THE INCREASING INCIDENCE OF NEWBORN CIRCUMCISION: DATA FROM THE NATIONWIDE INPATIENT SAMPLE

Acute glans ischemia after circumcision successfully treated with low-molecular-weight heparin and topical dihydrotestosterone: A case report

RATIONALE

Circumcision like any other surgical procedure is not devoid of complications. Serious complications are rare and include iatrogenic hypospadias, glans ischemia/necrosis, and glans amputation, all of which require an emergent treatment.

PATIENT CONCERNS

We report here a case of 6 months-old-boy with a superficial glans ischemia following circumcision.

DIAGNOSIS

Physical examination revealed a severely cyanotic glans with the moderate edema of the dorsal penile skin. Plasma levels of D-dimer were 8.57 mg/L. Urine passage was unremarkable while color Doppler ultrasonography revealed a normal blood flow.

INTERVENTIONS

The patient was successfully treated with subcutaneous injection of enoxaparin (low-molecular-weight heparin) and topical 2.5% dihydrotestosterone.

OUTCOMES

The appearance of the glans penis on the 5th day was close to normal while the control levels of D-dimer dropped to the reference range. The patient was discharged from the hospital on the 6th day. At 6-month follow-up, the appearance of the glans penis was normal.

LESSONS

Acute glans penis ischemia following circumcision is a rare complication. Its successful treatment with enoxaparin and topical dihydrotestosterone has not been previously reported in the literature.

The Effect of Religious Beliefs on the Publication Productivity of Countries in Circumcision: A Comprehensive Bibliometric View

Circumcision is one of the most common surgical operations in newborns, babies, and children due to cultural, religious, and medical reasons. Religious beliefs are known to have an important role in circumcision. Although bibliometric analyses have been performed about several topics with a lot of publications in literature, no studies in the literature were found to focus on male circumcision. This study aims to make a comprehensive bibliometric analysis of circumcision and investigate the relationship between publication productivity and religious beliefs of the countries. Web of Science was utilized to obtain the documents needed for bibliometric analyses. "Circumcision" keyword was used for search. The search included studies published between 1980 and 2018. The literature review indicated that there were 3694 publications about circumcision published between 1980 and 2018. Of these publications, 1770 (47.9%) were articles. This study provided a bibliometric summary of 1770 articles. The top five active countries about circumcision were the USA, England, South Africa, Turkey, and Kenya. The present study found that the religious beliefs of a country were directly related to publication productivity about circumcision. The top-cited study was the article entitled "Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized controlled trial" written by Bailey et al. and published in the journal of Lancet. The keyword analysis results showed that HIV was the top keyword used in all articles about circumcision. This study is believed to help researchers interested in circumcision topic to access a summary of the literature, see contemporary and more important topics, and discover new ideas about the issue.

Secondary phimosis after circumcision

OBJECTIVE

Male circumcision is one of the most common surgical procedures worldwide. Although it is widely performed because of health issues, in Muslim-majority countries, the primary motivation yielding to male circumcision is religious. It is a relatively safe procedure with a low overall complication rate. We herein report an underrated complication of circumcision that can be termed as "secondary phimosis."

MATERIAL AND METHODS

The medical records of 25 boys with post-circumcision secondary phimosis were reviewed. Demographics of the patients, method of circumcision, type of provider, peroperative findings and comorbidities were recorded.

RESULTS

Between January 2005 and December 2016, 25 boys with post-circumcision secondary phimosis were treated surgically. The median age of the patients was 3 (2-5) years. The majority of the patients were circumcised by the Gomco clamp or Plastibell method (n=16). Of the patients' circumcisions, six were performed by the freehand method, and three by the dorsal slit method. In 15 boys, circumcision was performed by a traditional provider. Of the boys, seven were circumcised by a physician, and three were circumcised by a pediatric surgeon. All the patients were re-circumcised. The common peroperative finding was the redundant mucosal inner layer of the prepucium. Excess suprapubic fat was present in 12 patients.

CONCLUSION

Although circumcision is known as a minor surgical practice with low complication rate, it must be performed safely and especially by experienced physicians/surgeons. Secondary phimosis is a technical error that is caused by insufficient removal of the inner mucosal layer of the prepucium. Re-circumcision of the patient is inevitable, causing the patient second trauma.

Advising on the care of the uncircumcised penis: A survey of pediatric urologists in the United States

BACKGROUND

Parents of uncircumcised boys often report confusion regarding the proper care and hygiene practices for the uncircumcised penis. The lack of guidance from healthcare providers may be due to a lack of consensus on the proper care of the prepuce.

OBJECTIVE

The aim of this study was to determine whether or not there exists consensus among pediatric urologists on the care of the uncircumcised penis and on the advice they provide to parents.

METHODS

An electronic survey was delivered to 514 members of the Society for Pediatric Urology (SPU). The survey contained demographical and clinical questions which were analyzed using descriptive statistics.

RESULTS

Of 261 SPU members who opened the e-mail invitation, a total of 204 responses were received for a response rate of 78% (overall response rate 40%). Nine responses were excluded for members practicing outside of the United States or whose locations were not disclosed for a final number of responses of 195. Overall, pediatric urologists reported a high level of confidence in providing advice to parents with a median confidence score of 10 (scale 1-10, IQR 9-10). Only 66% reported providing advice to parents on when to begin retracting the foreskin, with 48% basing their advice on the patient's age and 19% on the patient's toilet training status (Figure). Respondents who based their advice on age, advised beginning retraction at 2-5 years (61%), 6-11 years (17%), less than 2 years (12%), and greater than 12 years (10%). For frequency of retraction before toilet training, 50% recommended no retraction, 25% with cleaning or baths, 10% with each diaper change, and 13% provided no advice. After toilet training, 48% of respondents recommended retracting the foreskin with cleaning or baths, 41% with each void, and 19% recommended no retraction. The majority of respondents agreed that problems with voiding (77%), infection (74%), and hygiene (64%) were indications for treatment of phimosis. In asymptomatic cases, 47% believed that phimosis required treatment if persisting beyond a specific age, the most common being greater than 12 years of age (40%).

