CUA: Circumcision (2018)

See Original Guideline

Phimosis

• Physiological phimosis
  • Naturally occurring adhesions between prepuce and glans
  • Mechanisms that lead to resolution of physiological phimosis (separation of physiological adhesions) over time (2):
    1. The collection of smegma (a white exudate of skin cells and keratin) separating the prepuce from the glans
    2. Repeated reflex erections
    • This process is complete by age 3 in 90% of boys; <1% by 17 years of age have phimosis
• Pathological phimosis
  • Uncommon pediatric diagnosis (0.6‒1.5% of boys)
  • Diagnosed by the presence of a whitish, fibrotic preputial ring.
• Diagnosis and Evaluation
  • Neonatal examination of the foreskin and urethral meatus should be part of routine clinical assessment of all newborn boys.
  • Continued examination of the foreskin without forcible retraction is recommended during yearly physical examinations to rule out pathological phimosis and document natural preputial retraction.
• Management
  • Normal foreskin care in early childhood only starts once the foreskin is retractable and this will happen at varying ages.
    • Once retractable, the child can be taught normal foreskin care: gently retract and clean during bathing with normal soap and water.
  • Active retraction should be avoided
    • Has the potential to cause microtears and lead to scarring and subsequently a true phimosis.
  • Persistent physiological phimosis in an asymptomatic child should not be an indication for circumcision
  • Indication for urological consultation in children with phimosis (4):
    1. Recurrent episodes of balanitis
    2. UTI
    3. Genital lichen sclerosis
    4. Suspicion of true (pathological) phimosis with evident scarring of the preputial ring
    • Ballooning of the foreskin during voiding is not associated with obstructed voiding and is not an indication for circumcision.
  • If the foreskin is not open by 8–10 years of age, there may be an indication for steroid therapy and gentle retraction
    • Topical steroids are the first-line treatment for persistent physiological phimosis requiring treatment with good success rates and low risk of complications
      • Topical steroids aid by thinning the preputial skin and obliterating the stratum corneum, which then allows gentle retraction over time
      • Moderately low-potency steroid (triamcinolone, clobetasone, hydrocortisone, mometasone) may have similar success compared to a highly potent steroid (betamethasone)
        • Rx: hydrocortisone 2.5% to affected area TID x 6-8 weeks
    • Patient selection to ensure compliance, demonstrating the technique of gentle retraction of the foreskin and continued retraction after initial success is important to achieve continued success to topical steroid therapy
  • Recurrence of physiological phimosis is common and normally responds to another course of topical steroids

Circumcision and risk of UTI

• Neonatal circumcision decreases the risk of UTI (Level 2a).
• The risk of UTI is low in infant males and decreases further beyond infancy
• Insufficient Level 1 evidence to justify recommending universal circumcision to prevent UTIs in normal males.
  • In boys with urological abnormalities (high-grade VUR, posterior urethral valves, primary megaureters), a stronger effect of neonatal circumcision in preventing UTIs has been demonstrated and, therefore, it is recommended that a discussion with the parents is advisable for this subgroup of neonates

Circumcision and risk of HIV

• Female to male transmission: compelling evidence that MC reduces the risk of HIV transmission from female partners to male. The magnitude of the effect is debatable and cannot be extrapolated to Canada from the African RCTs.
• Male to male transmission: Based on current evidence, MC does not provide protection for men who have sex with men
• Male to female transmission: Based on current evidence, MC is not protective for female partners
• Universal infant circumcision cannot be recommended to prevent HIV infection based on current evidence

Circumcision and risk of HPV

• High- risk oncogenic HPV subtypes, like 16 and 18, are implicated in cervical, penile, vulvar, vaginal, anal, and some oropharyngeal cancers, while low-risk non-oncogenic subtypes, like 6 and 11, cause genital warts
• HPV incidence or acquisition in men: No convincing evidence to suggest that MC decreases HPV acquisition or incident infections in HIV positive or -negative men (Level 1b‒2b).
• HPV prevalence in men: Current evidence suggests a modest decrease in HPV prevalence in the glans and coronal sulcus up to 2 years following MC.
  • The protective effect is partial, does not cover all high- risk types and is weaker further away from the glans and coronal sulcus.
  • It is not clear whether this effect will persist into adulthood following neonatal circumcision.
• HPV clearance in men: No evidence (except a single RCT on HIV-negative men) that MC increases HPV clearance (Level 1b‒2b). If it did increase clearance, this may also inflate the impact of the prevalence benefits mentioned.
• HPV in female partners: MC lowers prevalence and incidence in partners of HIV-negative men and improves clearance rates (Level 1b‒2b).
• As a public health intervention, it is likely that the effect of HPV vaccination and behavioural modification will be more effective than performing universal neonatal circumcisions on all males

