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From Medscape Education Clinical Briefs

AAP Issues Recommendations on Male Newborn Circumcision CME/CE

News Author: Yael Waknine

  CME Author: Charles P. Vega, MD, FAAFP Faculty and Disclosures

CME/CE Released: 09/05/2012; Valid for credit through 09/05/2013

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Clinical Context

Circumcision is one of the oldest procedures in medicine, and data from 

the US Centers for Disease Control and Prevention (CDC) suggest that more  

than half of male newborn infants in the United States receive  

circumcision in the hospital. The most common reason that parents cite for  

choosing circumcision is health and medical benefits, followed by social  

concerns. Religious concerns are less important in the overall practice of  

circumcision in the United States.

The current policy statement from the American Academy of Pediatrics (AAP) 

updates the group's previous recommendations from 1999. The principal  

recommendations along with their rationale are presented in the Study  

Highlights section.

Study Synopsis and Perspective

New scientific evidence shows that benefits of male circumcision (MC)  

outweigh its small risks and justify access to the procedure for families  

who choose it, according to an updated policy statement published online  

August 27 in Pediatrics by the AAP.

Benefits cited in the accompanying technical report compiled by the AAP  

Task Force include the prevention of urinary tract infections and  

decreased transmission of some sexually transmitted infections such as 

HIV/AIDS, herpes, and human papillomavirus (HPV), which has been linked to  

the development of cancer in men and their female partners.

The report also states that the procedure is "well tolerated when  

performed by trained professionals under sterile conditions with  

appropriate pain management," and that complications such as bleeding and  

infection are rare.

Although the procedure remains elective, prospective parents should be  

routinely educated regarding the procedure to make an informed decision.

"Ultimately, this is a decision that parents will have to make," said  

Susan Blank, MD, FAAP, in an AAP news release. "Parents are entitled to  

medically accurate and non-biased information about circumcision, and they  

should weigh this medical information in the context of their own  

religious, ethical and cultural beliefs."

"It's a good idea to have this conversation during pregnancy, and to learn  

whether your insurance will cover the procedure, so you have time to make  

the decision," Dr. Blank added, noting that MC should be performed during  

the newborn period to maximize both safety and health benefits.

Dr. Blank is chair of the task force that authored the AAP policy  

statement and technical report.

The AAP also supports third-party coverage of MC, the cost of which would  

be offset by significant long-term health savings.

Cuts in Coverage Could Cost $1 Billion

As previously reportedby Medscape Medical News, cuts in state coverage  

during the last 20 years have had a major effect on MC rates, which have  

decreased from 79% to 54.7%.

Mathematical modeling suggests that continued decreases leading to the  

European MC rate (10%) could inflate healthcare costs by nearly $916  

million for every birth cohort because of potentially preventable cases of  

HIV/AIDS, sexually transmitted infections, and cancer.

The updated policy confirms the "potential benefits" cited in the 1999 and  

2005 AAP statements and has been endorsed by the American College of  

Obstetricians and Gynecologists.

"This information will be helpful for obstetricians who are often the  

medical providers who counsel parents about circumcision," Sabrina Craigo,  

MD, the college's liaison to the AAP task force on circumcision, said in  

the news release. "We support the idea that parents choosing circumcision  

should have access to the procedure."

The majority of male urinary tract infections occur during the first year  

of life and may involve the possibility of an invasive procedure and  

hospitalization.

Literature analysis suggests that MC significantly decreases the incidence  

rate of urinary tract infections to 0.1% or 0.2% during this period  

compared with 0.7% to 1.4% for uncircumcised infants.

Plausible explanations for the effect include the decreased presence of  

uropathogenic bacteria around the urethral meatus of circumcised infants  

and a decreased bacterial adherence to the keratinized surface of the  

circumcised foreskin.

A review of the literature revealed a consistently reported protective  

effect of 40% to 60% for MC in reducing the risk for HIV acquisition among  

heterosexual men in areas with high disease prevalence, such as Africa.

CDC modeling based on these data suggests that circumcising all currently 

uncircumcised heterosexual US males would yield a 15.7% reduction in  

lifetime HIV risk for all men, given that heterosexual men account for 27%  

of new infections and 61% occur in men who have sex with men, for whom MC  

has not shown a protective effect.

According to the authors, the uncircumcised foreskin contains a high 

density of HIV target cells, has an easily abraded inner surface that can  

serve as a port of entry for pathogens, and "traps" pathogens in an  

incubation-friendly environment.

Two randomized African trials have yielded good evidence that MC confers a  

32% to 35% decrease in risk for oncogenic and nononcogenic HPV in men; 1  

study showed a 28% decrease in risk for male-to-female transmission of  

high-risk HPV from HIV-negative men.