CONCLUSIONS

Although pediatric urologists reported being highly confident in advising parents on the care of the uncircumcised penis, there is not a clear consensus among these subspecialists on when to begin and how often to retract the foreskin, or when phimosis requires treatment. These findings offer insight into current practice patterns to better inform primary care providers and parents.

A Longitudinal Population Analysis of Cumulative Risks of Circumcision

BACKGROUND

Circumcision is widely accepted for newborns in the United States. However, circumcision carries a risk of complications, the rates of which are not well described in the contemporary era.

METHODS

We performed a longitudinal population analysis of the California Office of Statewide Health Planning and Development database between 2005 and 2010. Using International Classification of Procedures, Ninth Revision, Clinical Modification and Current Procedural Terminology codes, we calculated early and late complication rates by Kaplan-Meier survival estimates. Late complications were defined as those that occurred between 30 d and 5 y after circumcision. Descriptive analysis of complications was obtained by analysis of variance, chi-square test, or log-rank test. On adjusted analysis, a Cox proportional hazard model was performed to determine the risk of early and late complications, adjusting for patient demographics.

RESULTS

A total of 24,432 circumcised children under age 5 y were analyzed. Overall, cumulative complication rates over 5 y were 1.5% in neonates, 0.5% of which were early, and 2.9% in non-neonates, 2.2% of which were early. On adjusted analysis, non-neonates had a higher risk of early complications (OR 18.5). In both neonates and non-neonates, the majority of patients with late complications underwent circumcision revision.

CONCLUSIONS

Circumcision has a complication rate higher than previously recognized. Most patients with late complications after circumcision received an operative circumcision revision. Clinicians should weigh the surgical risks against the reported medical benefits of circumcision when counseling parents about circumcision.

Use of a disposable circumcision suture device versus conventional circumcision: a systematic review and meta-analysis

This systematic review assessed the safety and efficacy of the disposable circumcision suture device (DCSD) and conventional circumcision (CC) in the treatment of redundant prepuce and phimosis. Two independent reviewers conducted a literature search for randomized controlled trials (RCTs) using the DCSD and CC for the treatment of redundant prepuce or phimosis in China and abroad. Nine RCTs (1898 cases) were included. Compared with the CC group, the DCSD group had a shorter operative time (standardized mean difference [SMD] = -21.44; 95% confidence intervals [95% CIs] [-25.08, -17.79]; P < 0.00001), shorter wound healing time (SMD = -3.66; 95% CI [-5.46, -1.85]; P < 0.0001), less intraoperative blood loss (SMD = -9.64; 95% CI [-11.37, -7.90]; P < 0.00001), better cosmetic penile appearance (odds ratio [OR] =8.77; 95% CI [5.90, 13.02]; P < 0.00001), lower intraoperative pain score, lower 24-h postoperative pain score, lower incidence of infection, less incision edema, and fewer adverse events. There were no differences between the CC and DCSD groups in the incidences of dehiscence, or hematoma. The results of this meta-analysis indicate that the DCSD appears to be safer and more effective than CC. However, additional high-quality RCTs with larger study populations are needed.

Circumcision-related tragedies seen in children at the Komfo Anokye Teaching Hospital, Kumasi, Ghana

Background

Circumcision is a common minor surgical procedure and it is performed to a varying extent across countries and religions. Despite being a minor surgical procedure, major complications may result from it. In Ghana, although commonly practiced, circumcision-related injuries have not been well documented. This study is to describe the scope of circumcision-related injuries seen at the Komfo Anokye Teaching Hospital in Kumasi, Ghana.

Methods

The study was conducted at the Urology Unit of the Komfo Anokye Teaching Hospital in Kumasi. Consecutive cases of circumcision-related injuries seen at the unit over an 18 month period were identified and included in the study. Data was collected using a structured questionnaire. Data was entered and analysed using SPSS version 16. Charts and tables were generated using Microsoft Excel.

Results

A total of 72 cases of circumcision-related injuries were recorded during the 18 month period. Urethrocutaneous fistula was the commonest injury recorded, accounting for 77.8 % of cases. Other injuries recorded were glans amputations (6.9 %); iatrogenic hypospadias (5.6 %), and epidermal inclusion cysts (2.8 %). The majority of children were circumcised in health facilities (75 %) and nurses were the leading providers (77.8 %). The majority of circumcisions were conducted in the neonatal period (94.7 %).

Conclusion

Circumcision-related injuries commonly occurred in the neonatal period. Most of the injuries happened in health facilities. The most common injury recorded was urethrocutaneous fistula but the most tragic was penile amputation. There is the need for education and training of providers to minimise circumcision-related injuries in Ghana.

Factors Associated with Knowledge of and Willingness for Adult Male Circumcision in Changsha, China

BACKGROUND

Male circumcision (MC) has been shown to reduce the risk of male genital diseases. MC is not commonly practiced among Chinese males and little is known about the factors associated with their knowledge of and willingness for MC. This study was to explore the knowledge regarding the foreskin among Chinese males and to identify factors associated with their willingness to undergo circumcision.

METHODS

A total of 237 patients with redundant prepuce/phimosis were interviewed through face-to-face interviews. The items on the questionnaire included: demographics, an objective scale assessing knowledge about the foreskin, willingness to have MC, the attitudes of sexual partners and doctors toward redundant prepuce/phimosis, and the approaches that patients used to acquire knowledge regarding the prepuce. Univariate analysis and multiple logistic regression analysis were performed to identify factors that are associated with willingness to be circumcised (WTC).

RESULTS

A total of 212 patients completed the interview. Multivariable logistic regression showed that three factors were significantly associated with WTC: being married (OR = 0.43), perceiving redundant prepuce/phimosis as a disease (OR = 1.93), and if a patient's partner supported MC (OR = 1.39). 58% (n = 122) had received information about the foreskin from another party: 18% (n = 37) from school, 8% (n = 17) from family, 17% (n = 36) from friends, 27% (n = 57) from health care providers. About 4% (n = 8) believed that their partners disliked their redundant prepuce/phimosis. 20% (n = 42) had received doctors' advice to undergo circumcision.

