American Academy of Pediatrics Task Force on Circumcision. Male circumcision

When Black and White Turns Gray: Navigating the Ethical Challenges of Implementing Shared Infant Feeding Decisions for Persons Living with Human Immunodeficiency Virus in the United States

In 2023, US guidelines for feeding perinatally human immunodeficiency virus (HIV)-exposed infants were revised to encourage collaborative decision-making in lieu of categorical proscription of breastfeeding. This change advances autonomy and health equity for persons living with HIV in the United States, for the first time supporting those who prioritize the maternal and infant benefits of breastfeeding in the setting of effective, well-established HIV risk mitigation. The authors review key moral dilemmas facing clinicians and patients who must navigate the reversal of longstanding dogma against breastfeeding and provide recommendations for implementation of a new ethical paradigm.

Surgical repair of extensive penile shaft skin injuries following neonatal circumcision

Circumcision is a common procedure performed since ancient times with an excellent safety profile and potential health benefits. In the United States, it is commonly performed in the neonatal period using devices such as the Gomco, Mogen, or Plastibell device. In the rare circumstance of a complication, it is often related to bleeding and usually managed conservatively. However, complications requiring surgical intervention can occur and remind practitioners of the importance of proper equipment and technique. Herein, we report a case in which extensive injuries to the penile skin after neonatal circumcision using a Gomco clamp required emergent intervention.

Parental regret following decision for sons to undergo elective post-neonatal circumcision

INTRODUCTION

The reasons for performing a circumcision among males after the neonatal period are usually cultural or medical. We aimed to evaluate parental regret for providing consent and to identify factors associated with such regret.

METHODS

Included were the parents of males aged 6 months to 18 years who underwent circumcision under general anesthesia at a single center between 2/2017 and 01/2023. Those who underwent additional surgical procedures during the same session were excluded. Parents responded telephonically to the Decision Regret Scale (DRS) questionnaire. Regret was classified as none (0 points), mild (1-25) or moderate-to-strong (26-100). Surgical and demographic data were retrieved for comparison to DRS scores and identification of predictors of parental regret.

RESULTS

In total, 201 of the 265 suitable patients met the inclusion criteria. Parents of 130 patients (65% response rate) whose average age was 5.06 (IQR 1.58,7.53) years completed the DRS questionnaire (study group). The average time since surgery was 41.8 (IQR 25.4,59.3) months. Forty surgeries were undertaken for cultural reasons and 90 for medical considerations. Eighteen parents reported regret (15 mild and 3 moderate-to-strong) for their decision to consent to their son's circumcision. The time from responding since surgery was the only significant variable in the DRS scores, with a 33-month gap predicting no regret (p = 0.02 compared to shorter gaps). The reasons for circumcision did not significantly differ between the "regret" and "no-regret" groups (p = 0.23).

DISCUSSION

Our current investigation revealed a lower incidence of parental regret when compared to previous reports following distal hypospadias repair, likely attributable to the lower complication rate associated with circumcision. Our data reflect the experience of a single center in a country where neonatal male circumcision is routinely performed for cultural and religious reasons, thus precluding the generalization of our findings to places where post-natal circumcision is less commonplace.

CONCLUSION

Consent to their son's post-neonatal circumcision was regretted by 13.8% of parents. Time since surgery significantly influenced the reduction of their negative attitudes.

Evaluating Safety of Ring Versus Clamp Devices in Neonatal Circumcision: A Meta-Analysis

BACKGROUND

While device-based circumcision is considered non-inferior to traditional dissection, there is no consensus on the efficacy and safety of ring devices in comparison with clamp devices. We aimed to compare the safety outcomes of ring-based versus clamp-based circumcision techniques in neonates.

METHODS

MEDLINE, EMBASE, Scopus, and CINAHL were searched following the Cochrane collaboration (PRISMA guidelines), without language restrictions, to identify relevant randomized controlled trials. Adverse events, bleeding events, infection events, and procedure time were extracted and analyzed from the selected studies.

RESULTS

From 1661 citations, seven trials were included, encompassing 3390 patients. These studies compared ring-based to clamp-based circumcision devices in neonates. No significant difference was found in overall adverse events between the two groups. However, ring devices showed significantly fewer bleeding events compared to clamp devices. Infection events and procedure time were similar for both groups.

CONCLUSIONS

Both ring and clamp devices have similar safety profiles, with ring devices potentially offering a reduced risk of bleeding. A comprehensive understanding of ring-specific complications and cosmetic outcomes is necessary for a more complete evaluation of these circumcision techniques. Our analysis is limited from a lack of detailed examination of ring-specific complications and their impact on cosmetic results. The included studies varied in quality, and some exhibited a risk of bias.

