may cause pain during sexual activity.

–Acquired or pathological phimosis occurs as a result of:

•Poor hygiene

•Chronic or repeated episodes of balanoposthitis

•Repetitive forceful retraction of the foreskin

•Scaring from the skin disease balanitis xerotica obliterans (BXO)

•Circumcision complication

–Circumcision is the treatment for pathological phimosis.

•Paraphimosis:

–Paraphimosis is the inability to reduce a retracted foreskin over the glans penis to its naturally occurring position.

–Paraphimosis can result when parents or physicians forcibly retract the foreskin to clean the penis or attempt catheterization and do not return the foreskin to its original position.

–Edema, tenderness, and erythema of the glans are seen, along with edema of the distal foreskin and flaccidity of the penile shaft proximal to the areas of paraphimosis.

–Paraphimosis is a true urologic emergency and should be treated as soon as possible.

–If not treated promptly, it can result in venous engorgement and edema of the glans and foreskin which, over time, progresses to arterial occlusion and the risk of ischemic loss of portions or the entire glans penis.

–Paraphimosis is treated by manual reduction of the prepuce over the glans.

–If manual reduction fails, a dorsal incision at the level of the constricting band releases the foreskin.

–Circumcision should later be performed electively.

•Balanitis or posthitis:

–Posthitis is an infection of the prepuce, whereas balanitis is an infection of the glans penis.

–An inflammation of the glans penis and foreskin is called balanoposthitis

–Balanitis and posthitis may be the result of poor hygiene.

–Most cases occur in uncircumcised males, affecting 4–11 % of uncircumcised males.

–The moist, warm space underneath the foreskin is thought to facilitate the growth of pathogens, particularly when hygiene is poor.

–The infection is usually caused by mixed flora.

–Yeasts, especially Candida albicans, are the most common penile infection

–Trichomonal balanitis and candidal infections may be seen in sexually active teenagers.

–Posthitis is characterized by erythema, swelling, warmth, and tenderness of the foreskin.

–Balanitis is characterized by erythema, swelling, warmth, and tenderness of the glans penis.

–A foul-smelling, thin, seropurulent exudate may be seen.

–Both of these infections are treated with oral and topical antibiotics and warm baths.

–Circumcision is a treatment option for refractory or recurrent balanoposthitis.

•Management of urinary tract infections:

–A urinary tract infections affects parts of the urinary system including the urethra, bladder, and kidneys.

–There is about a 1 % risk of UTIs in boys under 2 years of age, and the majority of incidents occur in the first year of life.

–Urinary tract infections are more common in male neonates than in females.

–There is an increased rate of urinary tract infections in uncircumcised males, especially in infants younger than 1 year.

–A study of infants with UTIs showed that 75% of those younger than 3 months were males and, of those, 95% were uncircumcised.

–There is good evidence that circumcision reduces the incidence of urinary tract infections in boys under 2 years of age.

–Recommending routine circumcision in all newborn males is controversial and prevention of UTIs does not justify routine use of circumcision, however.

–Circumcision is most likely to benefit boys who have a high risk of urinary tract infections due to anatomical defects, and may be used to treat recurrent UTIs. Circumcision may reduce the risk of urinary tract infections through a decrease in the bacteria population.

–Some children are at increased risk for UTIs, such as children with neurogenic bladders who require clean, intermittent catheterization or children with poorly emptying urinary tracts. Circumcision in these patients will facilitate the procedure and reduce the risk of UTIs.

•Management of sexually transmitted diseases (STDs):

–There is strong evidence that circumcision reduces the risk of HIV infection in heterosexual men in high-risk populations.

–The finding that circumcision significantly reduces female-to-male HIV transmission in the HIV/AIDS epidemic sub-Saharan Africa prompted the World Health Organization (WHO) to recommend circumcision as an additional method of controlling the spread of HIV.

–Circumcision is recommended as part of a comprehensive program for prevention of HIV transmission in areas with high endemic rates of HIV.

–Evidence among heterosexual men in subSaharan Africa shows an absolute decrease in risk of 1.8 % which is a relative decrease of between 38 and 66 % over 2 years, and in this population studies rate it cost effective.