CONCLUSION

Knowledge about the foreskin was low among Chinese males. Our study elucidates the factors associated with WTC and suggests that more education of the population about the foreskin can help improve the recognition of a correctible abnormality and help patients assess the potential role of MC in their health.

Impact of Health Insurance Type on Trends in Newborn Circumcision, United States, 2000 to 2010

OBJECTIVES

We explored how changes in insurance coverage contributed to recent nationwide decreases in newborn circumcision.

METHODS

Hospital discharge data from the 2000-2010 Nationwide Inpatient Sample were analyzed to assess trends in circumcision incidence among male newborn birth hospitalizations covered by private insurance or Medicaid. We examined the impact of insurance coverage on circumcision incidence.

RESULTS

Overall, circumcision incidence decreased significantly from 61.3% in 2000 to 56.9% in 2010 in unadjusted analyses (P for trend = .008), but not in analyses adjusted for insurance status (P for trend = .46) and other predictors (P for trend = .55). Significant decreases were observed only in the South, where adjusted analyses revealed decreases in circumcision overall (P for trend = .007) and among hospitalizations with Medicaid (P for trend = .005) but not those with private insurance (P for trend = .13). Newborn male birth hospitalizations covered by Medicaid increased from 36.0% (2000) to 50.1% (2010; P for trend < .001), suggesting 390,000 additional circumcisions might have occurred nationwide had insurance coverage remained constant.

CONCLUSIONS

Shifts in insurance coverage, particularly toward Medicaid, likely contributed to decreases in newborn circumcision nationwide and in the South. Barriers to the availability of circumcision should be revisited, particularly for families who desire but have less financial access to the procedure.

You either have it or you don't: The impact of male circumcision status on sexual partners

This study was an exploration of the impact of men's circumcision status on their sexual partners, focusing on sexual functioning, sexual satisfaction, general preferences for circumcision status, and beliefs about circumcision status. A total of 196 individuals (168 women, 28 men) currently in a sexual relationship with a man were recruited for an online survey. Sexual functioning for female or male participants (assessed by the FSFI or IIEF-MSM, respectively) was not impacted by circumcision status, but women with intact partners reported higher levels of sexual satisfaction, while no differences were observed in the male sample. Women's responses indicated that circumcision status minimally impacted satisfaction with partner's genitals, while men with intact partners indicated significantly higher levels of satisfaction than those with circumcised partners. Overall, women and men rated high levels of satisfaction with their partner's circumcision status and did not wish for it to change. Women indicated a slight preference for circumcised penises for vaginal intercourse and fellatio, and held more positive beliefs about circumcised penises, while men indicated a strong preference toward intact penises for all sexual activities assessed and held more positive beliefs about intact penises. The current study demonstrates distinct gender differences in attitudes toward circumcision status but minimal impact of circumcision status on sexual functioning. Future research should further explore sexual correlates of circumcision status, with a focus on directionality of said correlates and the impact on couples, as well as replicating the findings with a larger sample, specifically with respect to the male sample.

Epinephrine Injection Associated Scrotal Skin Necrosis

Male circumcision is among the most frequent surgical interventions throughout history. Although considered as a minor intervention, it may have complications ranging from insignificant to catastrophic. These complications can be attributed to the surgical procedure and anesthesia. In this report we present two cases of scrotal skin necrosis after lidocaine with epinephrine injection using subcutaneous ring block technique prior to circumcision.

Introducing the Quill™ device for modified sleeve circumcision with subcutaneous suture: a retrospective study of 70 cases

OBJECTIVE

The purpose of the study was to evaluate the safety and feasibility of treatment for male circumcision using modified sleeve circumcision and subcuticular suture with the Quill™ device.

METHODS

From May 2011 to March 2012, 70 consecutive cases of male circumcision were performed using an alternative technique with the Quill™ device by a single surgeon in our institution. The inclusion and exclusion criteria for the selection process of this procedure were the same as for conventional circumcision. We evaluated the indications and perioperative outcomes. The circumcisions were performed as day-case procedures under local anesthesia.

RESULTS

All patients were followed up for a minimum of 3-6 months. The ages ranged from 8 to 68 (mean = 27.0 years, SD = 10). The indications for surgery were either cosmetic (n = 16, 22.9%) or medical [redundant prepuce (n = 36, 51.4%), phimosis (n = 5, 7.1%), paraphimosis (n = 2, 2.9%), balanoposthitis (n = 9, 12.9%), melanoma (n = 1, 1.4%), and condyloma acuminata (n = 1, 1.4%)] (n = 54, 77.1%). The mean operation time in this group was 29 min (19-38 min) when the Quill™ device was used. In all, 3 cases developed complications (4.3%). The final cosmetic result was satisfactory for both the patients and their spouses or parents.

CONCLUSION

This study showed that modified sleeve circumcision and subcuticular suture were safe and reliable surgical methods of circumcision that provide a better cosmetic result.

Infant male circumcision: healthcare provider knowledge and associated factors

BACKGROUND AND OBJECTIVES

The emerging science demonstrates various health benefits associated with infant male circumcision and adult male circumcision; yet rates are declining in the United States. The American Academy of Pediatrics and the Centers for Disease Control and Prevention recommend that healthcare providers present evidence-based risk and benefit information for infant male circumcision to parent(s) and guardian(s). The purpose of this study was to assess providers' level of infant male circumcision knowledge and to identify the associated characteristics.

METHODS

An online survey was administered to healthcare providers in the family medicine, obstetrics, and pediatrics medical specialties at an urban academic health center. To assess infant male circumcision knowledge, a 17 point summary score was constructed to identify level of provider knowledge within the survey.