LEVEL OF EVIDENCE

Level IV Treatment Study.

Alisklamp versus Conventional Dorsal Slit Circumcision: A Multicentric Randomized Controlled Trial

Background: There are numerous methods of circumcision performed worldwide, typically classified into two main groups: conventional surgical techniques and various device-assisted techniques. Each method has its own advantages, limitations, and potential complications. The aim of this study was to compare outcomes of the Alisklamp technique versus the dorsal slit technique in male circumcision procedures. Method: This multicenter RCT compared the dorsal slit and Alisklamp techniques for circumcision, assessing patient demographics and intraoperative and postoperative outcomes. All patients, under local anesthesia via dorsal penile nerve block, were discharged on the same day and followed up at 24-48 h, 1 week, and 1 month. Results: A total of 180 patients enrolled, and 166 patients were included. The study compared postoperative outcomes between the Alisklamp (AK) and dorsal slit (DS) circumcision techniques in 166 patients. Key findings included significantly higher penile edema in the DS group (19%) compared to the AK group (2.4%) (p < 0.001), with severe edema occurring only in the DS group. Wound gaping was more common in the AK group (8.3%) compared to the DS group (1.2%) (p = 0.030). Skin tunnels were observed only in the DS group (9.5%) (p = 0.004). There were no significant differences in nausea, vomiting, bleeding, necrosis, infection, wound dehiscence, chordee, rotational anomalies, or secondary phimosis between the groups. Mean operation time was lower in the AK group than the DS group (7.8 min vs. 15.5 min; p < 0.001). Conclusions: The Alisklamp technique is recommended as the preferred method for circumcision because it minimizes complications, shortens the procedure time, and is easy to apply.

Foreskin neurovascular structure: A histological analysis comparing 0-3 years and 6-11 years children

BACKGROUND

Circumcision is a surgical operation that is frequently performed throughout the world due to religious, cultural, and medical reasons. The best age for circumcision is still debatable, with different procedures depending on geography, culture, and surgeon preference.

OBJECTIVE

This study aims to immunohistochemical examination using S100 staining and histologically evaluate the neurovascular structures in foreskin samples obtained from children aged 0-3 years and 6-11 years. The goal is to provide guidance in determining an appropriate age for circumcision based on these data.

STUDY DESIGN

Concerns regarding potential effects on glans sensitivity and sexual function led to the investigation and comparison of sensory innervation in the foreskin of children aged 0-3 and 6-11 years, a total 54 samples, divided into pre-phallic (0-3 years) and post-phallic (6-11 years) groups, were examined. The mean number of Meissner and Pacinian corpuscles, Ruffini endings, free nerve endings and the diameters of arteries were investigated.

RESULTS

Our findings show that compared to the 6-11 age group, the 0-3 age group had considerably lower sensory innervation in terms of, Meissner's corpuscles, Pacinian corpuscles, Ruffini endings and free nerve endings. Additionally, the diameter of arteries was noticeably smaller in the 0-3 age group.

CONCLUSIONS

In conclusion, this study supports the idea that circumcision performed in the early years of life may be associated with less adverse effects on neurovascular structures.

Optimizing treatment strategies for pediatric phimosis and redundant prepuce: a comparative study of traditional circumcision and disposable circumcision stapler

Objective

To investigate the surgical outcomes and complication rates of traditional circumcision and disposable circumcision stapler in the treatment of pediatric patients with phimosis and redundant prepuce.

Methods

A retrospective analysis was conducted on pediatric patients with phimosis or preputial redundancy treated at our pediatric surgery department from January 2022 to December 2023. The patients were divided into two groups: treated with traditional circumcision (control group) and treated with a disposable circumcision stapler (experimental group). Surgical parameters (operation time, intraoperative bleeding), postoperative outcomes (postoperative pain scores, wound healing time, severe edge swelling, wound dehiscence, postoperative rebleeding, postoperative infection, aesthetic satisfaction), were compared between the two groups.

Results

A total of 301 pediatric patients were included in our study, with 146 in the traditional group and 155 in the stapler group. The stapler group showed significantly lower values in operation time, intraoperative bleeding, and postoperative rebleeding compared to the traditional group (P < 0.05). However, the traditional group had a significant advantage in postoperative wound healing time and the occurrence of severe edge swelling (P < 0.05). There were no significant differences between the two groups in terms of anesthetic drug dosage, postoperative pain level, postoperative infection rate, wound dehiscence, and aesthetic satisfaction (P > 0.05).