Circumcision and risk of other sexually transmitted infections

• Currently, there is no significant evidence to support the protective role of MC in the acquisition of non-HPV, non-ulcerative STIs
• Currently, there is no significant evidence to support the protective role of universal neonatal circumcision for males and females in the acquisition of ulcerative STIs
• There is weak evidence of decreased seroconversion for HSV-2 following MC in adult men in Africa

Circumcision and the risk of penile cancer

• Circumcision decreases the risk of penile cancer
• However, given the low incidence of invasive penile cancer, the partial protective effect of MC, and the availability of other preventive strategies, such as HPV vaccination, condom use, and smoking cessation programs, it is difficult to justify universal neonatal circumcision as a preventive strategy for preventing penile cancer
• Recognition and treatment of phimosis during regular health visits is recommended to decrease the risk of penile cancer.
  • A genitourinary exam during puberty is recommended to ensure preputial retractability and hygiene, rule out phimosis, and counsel regarding HPV vaccination and safe sexual practices, as well as to offer the possibility of circumcision as a preventive measure against STIs while specifying the drawbacks and efficacy of other preventive measures
• There is no convincing evidence on the protective effect of MC against prostate cancer
• There is lack of any convincing evidence that neonatal circumcision will impact sexual function or cause a perceptible change in penile sensation in adulthood

See Table 2 from Original Guideline

In an overall societal perspective, given our healthcare system and the socioeconomic and educational status of our population, universal neonatal circumcision is not justified based on the evidence available.

Medical indications for childhood circumcision

1. Pathologic phimosis
   • Alternative treatments, such as preputioplasty, dorsal slit, or steroid therapy, can be attempted, but depending on the severity of the scar tissue circumcision may be the only curative option when true phimosis is diagnosed.
2. Genital lichen sclerosis (LS)
   • See Lichen Sclerosis section in Penis and Urethra Surgery Chapter Notes
   • Also known as balanitis xerotica obliterans
   • A chronic, inflammatory dermatosis of the prepuce and glans penis, which can potentially involve the meatus and urethra.
     • Overall, the incidence of meatal involvement leading to stenosis is low (2%).
   • Etiology is unknown and probably multifactorial, with a possible autoimmune or infective etiology.
   • Should be suspected when clinical examination reveals a more impressive (than phimosis) thick white ring-like cicatrix at the distal preputial ring, associated with white discoloration and plaque formation.
   • Management
     • The use of topical steroids in LS is debatable, with low response rates. It also requires close follow-up, as disease progression may lead to glans and urethral involvement.
     • Circumcision is usually curative, but some children, depending on the degree of involvement, may need a meatoplasty, glans resurfacing, or urethral reconstruction.
     • A trial of steroids may alleviate the need for surgery in selected cases, although if phimosis is an issue then a circumcision is generally required§
3. An adjunct or alternative to prophylactic antibiotics in infants with UTI-predisposing urological abnormalities, as described above.

Contraindications of neonatal circumcision

• Neonatal circumcision should be performed on medically stable, term infants without other medical conditions that require ongoing management or increase risk of surgery.
• Routine neonatal circumcision should not be carried out in children with congenital anomalies of the penis that require surgical correction, including (7):
  1. Hypospadias
  2. Epispadias
  3. Penoscrotal webbing
  4. Concealed penis (buried penis, webbed penis)
  5. Dorsal hood deformity
  6. Ventral curvature
• Children with blood dyscrasias can undergo circumcision, under appropriate treatment and care

Anesthesia for neonatal circumcision

• Different methods used for providing anesthesia and/or analgesia during circumcision:
  1. General anesthesia
  2. Penile nerve blocks
     • A dorsal nerve penile with a ring block is the most effective technique to provide anesthesia during a neonatal circumcision
  3. Topical anesthetics
     • Inferior as monotherapy to nerve and ring blocks and require an adequate time interval for efficacy
     • Can be used as an adjunct to penile blocks.
  4. Oral sucroseglucose administration
  5. Non-nutritive sucking
  6. Caudal block
  7. Various combinations of the above
  • Oral sucrose, non-nutritive sucking, music, and other environmental interventions should only be used as an adjunct.