RESULTS

Ninety-two providers completed the survey. Providers scored high for the following knowledge items: adverse event rates, protects against phimosis and urinary tract infections, and does not prevent hypospadias. Providers scored lower for items related to more recent research: protection against cervical cancer, genital ulcer disease, bacterial vaginosis, and reduction in HIV acquisition. Two models were constructed looking at (1) overall knowledge about male circumcision, and (2) knowledge about male circumcision reduction in HIV acquisition. Pediatricians demonstrated greater overall infant male circumcision knowledge, while obstetricians exhibited significantly greater knowledge for the HIV acquisition item.

CONCLUSION

Providers' knowledge levels regarding the risks and benefits of infant male circumcision are highly variable, indicating the need for system-based educational interventions.

SmartClamp circumcision versus conventional dissection technique in terms of parental anxiety and outcomes: A prospective clinical study

INTRODUCTION

We prospectively analyzed parental anxiety and outcomes of the SmartClamp circumcision and the classic surgical dissection technique.

METHODS

A total of 250 boys underwent circumcision between 2009 and 2012 at Kars State Hospital and Kafkas University Faculty of Medicine in Turkey. The initial 125 children were circumcised by conventional dissection method and the remaining children were operated on with a SmartClamp device. Children in both groups were compared in terms of bleeding, infection, penile edema, operative time, cosmetic result, length of the inner mucosal layer, and parental anxiety. We used a State-Trait Anxiety Inventory (STAI) form to gauge how the circumcision affected parental anxiety. This form was completed by parents on postoperative day 2.

RESULTS

There were no statistically significant differences among the 2 groups in terms of age, bleeding, infection, and cosmetic displeasure (p > 0.05). The STAI scores of the parents from the SmartClamp group were statistically higher than that of the other group (p < 0.001). Penile edema was more common in the SmartClamp group (p = 0.039). However, the mean operative time was statistically shorter (p < 0.001) and the inner mucosal length was significantly longer in the SmartClamp group (p < 0.001).

CONCLUSION

Circumcision with the SmartClamp device was faster. Cosmetic results and complication rates were similar. Unfortunately, this technique seemed to entail the disadvantages of longer mucosal length, penile edema, and higher parental anxiety. Urologists should keep these points in mind when choosing a technique.

Counseling parents who are considering newborn male circumcision

The American Academy of Pediatrics recently issued a statement that the health benefits of newborn male circumcision exceed the risks and therefore justify access to the procedure for families who choose it. Further, clinicians are charged with providing factually correct information that communicates the risks and benefits of elective newborn male circumcision in a nonbiased manner. However, many clinicians lack adequate information to discuss the risks and benefits of male circumcision. The purpose of this review is to highlight evidence on the risks and benefits of newborn male circumcision and provide clinicians with counseling points that can be used to guide discussion with parents considering newborn male circumcision.

The spectrum of genital median raphe anomalies among infants undergoing ritual circumcision

OBJECTIVE

To evaluate the extent of genital median raphe (GMR) anomalies and their relation to other genitourinary anomalies, as well as the impact on performing ritual circumcision.

PATIENTS AND METHODS

This prospective study was designed to collect data from neonates coming for ritual circumcision in order to detect any associated congenital anomalies in their genitalia, particularly in the genital raphe. 2880 babies aged from 1 day to 7 weeks were examined, from 2006 to 2011. All doubtful cases were reevaluated and cases with GMR anomalies were investigated for detection of other congenital anomalies and enrolled in the study.

RESULTS

57 cases of GMR anomalies were detected with an overall incidence of 2%; 18 of them had hypospadias, 5 had renal anomalies and 3 had limb anomalies. Circumcision was postponed in 37 cases where further investigations were done, but routine circumcision was carried out in the remaining 20.

CONCLUSION

It is crucial to examine every baby coming for circumcision to detect obvious or hidden congenital genital anomalies. Congenital anomalies of GMR are not so rare as thought, and some of these anomalies may necessitate surgical correction, and are commonly accompanied by urinary tract anomalies.

Allocation of healthcare dollars: analysis of nonneonatal circumcisions in Florida

Circumcision remains a controversial operation. Most procedures are performed in the neonatal period and avoid general anesthesia. Legislation driven by policy statements from the American Academy of Pediatrics led to significant changes in circumcisions in Florida with a shift to nonneonatal procedures as a result of costs. We sought to study the prevalence and financial implications of nonneonatal circumcisions in Florida. A retrospective population study was performed using the Florida Agency for Health Care Administration outpatient procedure database. We queried for patients 0 to 17 years of age undergoing circumcision between 2003 and 2008. Demographics, charges, and insurance status were analyzed. From 2003 to 2008, 31,741 outpatient circumcisions were performed. Publicly funded circumcisions accounted for 17,537 charging the state $6,263 on average for each circumcision at an expense of $111.8 million for the 5-year time period analyzed. Publicly funded circumcision procedures increased more than sixfold (P < 0.0001) than those covered by private insurance. Black circumcision procedures increased 77.3 per cent, whereas white circumcisions increased 28.7 per cent. There has been a significant increase in the number of nonneonatal circumcisions performed. This has resulted in an increase in economic health care. Public funding of neonatal circumcision could result in significant cost savings and avoid potential complications of general anesthesia.

Routine neonatal circumcision: opportunities for improving residency training

OBJECTIVES

Primary care physicians are the routine providers of neonatal circumcision, yet urologists commonly manage the complications. We previously identified a need for improved formalized training in neonatal circumcisions among ob-gyn residents. Here we extend the needs assessment to urology residents.

METHODS

From Nov 2008 to Nov 2009, ob-gyn and urology residents at our institution were given an online survey to assess comfort, education, and proficiency in pre-operative evaluation and performance of circumcisions.