Conclusion

In the treatment of pediatric phimosis and redundant prepuce, the advantage of traditional circumcision lies in faster postoperative recovery and less severe edge swelling. The disposable circumcision stapler excels in thorough hemostasis, easy and safe operation, suitable for primary medical use, but lags behind in postoperative recovery compared to the traditional method. Each treatment approach has its own advantages, and the choice should be based on the actual condition and circumstances of the patient. Personalized treatment decisions should be made collaboratively to achieve the best therapeutic outcomes.

Genital Modifications in Prepubescent Minors: When May Clinicians Ethically Proceed?

When is it ethically permissible for clinicians to surgically intervene into the genitals of a legal minor? We distinguish between voluntary and nonvoluntary procedures and focus on nonvoluntary procedures, specifically in prepubescent minors ("children"). We do not address procedures in adolescence or adulthood. With respect to children categorized as female at birth who have no apparent differences of sex development (i.e., non-intersex or "endosex" females) there is a near-universal ethical consensus in the Global North. This consensus holds that clinicians may not perform any nonvoluntary genital cutting or surgery, from "cosmetic" labiaplasty to medicalized ritual "pricking" of the vulva, insofar as the procedure is not strictly necessary to protect the child's physical health. All other motivations, including possible psychosocial, cultural, subjective-aesthetic, or prophylactic benefits as judged by doctors or parents, are seen as categorically inappropriate grounds for a clinician to proceed with a nonvoluntary genital procedure in this population. We argue that the main ethical reasons capable of supporting this consensus turn not on empirically contestable benefit-risk calculations, but on a fundamental concern to respect the child's privacy, bodily integrity, developing sexual boundaries, and (future) genital autonomy. We show that these ethical reasons are sound. However, as we argue, they do not only apply to endosex female children, but rather to all children regardless of sex characteristics, including those with intersex traits and endosex males. We conclude, therefore, that as a matter of justice, inclusivity, and gender equality in medical-ethical policy (we do not take a position as to criminal law), clinicians should not be permitted to perform any nonvoluntary genital cutting or surgery in prepubescent minors, irrespective of the latter's sex traits or gender assignment, unless urgently necessary to protect their physical health. By contrast, we suggest that voluntary surgeries in older individuals might, under certain conditions, permissibly be performed for a wider range of reasons, including reasons of self-identity or psychosocial well-being, in keeping with the circumstances, values, and explicit needs and preferences of the persons so concerned. Note: Because our position is tied to clinicians' widely accepted role-specific duties as medical practitioners within regulated healthcare systems, we do not consider genital procedures performed outside of a healthcare context (e.g., for religious reasons) or by persons other than licensed healthcare providers working in their professional capacity.

Comparison of the penile microbiome in infant male circumcision: Mogen clamp versus Shangring

BACKGROUND

This study aimed to characterise the infant penile (coronal sulcus) microbiome and the effects of early infant male circumcision (EIMC), following a standard surgical method (Mogen Clamp) and a non-surgical alternative (ShangRing).

METHODS

We collected coronal sulcus swabs at baseline and on days 7 and 14 post-circumcision from infants assigned to receive EIMC by Mogen Clamp (n = 15) or ShangRing (n = 15), in a randomised trial in Rakai and Kakuuto, Uganda. We used 16S rRNA gene-based sequencing and broad-coverage qPCR to characterise the infant penile microbiome and assess the effects of EIMC in both study arms.

FINDINGS

Prior to EIMC, the infant penile microbiome had a mixture of facultative and strict anaerobes. In both study arms, EIMC caused penile microbiome proportional abundance changes characterised by decreases in penile anaerobes [ShangRing Prevotella: -15.0%, (SD = 19.1); Mogen clamp Prevotella: -3.6% (11.2); ShangRing Veillonella: -11.3% (17.2); Mogen clamp Veillonella: -2.6% (11.8)] and increases in skin-associated facultative anaerobes [ShangRing Corynebacterium: 24.9%, (22.4); Mogen clamp Corynebacterium: 4.7% (21.3); ShangRing Staphylococcus: 21.1% (20.5); Mogen clamp Staphylococcus: 18.1% (20.1)]. Clostridium tetani was not detected during the study.

INTERPRETATION

Mogen Clamp and ShangRing EIMC both changed the composition of the infant penile microbiome by reducing the proportional abundances of anaerobes and uropathogens, which is consistent with medical male circumcision findings in adults. C. tetani was not increased by either EIMC method.

FUNDING

Bill and Melinda Gates Foundation.