Methods of circumcision

• Classified into one of 3 types or combinations thereof:
  1. Dorsal slit
  2. Shield and clamp
     1. Mogen clamp
     2. Plastibell
     3. Gomco
     4. Others
  3. Excision

Complications of circumcision

• Early:
  1. Bleeding, infection
  2. Glans necrosis and amputation
  3. Delayed/early slippage of circumcision devices
  4. Death (very rarely)
• Late:
  1. Inadequate skin removal
  2. Cosmetic issues
  3. Inclusion cysts
  4. Adhesions and skin bridges
  5. Suture sinus tracts
  6. Ventral curvature
  7. Secondary buried penis and phimosis
     • A trapped/buried penis can develop in which the healing skin edges migrate distally over the glans, which in turn can cause an obstructing cicatrix.
     • Management
       • Conservative management with a topical steroid ointment (0.05-0.1% betamethasone) for 6 weeks may result in resolution of the cicatrix and spontaneous retraction of the overlying skin in up to 2/3 of patients.
       • In unresponsive cases or patients with more acute problems such as infection or retention, consider use of antibiotics and/or surgical intervention with a dorsal slit
  8. Urethrocutaneous fistulae
  9. Meatal stenosis
• Complication rates post-neonatal circumcision are usually low (≈2%), but given the variability in quoted complication rates and risk of delayed complications not treated by the original physician performing the neonatal circumcision, it is likely that the overall complication rate is slightly higher
• Operator experience and training, recognition of contraindications to circumcision, technique used, age, and patient-related variables can impact results and proper reporting and auditing of results is recommended

Questions

1. What are the mechanisms that result in physiological retraction of the foreskin? By what age is this process usually complete by? At what age should intervention be considered if the foreskin is not reduced naturally? What intervention should be considered at this age?
2. Parents of a child ask if they should retract the child’s foreskin during bathing for genital hygiene? When should foreskin care be initiated?
3. What are indications for urological referral in a patient with phimosis?
4. Which steroids are recommended to treat persistent phimosis?
5. Which children are most likely to benefit from circumcision to reduce the risk of UTI?
6. In which patient population has circumcision been shown to the risk of HIV transmission?
7. What is the effect of circumcision on HPV incidence and prevalence in men?
8. What are the medical indications for circumcision?
9. What are the contraindications to circumcision?
10. What is the most effective technique to achieve anesthesia for circumcision?
11. List potential complications related to circumcision

Answers

1. What are the mechanisms that result in physiological retraction of the foreskin? By what age is this process usually complete by? At what age should intervention be considered if the foreskin is not reduced naturally? What intervention should be considered at this age?
   • Repeated erections and accumulation of smegma
   • Age 3
   • Age 8-10
   • Topical steroids
2. Parents of a child ask if they should retract the child’s foreskin during bathing for genital hygiene? When should foreskin care be initiated?
   • They should not as it increases risk of scar formation
   • Foreskin care should be initiated when foreskin is reducible
3. What are indications for urological referral in a patient with phimosis?
   1. Recurrent balanitis
   2. Recurrent UTI, possibly in context of associated abnormality (high-grade VUR, PUV, primary megaureters)
   3. Phimosis associated with lichen sclerosis
   4. True pathological scarring
4. Which steroids are recommended to treat persistent phimosis?
   • Moderate potency such as hydrocortisone
5. Which children are most likely to benefit from circumcision to reduce the risk of UTI?
   • Boys with urologic abnormalities (high-grade VUR, PUV, primary megaureters)
6. In which patient population has circumcision been shown to the risk of HIV transmission?
   • Females to males
7. What is the effect of circumcision on HPV incidence and prevalence in men?
   • Reduced prevalence, no change in incidence
8. What are the medical indications for circumcision?
   1. Recurrent balanitis
   2. Recurrent UTI
   3. Phimosis associated with lichen sclerosis
   4. True pathological scarring
9. What are the contraindications to circumcision?
   1. Congenital penile deformity (epispadias, hypospadias, penoscrotal webbing, concealed penis, dorsal hood deformity, ventral curvature)
   2. Uncontrolled coagulopathy; however, children with blood dyscrasias can undergo circumcision, under appropriate treatment and care
10. What is the most effective technique to achieve anesthesia for circumcision?
    • Dorsal penile nerve and ring block
11. List potential complications related to circumcision
    1. Bleeding
    2. Infection
    3. Wound separation
    4. Poor cosmesis
    5. Meatal stenosis
    6. Glans amputation and necrosis
    7. Inclusion cysts
    8. Adhesions and skin bridges
    9. Suture sinus tracts
    10. Ventral curvature
    11. Secondary buried penis and phimosis
    12. Urethrocutaneous fisulae