RESULTS

26/35 (74%) ob-gyn and 12/17 (65%) urology residents responded to the survey. 62% of ob-gyn and 33% of urology residents intended to perform neonatal circumcisions in practice. Both groups described having little formal training in neonatal circumcision. Ob-gyn residents felt more comfortable than urology residents in performing neonatal circumcisions [mean 5.9 vs. 4.3, p = 0.001; 1 (very uncomfortable) - 7 (very comfortable)], though urology residents' comfort level increased with resident year. Ob-gyn residents felt less comfortable than urology residents (mean 3.9 vs. 5.1, p = 0.031) evaluating if a newborn penis may undergo circumcision safely. Urology residents performed better than ob-gyn residents at identifying contraindications to routine circumcision from 10 scenarios (mean 63% vs. 42% p < 0.001). Both felt that an online module was a good alternative to practical experience.

CONCLUSIONS

At our institution, ob-gyn and urology residents have little formalized training in neonatal circumcision. While ob-gyn residents are comfortable performing circumcisions, they feel less comfortable evaluating the newborn penis and correctly managed fewer scenarios than did urology residents. This highlights the need for further curriculum development and formalized training.

Dermatological complications of circumcision: lesson learned from cases in a pediatric dermatology practice

We discuss 11 cases of boys who presented with dermatologic complications of circumcision in an outpatient pediatric dermatology clinic. A medical practitioner had previously circumcised all patients during the newborn period. The majority of cases were found incidentally during initial thorough dermatologic examination. Late cutaneous complications included penile skin bridge, glandular adhesion of remnant foreskin, concealed penis, and a penile epidermal inclusion cyst. Minor surgical procedures under local anesthesia were performed in all but two cases. These cases should help dermatologists recognize the common late cutaneous complications of male newborn circumcision and provide insight into potential options for early intervention and management.

Trends in revision circumcision at pediatric hospitals

BACKGROUND

We sought to determine the incidence of revision circumcision at freestanding children's hospitals, and examine trends over time.

METHODS

We searched the Pediatric Health Information Systems database to identify boys undergoing revision circumcision (RC), primary non-newborn circumcision (PC), or lysis of penile adhesions (LPA) from 2004 to 2009. Rates of RC procedures were calculated by dividing the incidence of procedures by the total male ambulatory surgical volume.

RESULTS

We identified 34,568 patients of whom 5632 underwent RC, 25,768 PC, and 3168 LPA. The rate of RC increased 119%, which was significantly more than PC (19%; P<.001) or LPA (37%; P<.001). Urologists performed 76% of RC and 12% were performed with other genitourinary procedures. Boys undergoing RC were predominately white (60%) and publicly insured (61%).

CONCLUSIONS

There was a disproportionate increased rate of RC performed at Pediatric Health Information Systems hospitals compared with PC or LPA. Wide variation exists in rate increases among hospitals.

Analgesia for infants' circumcision

Male circumcision (MC) is one of the oldest and most common operations performed all over the world. It can be performed at different ages, using different surgical techniques, for different religious, cultural and medical reasons.Our aim is to examine and compare the various methods of analgesia and different surgical procedures reported in literature that are applied in infant MC. We performed a PubMed, MEDLINE, EMBASE and Cochrane search in the papers published since 2000: 14 studies met the inclusion criteria, most of them showing that a combined pharmacological and non-pharmacological intervention is the best analgesic option, in particular when the dorsal penile nerve block is combined with other treatments. The Mogen surgical procedure seems to be the less painful surgical intervention, when compared with Gomco clamp or PlastiBell device. Only 3 papers studied groups of at least 20 babies each with the use of validated pain scales. Data show a dramatic decrease of pain with dorsal penile nerve block, plus acetaminophen associated to oral sucrose or topic analgesic cream. However, no procedure has been found to definetively eliminate pain; the gold standard procedure to make MC totally painfree has not yet been established.

Prenatal and perinatal analgesic exposure and autism: an ecological link

BACKGROUND

Autism and Autism Spectrum Disorder (ASD) are complex neurodevelopmental disorders. Susceptibility is believed to be the interaction of genetic heritability and environmental factors. The synchronous rises in autism/ASD prevalence and paracetamol (acetaminophen) use, as well as biologic plausibility have led to the hypothesis that paracetamol exposure may increase autism/ASD risk.

METHODS

To explore the relationship of antenatal paracetamol exposure to ASD, population weighted average autism prevalence rates and paracetamol usage rates were compared. To explore the relationship of early neonatal paracetamol exposure to autism/ASD, population weighted average male autism prevalence rates for all available countries and U.S. states were compared to male circumcision rates - a procedure for which paracetamol has been widely prescribed since the mid-1990s. Prevalence studies were extracted from the U.S. Centers for Disease Control and Prevention Summary of Autism/ASD Prevalence Studies database. Maternal paracetamol usage and circumcision rates were identified by searches on Pub Med.

RESULTS

Using all available country-level data (n = 8) for the period 1984 to 2005, prenatal use of paracetamol was correlated with autism/ASD prevalence (r = 0.80). For studies including boys born after 1995, there was a strong correlation between country-level (n = 9) autism/ASD prevalence in males and a country's circumcision rate (r = 0.98). A very similar pattern was seen among U.S. states and when comparing the 3 main racial/ethnic groups in the U.S. The country-level correlation between autism/ASD prevalence in males and paracetamol was considerably weaker before 1995 when the drug became widely used during circumcision.

CONCLUSIONS

This ecological analysis identified country-level correlations between indicators of prenatal and perinatal paracetamol exposure and autism/ASD. State level correlation was also identified for the indicator of perinatal paracetamol exposure and autism/ASD. Like all ecological analyses, these data cannot provide strong evidence of causality. However, biologic plausibility is provided by a growing body of experimental and clinical evidence linking paracetamol metabolism to pathways shown to be important in autism and related developmental abnormalities. Taken together, these ecological findings and mechanistic evidence suggest the need for formal study of the role of paracetamol in autism.

Circumcision in the United States: where are we?