Although penile cancer is rare and incidence rates seem to be declining in 

countries with both low and high MC rates (Denmark and the United States,  

respectively), fair evidence from 2 case-control studies has shown that  

the absence of circumcision confers a risk for invasive squamous cell  

carcinoma (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.3 – 4.1),  

but not carcinoma in situ (OR, 1.1).

According to the authors, the effect is likely derived from a reduced risk  

for phimosis (which raises the risk for invasive penile cancer by a factor  

of 11.4) and decreased prevalence of oncogenic HPV in circumcised men.

Persistent infection with oncogenic types of HPV is the main prerequisite  

to developing cervical squamous cell carcinoma, a leading cause of death  

for women in developing countries. One study showed a significantly  

decreased incidence of HPV in circumcised men with multiple female  

partners (5.5% vs 19.6% for uncircumcised men; OR, 0.37; 95% CI, 0.16 –  

0.85), which correlated to a significant decrease in the women's risk for  

cervical cancer (OR, .42).

Genital ulcers are notable for their association with morbidity and  

mortality and because their presence increases the risk for HIV  

transmission.

Genital herpes is a sexually transmitted infection that has been diagnosed  

at some point in 18.9% of Americans aged 20 to 49 years. Good evidence  

 from 2 randomized controlled African studies shows that MC decreases the  

risk for herpes simplex type 2 viral infection by from 28% to 34%; fair  

evidence suggests that MC protects female partners from infection as well.

According to a report by the CDC, the total number of syphilis cases in  

the United States has increased 2.2% (from 44,830 to 45,834 cases) during  

2009 to 2010, with 67% of primary and secondary cases in 2010 being  

reported in men who have sex with men. The balance of evidence suggests  

that MC decreases syphilis risk. A meta-analysis reported a relative risk  

of 0.67 (95% CI, 0.54 – 0.83), but considerable heterogeneity was observed  

among the studies included.

Bacterial vaginosis is common among pregnant women, affecting more than 1  

million annually. Several studies also provide good evidence that MC is  

protective against bacterial vaginosis in female partners.

Pediatrics. Published online August 27, 2012. Policy statement full text,  

Technical report full text

Study Highlights

Parents should receive factual and unbiased information on circumcision  

before conception and early in pregnancy. Currently, most parents decide  

whether to circumcise during this time and before discussing the subject  

with a clinician. Parents should understand that circumcision is an  

elective procedure.

The health benefits of newborn MC outweigh the potential risks, and these 

benefits justify access to circumcision for families who choose it.

Specifically, circumcision is associated with a lower prevalence of HPV  

infection and reduced transmission of herpes simplex virus type 2. It is  

also associated with a lower risk for bacterial vaginosis among female  

partners.

Circumcision does not appear protective against gonorrhea or chlamydia.

14 studies provide fair evidence that circumcision is protective against  

heterosexually acquired HIV infection among men. In fact, it is a  

cost-effective means to reduce the prevalence of HIV infection.

Circumcision is less likely to be protective against HIV infection among 

men who have sex with men.

Circumcision is associated with a lower risk for urinary tract infection  

among children younger than 2 years.

Circumcision also reduces the risk for penile cancer, although the number  

of circumcisions required to prevent 1 additional case of this rare cancer  

is very high.

2 controlled trials of adult circumcision found improved sexual  

satisfaction and sensitivity after circumcision. Good evidence exists that  

sexual function is not impaired among circumcised vs uncircumcised men.

Provider experience and skill in circumcision outweigh the training  

background of the provider.

Analgesia should be provided during circumcision, and nonpharmacologic  

techniques such as positioning or sucrose pacifiers are insufficient as  

the only means to reduce procedural pain. Nerve blocks are more effective  

than topical lidocaine-prilocaine in reducing pain during and after  

circumcision.

Significant acute complications of newborn MC occur in approximately 1 in  

500 cases. The specific technique of circumcision used does little to  

influence the risk for adverse events.

In a study by the CDC, the average cost of circumcision ranged between  

$216 and $601. Circumcision rates are higher in states where Medicaid  

covers the procedure. The health benefits of circumcision warrant  

third-party reimbursement of the surgery.

Professional organizations should collaborate to promote better standards  

for training in circumcision and offering new training opportunities.

Clinical Implications

Circumcision is associated with a lower prevalence of HPV infection and  

reduced transmission of herpes simplex virus type 2. Circumcision does not  

appear protective against gonorrhea or chlamydia. Circumcision prevents  

HIV infection among heterosexual men but not among men who have sex with 

men.

The current recommendations from the AAP state that the health benefits of  

newborn MC outweigh the potential risks, and these benefits justify access 

to circumcision for families who choose it.