Efficacy and safety of two disposable circumcision suture devices for circumcision in adults: a prospective comparative multicenter study

The objective of this study was to evaluate and compare efficacy and safety of two different Disposable circumcision suture devices (DCSDs). A prospective comparative non-randomized multicenter study was performed between November 2019 and February 2023. Patients underwent circumcision using a DCSD (CircCurerTM or the ZSR® device) according to the surgeon preference and device availability. A total of 378 patients were circumcised; 184 using CircCurerTM and 194 patients using ZSR®. No differences in baseline characteristics were observed. CircCurer and ZSR Groups showed similar rates of operative time (7.7 ±2.1 vs 7.3 ±2.0 min), surgical site infection (1.1% Vs 1.5%), edema (13% Vs 8.2%), hematomas (2.7% Vs 1.1%), and postoperative pain (2.5 Vs 2.0 points). ZSR Group had a significantly higher rate of clip fallout (62.9% Vs 38%, p < 0.001). At 2 months, patients of both groups reported a median satisfaction of 9 (8-9) points. Main limitation consist in non-randomized study. DCSDs seem to be effective and safe, with short operative times, uncommon and mild complications, and high patient satisfaction. ZSR® device has a higher rate of spontaneous staple dropout.

Comparative analysis of two methods in circumcision: a new disposable device versus classic sleeve technique

PURPOSE

Circumcision is the most common surgical procedures performed in males. Medical circumcision is recommended for diseases such as phimosis, paraphimosis, balanoposthitis and common urinary tract infections, although there is no exact indication. Conversely, Jewish and Muslim individuals commonly undergo circumcision regardless of medical necessity. Circumcision devices are designed to shorten surgery time, achieve an aesthetic appearance and ensure safe surgery. The aim of this study is to evaluate the effectiveness of the NeoAlis clamp, a disposable circumcision device, by comparing it with the sleeve technique in children.

MATERIALS AND METHODS

Between 2017 and 2023, retrospective evaluation of 2626 patients who underwent circumcision using either the NeoAlis clamp (group 1) or the sleeve technique (group 2) was conducted. Operation time, results, cost, complications were compared between the two groups.

RESULTS

The study encompassed 2626 patients who fulfilled the inclusion criteria. Group 1 comprised 2403 patients, whereas Group 2 consisted of 223 patients. The overall complication rate, as denoted by n = 47, was 1.7%. Group 1 operation time was shorter than group 2. Bleeding, the most feared complication in the early period, was higher in the second group. No statistically significant difference was observed between the two groups regarding cost comparison.

CONCLUSION

The primary concern during circumcision is to avoid complications related to general anesthesia in newborns and infants. The use of disposable ring devices has been facilitated by the shorter operation time and the absence of the need for sutures when performing circumcision under local anesthesia. However, knowledge of advanced surgical circumcision techniques is necessary in cases of bleeding and inappropriate ring placement.

Recommendations to Improve Neonatal Circumcision Training

BACKGROUND

Although multiple specialties perform neonatal circumcision (NC), overall NC proceduralist availability is limited. The approach to training new practitioners varies. This study aims to describe NC training experiences, current practices, and make suggestions for future improvements.

METHODS

Perinatal physicians across 11 hospitals in a large Midwestern United States city who perform NC or who conduct newborn examinations and provide circumcision counseling were recruited for semistructured interviews about NC care. Interviews were transcribed; training-related comments underwent inductive and deductive qualitative coding. Themes related to circumcision training and recommendations for improving the experience of future circumcision learners were summarized.

RESULTS

Twenty-three physicians (10 family medicine, 8 pediatrics, and 5 obstetrics; 78% currently perform circumcision) participated. All participants conducted newborn examinations and provided circumcision counseling, but only 21/23 were trained to perform circumcision. Several themes related to training emerged: (1) personal training experience, (2) training others to perform circumcision, and (3) current training needs and barriers. Most reported learning in residency by a "see one, do one, teach one" approach with minimal formal didactic or structured training. Compared with their personal experience, participants noted a shift toward more direct supervision and preprocedure preparation for current trainees. However, most reported that circumcision learning continues to be "hands-on." Participants desired a more structured approach for future trainees.

CONCLUSIONS

Perinatal physicians noted a shift in the current NC training to a more hands-on approach than they experienced personally. Development of a structured NC curriculum was recommended to improve training.

Comparative Genitourinary Safety of In-class Sodium-Glucose Cotransporter-2 Inhibitors among Patients with Heart Failure with Preserved Ejection Fraction: A Cohort Study

PURPOSE

The American Heart Association recommended sodium-glucose cotransporter-2 inhibitors (SGLT2i) for the management of heart failure with preserved ejection fraction (HFpEF). However, little is known about their real-world in-class comparative safety in patients with HFpEF. We aimed to assess the comparative safety of SGLT2i in the risk of urinary tract infection (UTI) or genital infection separately or as a composite outcome among patients with HFpEF.