Circumcision is one of the most common surgical procedures performed on males in the United States. Ethical considerations of the procedure have been considered for many years and, recently, research on the topic has shed more light on the debate. The purpose of this study was to review the history and emergence, current demographics, and practices of male circumcision, specifically, nonreligious, nonmedically indicated routine neonatal circumcision. A review of the current literature was conducted using PubMed and current practices from guidelines of major professional societies. Physicians should consider the various ethical concerns and provide the patient's guardians with unbiased counsel. There is a lack of evidence both in favor of and against recommending routine neonatal circumcisions in the United States. The question remains whether we should continue unwarranted male circumcisions, especially when the major tenet of medical ethics is "do no harm."

Circumcision in males with bleeding disorders

Introduction

Male circumcision practice is an invasive procedure that is using worldwide. It makes challenges to haemostatic system and its possible haemorrhagic side effects are more serious in bleeding individuals than normal subjects. In most cases, it can be complete controlled using infusion of appropriate amount of coagulation factors before and post circumcision.

Aim

We aim to documentation type of coagulation therapy and post circumcision practice haemorrhagic presentation among 463 bleeder males of both common and rare bleeding disorders in north eastern part of country.

Methods

We retrospectively gathered information using evaluation medical records in 3 major hospitals during last 15 years and list of patients with bleeding disorders that obtained from haemophilia center. Also a call phone established for each bleeder person to complete data and updating of them. The survey took time from Sep 2009 – Mar 2011. The designed question form included data on doing circumcision or not, types of treatment before and post the procedure and occurrence of bleeding episodes after the surgery.

Results

Overall among 424 cases with various common and rare bleeding disorders who had circumcised, 239 cases (56.3%) had passed the procedure with bleeding experience (indication of undiagnosed cases who underwent circumcision or inadequacy of coagulation therapy), while 185 cases (43.7%) had passed it successfully and without noticeable bleeding experience. The types of coagulation therapy in each group have been cited.

Conclusion

The circumcision practice in unequipped medical center for bleeder ones may make challenges for them and medical services. Also it needed supervision of expert haematologist for

Male circumcision

Male circumcision consists of the surgical removal of some, or all, of the foreskin (or prepuce) from the penis. It is one of the most common procedures in the world. In the United States, the procedure is commonly performed during the newborn period. In 2007, the American Academy of Pediatrics (AAP) convened a multidisciplinary workgroup of AAP members and other stakeholders to evaluate the evidence regarding male circumcision and update the AAP's 1999 recommendations in this area. The Task Force included AAP representatives from specialty areas as well as members of the AAP Board of Directors and liaisons representing the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention. The Task Force members identified selected topics relevant to male circumcision and conducted a critical review of peer-reviewed literature by using the American Heart Association's template for evidence evaluation. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it. Specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction. It is imperative that those providing circumcision are adequately trained and that both sterile techniques and effective pain management are used. Significant acute complications are rare. In general, untrained providers who perform circumcisions have more complications than well-trained providers who perform the procedure, regardless of whether the former are physicians, nurses, or traditional religious providers. Parents are entitled to factually correct, nonbiased information about circumcision and should receive this information from clinicians before conception or early in pregnancy, which is when parents typically make circumcision decisions. Parents should determine what is in the best interest of their child. Physicians who counsel families about this decision should provide assistance by explaining the potential benefits and risks and ensuring that parents understand that circumcision is an elective procedure. The Task Force strongly recommends the creation, revision, and enhancement of educational materials to assist parents of male infants with the care of circumcised and uncircumcised penises. The Task Force also strongly recommends the development of educational materials for providers to enhance practitioners' competency in discussing circumcision's benefits and risks with parents. The Task Force made the following recommendations:Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it. Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child. Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks and by ensuring that they understand the elective nature of the procedure. Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families. Parents of newborn boys should be instructed in the care of the penis, regardless of whether the newborn has been circumcised or not. Elective circumcision should be performed only if the infant's condition is stable and healthy. Male circumcision should be performed by trained and competent practitioners, by using sterile techniques and effective pain management. Analgesia is safe and effective in reducing the procedural pain associated with newborn circumcision; thus, adequate analgesia should be provided whenever newborn circumcision is performed.Nonpharmacologic techniques (eg, positioning, sucrose pacifiers) alone are insufficient to prevent procedural and postprocedural pain and are not recommended as the sole method of analgesia. They should be used only as analgesic adjuncts to improve infant comfort during circumcision. If used, topical creams may cause a higher incidence of skin irritation in low birth weight infants, compared with infants of normal weight; penile nerve block techniques should therefore be chosen for this group of newborns. Key professional organizations (AAP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Society of Anesthesiologists, the American College of Nurse Midwives, and other midlevel clinicians such as nurse practitioners) should work collaboratively to:Develop standards of trainee proficiency in the performance of anesthetic and procedure techniques, including suturing; Teach the procedure and analgesic techniques during postgraduate training programs; Develop educational materials for clinicians to enhance their own competency in discussing the benefits and risks of circumcision with parents; Offer educational materials to assist parents of male infants with the care of both circumcised and uncircumcised penises. The preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure. The American College of Obstetricians and Gynecologists has endorsed this technical report.

Complications of circumcision

In the United States, circumcision is a commonly performed procedure. It is a relatively safe procedure with a low overall complication rate. Most complications are minor and can be managed easily. Though uncommon, complications of circumcision do represent a significant percentage of cases seen by pediatric urologists. Often they require surgical correction that results in a significant cost to the health care system. Severe complications are quite rare, but death has been reported as a result in some cases. A thorough and complete preoperative evaluation, focusing on bleeding history and birth history, is imperative. Proper selection of patients based on age and anatomic considerations as well as proper sterile surgical technique are critical to prevent future circumcision-related adverse events.

Trends in hospitalization for pediatric pyelonephritis: a population based study of California from 1985 to 2006

PURPOSE

We examined trends in pediatric hospitalization for pyelonephritis from 1985 to 2006 and identified factors associated with admission.

MATERIALS AND METHODS

We performed a population based analysis of hospital discharges using the Office of Statewide Health Planning and Development database to evaluate trends in California regarding pediatric hospitalizations for pyelonephritis from 1985 to 2006. Multivariable logistic regression was performed to identify factors associated with admission for pyelonephritis.