–Whether it is of benefit in developed countries is undetermined.

–Circumcision only provides partial protection from HIV and known methods should not replace HIV prevention.

–There are several mechanisms proposed to explain the increased risk for STDs in uncircumcised males. These include:

•A relatively nonkeratinized inner layer of the prepuce which increases its susceptibility to minor trauma during intercourse, allowing pathogens to penetrate through microscopic abrasions.

•The warm microclimate created by the preputial pouch permits the microorganisms to thrive in the smegma that collects in this area.

•The superficial skin layers of the penis contain Langerhans cells, which are targeted by HIV; removing the foreskin reduces the number of these cells.

•When an uncircumcised penis is erect during intercourse, any small tears on the inner surface of the foreskin come into direct contact with the vaginal walls, providing a pathway for transmission.

–A significant twoto sevenfold increased risk of genital syphilis and chancroid was reported in uncircumcised male patients.

–Circumcision was found to be associated with lower rates of syphilis, chancroid and possibly genital herpes.

–Circumcision reduced the incidence of HSV-2 (herpes simplex virus, type 2) infections by 28 %.

•Management of human papillomavirus and cervical cancer:

–Human papilloma virus (HPV) can be oncogenic or nononcogenic.

–Nononcogenic HPV (genotypes 6 and 11) causes genital warts in men and women.

–Oncogenic HPV (genotypes 16, 18, 31, and 33) are responsible for the great majority of cervical, vulvar, vaginal, anal, and penile cancers.

–Circumcision significantly reduces the risk of penile HPV infection in men and of cervical cancer in the female partners of male individuals who practice high-risk behaviors such as engaging in sexual activity with multiple partners.

–Human papilloma virus (HPV) is the most common sexually transmitted infection, affecting both men and women. While most infections are asymptomatic and are cleared by the immune system, some types of the virus cause genital warts, and other types, if untreated, cause various forms of cancer, including cervical cancer and penile cancer.

–Genital warts and cervical cancer are the two most common problems resulting from HPV.

–Circumcised man are less likely to be infected with cancer-causing types of HPV.

–Circumcision decreases the likelihood of multiple infections.

•Penile cancer:

–Circumcision has a protective effect against the risks of penile cancer in men, and cervical cancer in the female sexual partners of heterosexual men.

–Penile cancer is rare, with about 1 new case per 100,000 people per year in developed countries, and higher incidence rates per 100,000 in sub-Saharan Africa (for example, 1.6 in Zimbabwe, 2.7 in Uganda and 3.2 in Swaziland).

–Penile cancer development can be detected in the carcinoma in situ (CIS) cancerous precursor stage and at the more advanced invasive squamous cell carcinoma stage.

–Childhood or adolescent circumcision is associated with a reduced risk of invasive squamous cell carcinoma in particular.

–There is an association between adult circumcision and an increased risk of invasive penile cancer; this is believed to be from men being circumcised as a treatment for penile cancer or a condition that is a precursor to cancer rather than a consequence of circumcision itself.

–The most important factor associated with the development of penile cancer is an intact foreskin.

–Penile cancer has been observed to be nearly eliminated in populations of males circumcised neonatally.

–Jewish men (the great majority of them circumcised) rarely develop penile cancer.

–The other known major risk factor associated with penile cancer is phimosis.

–Circumcision completely eliminates these risks.

22.6Contraindications to Circumcision

•Prematurity

•Chordee of the penis

•Curvature of the penis

•Hypospadias

•Epispadias

•Concealed or buried penis

•Micropenis

•Webbed penis

•Ambiguous genitalia

•Bleeding diatheses

•In those with chordee of the penis, curvature of the penis, micropenis, webbed penis and concealed or buried penis, circumcision is delayed and open classic surgical circumcision is performed.

•In those with Hypospadias, Epispadias and Ambiguous genitalia, circumcision is done as part of the corrective surgery of these anomalies.

•Bleeding diatheses are not absolute contraindications for circumcision, and circumcisions