RESULTS

A total of 46,300 children were hospitalized for pyelonephritis in California from 1985 to 2006. The overall rate of hospitalization for pyelonephritis increased by greater than 80%, from 17 per 100,000 children in the California population in 1985 to 31 per 100,000 in 2005. This change was primarily due to the nearly ninefold increase in pyelonephritis hospitalizations observed in children younger than 1 year, from 28 per 100,000 in 1985 to 238 per 100,000 in 2005. Among children younger than 1 year males without private insurance and of nonwhite race had increased odds of hospitalization, while females with private insurance and of Asian race had increased odds of hospitalization, compared with nonprivate insurance and white race, respectively.

CONCLUSIONS

A significant increase in hospital admissions for pyelonephritis, primarily in children younger than 1 year, occurred in California between 1985 and 2006. Further studies are needed to establish the cause of this striking increase and to determine why certain pediatric populations are at increased risk for hospitalization.

Updated parental viewpoints on male neonatal circumcision in the United States

Through a questionnaire, the authors sought to elicit information about initial attitudes concerning circumcision after reading a summary of the American Academy of Pediatrics (AAP) Policy Statement and, again, after reading a description of recent HIV/HPV studies. Predictors of increased support for circumcision included having a prior circumcised boy and being US born. Predictors of decreased support included being of Hispanic ethnicity and believing that the uncircumcised penis was more culturally normal. After reading the AAP statement, 86% of respondents remained favorable of elective circumcision, whereas 13% viewed it less favorably. After reading the passage about the HIV/HPV studies, the majority maintained their initial level of support. Certain characteristics were associated with an individual's desire to perform circumcision on his/her infant. Despite a slight decrease in support to perform circumcision after reading the AAP policy summary, respondents' initial attitudes toward circumcision were unchanged after subsequent review of recent HIV/HPV research.

Male circumcision for the prevention of acquisition and transmission of sexually transmitted infections: the case for neonatal circumcision

The American Academy of Pediatrics (AAP) male circumcision policy states that while there are potential medical benefits of newborn male circumcision, the data are insufficient to recommend routine neonatal circumcision. Since 2005, however, 3 randomized trials have evaluated male circumcision for prevention of sexually transmitted infections. The trials found that circumcision decreases human immunodeficiency virus acquisition by 53% to 60%, herpes simplex virus type 2 acquisition by 28% to 34%, and human papillomavirus prevalence by 32% to 35% in men. Among female partners of circumcised men, bacterial vaginosis was reduced by 40%, and Trichomonas vaginalis infection was reduced by 48%. Genital ulcer disease was also reduced among males and their female partners. These findings are also supported by observational studies conducted in the United States. The AAP policy has a major impact on neonatal circumcision in the United States. This review evaluates the recent data that support revision of the AAP policy to fully reflect the evidence of long-term health benefits of male circumcision.

Male circumcision in the United States for the prevention of HIV infection and other adverse health outcomes: report from a CDC consultation

In April 2007, the Centers for Disease Control and Prevention (CDC) held a two-day consultation with a broad spectrum of stakeholders to obtain input on the potential role of male circumcision (MC) in preventing transmission of human immunodeficiency virus (HIV) in the U.S. Working groups summarized data and discussed issues about the use of MC for prevention of HIV and other sexually transmitted infections among men who have sex with women, men who have sex with men (MSM), and newborn males. Consultants suggested that (1) sufficient evidence exists to propose that heterosexually active males be informed about the significant but partial efficacy of MC in reducing risk for HIV acquisition and be provided with affordable access to voluntary, high-quality surgical and risk-reduction counseling services; (2) information about the potential health benefits and risks of MC should be presented to parents considering infant circumcision, and financial barriers to accessing MC should be removed; and (3) insufficient data exist about the impact (if any) of MC on HIV acquisition by MSM, and additional research is warranted. If MC is recommended as a public health method, information will be required on its acceptability and uptake. Especially critical will be efforts to understand how to develop effective, culturally appropriate public health messages to mitigate increases in sexual risk behavior among men, both those already circumcised and those who may elect MC to reduce their risk of acquiring HIV.

Psychosocial factors influence parental decision for circumcision in pediatric males of African American descent

BACKGROUND

The most recent policy statement by the American Academy of Pediatrics suggests there are insufficient data to recommend routine newborn circumcision. Nevertheless, circumcision rates have not declined in the United States. Some studies suggest that African Americans are less likely to be circumcised. In blacks that choose to circumcise their males, we sought to examine the factors that drive parents to favor circumcision.

METHODS

The Parental Attitudes on Circumcision questionnaire was utilized to obtain demographic information and attitudinal responses to circumcision during urology clinic sessions at Howard University Hospital, a major teaching hospital located in an urban setting. Parents and caregivers of male children aged 3 months to 7 years participated. Valid responses from 146 participants were collected.

RESULTS

Ninety-six percent of our respondents believe that circumcision is healthy. Forty-one percent indicated health reasons as the most important influencing factor for choosing to circumcise their child, while 25% selected maternal preference. Eighty-one percent of all respondents indicated that 1 or more health care providers asked about their decision to circumcise their child. The mother was 12 times more likely than the father to make the final decision for circumcision, especially when her personal preference played a role. Eighty-eight percent of respondents felt that circumcision is painful, but 87% considered the procedure safe, and another 72% believe that it is a necessary procedure.

CONCLUSION

African American parents strongly believe that circumcision is essential for a healthy state and are willing to opt for the procedure despite the belief that it may be painful for the child. The mother primarily made the final decision to circumcise her child, largely based on the perceived health and hygiene benefits. In blacks, the mother yields considerable influence in the decision to circumcise the child, with maternal preference as the main reason for seeking circumcision in as much as a quarter of cases.

Considerations in the role of male circumcision in the prevention of HIV transmission in the USA

Male circumcision (MC) has been associated with a reduced risk for female–male HIV transmission in observational and ecological studies, as well as clinical trials. Three recent randomized, controlled trials in sub-Saharan Africa demonstrated a 50–60% reduction in HIV incidence among men randomized to circumcision compared with uncircumcised men. In 2007, WHO/UNAIDS recommended that MC be recognized as an additional efficacious intervention to prevent sexual transmission of HIV from women to men. This article reviews information on the potential role of MC for HIV prevention in the USA where, compared with the African clinical trial countries, the prevalence of HIV infection is lower, the main route of HIV transmission is male–male sex rather than heterosexual sex and the prevalence of MC is higher.

Neonatal circumcision in Maryland: a comparison of hospital discharge and maternal postpartum survey data

OBJECTIVE

To study circumcision rates in Maryland using hospital discharge and maternal survey data in order to provide healthcare providers, parents and policy makers with more accurate and comprehensive information about this common yet controversial procedure.

METHODS

Secondary data analyses were performed using Maryland hospital discharge data files containing records of 96,457 male newborns, and postpartum survey data collected from 4273 mothers through the Maryland Pregnancy Risk Assessment Monitoring System.

RESULTS

Hospital discharge data showed that 75.3% of male infants were circumcised, and survey data showed that 82.3% of male infants were circumcised. The circumcision rate among infants weighing <1500 g at birth was 38.9% using hospital discharge data and 74.5% using maternal survey data. Both sources revealed lower circumcision rates among Asian and Hispanic infants than among non-Hispanic white and non-Hispanic black infants.

CONCLUSIONS

Despite reports of decreasing circumcision rates nationally, rates remain high in Maryland. In addition to providing for the inclusion of circumcision procedures that may not have been coded properly in hospital discharge records and procedures that were performed after hospital discharge, maternal survey data provide more comprehensive information than hospital discharge data about parental characteristics and factors relevant to the circumcision decision-making process.

Determinants and policy implications of male circumcision in the United States

OBJECTIVE

We sought to determine whether lack of state Medicaid coverage for infant male circumcision correlates with lower circumcision rates.

METHODS

We used data from the Nationwide Inpatient Sample on 417 282 male newborns to calculate hospital-level circumcision rates. We used weighted multiple regression to correlate hospital circumcision rates with hospital-level predictors and state Medicaid coverage of circumcision.

RESULTS

The mean neonatal male circumcision rate was 55.9%. When we controlled for other factors, hospitals in states in which Medicaid covers routine male circumcision had circumcision rates that were 24 percentage points higher than did hospitals in states without such coverage (P<.001). Hospitals serving greater proportions of Hispanic patients had lower circumcision rates; this was not true of hospitals serving more African Americans. Medicaid coverage had a smaller effect on circumcision rates when a hospital had a greater percentage of Hispanic births.

CONCLUSIONS

Lack of Medicaid coverage for neonatal male circumcision correlated with lower rates of circumcision. Because uncircumcised males face greater risk of HIV and other sexually transmitted infections, lack of Medicaid coverage for circumcision may translate into future health disparities for children born to poor families covered by Medicaid.

Why circumcision is a biomedical imperative for the 21(st) century

Circumcision of males represents a surgical "vaccine" against a wide variety of infections, adverse medical conditions and potentially fatal diseases over their lifetime, and also protects their sexual partners. In experienced hands, this common, inexpensive procedure is very safe, can be pain-free and can be performed at any age. The benefits vastly outweigh risks. The enormous public health benefits include protection from urinary tract infections, sexually transmitted HIV, HPV, syphilis and chancroid, penile and prostate cancer, phimosis, thrush, and inflammatory dermatoses. In women circumcision of the male partner provides substantial protection from cervical cancer and chlamydia. Circumcision has socio-sexual benefits and reduces sexual problems with age. It has no adverse effect on penile sensitivity, function, or sensation during sexual arousal. Most women prefer the circumcised penis for appearance, hygiene and sex. Given the convincing epidemiological evidence and biological support, routine circumcision should be highly recommended by all health professionals.

RACP's policy statement on infant male circumcision is ill-conceived

OBJECTIVE

To conduct a critical peer-review of the 2004 Policy Statement on routine male circumcision produced by the Royal Australasian College of Physicians (RACP).

METHOD

Comprehensive evaluation in the context of the research field.

RESULTS

We find that the current Statement downplays the wide-ranging life-long benefits of circumcision in prevention of urinary tract infections (UTIs), penile and cervical cancer, genital herpes and chlamydia in women, HIV infection, phimosis, and various penile dermatoses, and at the same time overstates the complication rate. We highlight the many errors in the RACP Statement and note that it sidesteps making a conclusion based on circumcision's well-documented prophylactic health benefits by instead referring to the status of the foreskin at birth. In the era of preventative medicine we view this as irresponsible.

CONCLUSION

The RACP's Statement on routine male circumcision is not evidence-based and should be retracted.

IMPLICATIONS

In the interests of public health and individual well-being an extensive, comprehensive, evidence-based revision should be conducted so as to provide scientifically accurate, balanced information on the advantages, and also the low rate of mostly minor complications, associated with this simple procedure, which for maximum benefits and minimal risk should ideally be performed in the neonatal period.

Male versus female genital alteration: differences in legal, medical, and socioethical responses

The different legal, social, and medical approaches to ritually based male and female genital circumcision in the United States are highlighted in this article. The religious and historical origins of these practices are briefly examined, as well as the effect of changing policy statements by American medical associations on the number of circumcisions performed. Currently, no state or federal laws single out male circumcision for regulation. The tolerant attitudes toward male circumcision in law, medicine, and societal opinion stand in striking contrast to the attitudes of those disciplines toward even the least invasive form of female genital alteration. US law tacitly condones male circumcision by providing exemptions that are not available for other medical procedures, while criminalizing any similar or even less extensive procedure on females. The increase in immigration, over the past few decades, of people from countries in which female genital alteration is a cultural tradition has brought the issue to the United States. The medical profession's changing approach over time toward male circumcision is primarily responsible for such different legal and societal reactions toward female genital alteration.