METHODS

This cohort study using MarketScan® Commercial and Medicare supplemental databases (2012-2020) included patients aged ≥ 18 years with a diagnosis of HFpEF who initiated SGLT2i therapy. Three pairwise comparison groups were established: cohort 1, dapagliflozin versus canagliflozin; cohort 2, empagliflozin versus canagliflozin; and cohort 3, dapagliflozin versus empagliflozin. After stabilized inverse probability treatment weighting, Cox proportional hazards regression was used to compare the risk of UTI or genital infection separately or as a composite outcome in each cohort.

RESULTS

The risk of the composite outcome did not significantly differ between canagliflozin and dapagliflozin (adjusted hazard ratio [aHR] 0.64; 95% confidence interval [CI] 0.36-1.14) or between empagliflozin and canagliflozin (aHR 1.25; 95% CI 0.77-2.05). Similarly, there was no evidence of difference between dapagliflozin and empagliflozin in this risk (aHR 0.76; 95% CI 0.48-1.21). The results of analyses separately assessing UTI or genital infection were similar.

CONCLUSIONS

There was no significant difference in the risk of UTI or genital infection among patients with HFpEF who initiated canagliflozin, dapagliflozin, or empagliflozin.

Factor XI deficiency: phenotypic age-related considerations and clinical approach towards bleeding risk assessment

ABSTRACT

Factor XI (FXI) deficiency is a rare bleeding disorder that presents complex challenges in patient assessment and bleeding risk management. Despite generally causing mild to moderate bleeding symptoms, clinical manifestations can vary, and bleeding tendency does not always correlate with FXI plasma levels or genotype. Our manuscript delves into the age-related nuances of FXI deficiency across an individual's lifespan. We emphasize issues faced by specific groups, including neonates and females of reproductive age experiencing abnormal uterine bleeding and postpartum hemorrhage. Older patients present unique challenges and concerns related to the management of bleeding as well as thrombotic complications. The current assortment of diagnostic laboratory assays shows limited success in predicting bleeding risk in the perisurgical setting of patients with FXI deficiency. This review explores the intricate interplay between individual bleeding profiles, surgical sites, and FXI activity levels. We also evaluate the accuracy of existing laboratory assays in predicting bleeding and discuss the potential role of investigational global assays in perioperative assessment. Furthermore, we outline our suggested diagnostic approach to refine treatment strategies and decision making. Available treatment options are presented, including antifibrinolytics, replacement products, and recombinant activated FVII. Finally, we discuss promising nonreplacement therapies for the treatment of rare bleeding disorders that can potentially address the challenges faced when managing FXI deficiency-related bleeding complications.

Comparison the Diameter of the Urethral Meatus Before and After Circumcision and Evaluation of Urethral Stenosis

Objectives. This study focused on assessing the diameter of the meatus before and after circumcision to evaluate meatal stenosis. Methods. In this cross-sectional study, boys who met the inclusion criteria, their demographic parameters, and meatus diameter were recorded. Thirty days after circumcision, complications were evaluated meatus diameter was measured again and their information was analyzed by SPSS 26 software. Results. Four hundred boys were studied, and it was found that 41 cases (10.3%) developed meatal stenosis after circumcision, with 85% having a pre-circumcision meatus diameter of 4 mm or less. Statistical analysis revealed a significant correlation (P < .05) between smaller pre-circumcision meatus diameter and postoperative meatal stenosis. Conclusions. The study concludes that a smaller meatus diameter before circumcision significantly increases the risk of postoperative tightness. It suggests prophylactic measures like meatus dilatation or applying topical ointment for those at high risk (meatus diameter ≤ 4 mm) to prevent or mitigate postoperative meatal stenosis.

An Intelligent Customer-Driven Digital Solution to Improve Perioperative Health Outcomes Among Children Undergoing Circumcision and Their Parents: Development and Evaluation

BACKGROUND

Circumcision as a common elective pediatric surgery worldwide is a stressful and anxiety-inducing experience for parents and children. Although current perioperative interventions proved effective, such as reducing preoperative anxiety, there are limited holistic solutions using mobile apps.

OBJECTIVE

This paper aims to describe the development and primary evaluation of an intelligent customer-driven smartphone-based app program (ICory-Circumcision) to enhance health outcomes among children undergoing circumcision and their family caregivers.

METHODS

Based on the review of the literature and previous studies, Bandura's self-efficacy theory was adopted as the conceptual framework. A multidisciplinary team was built to identify the content and develop the apps. Semistructured interviews were conducted to evaluate the ICory-Circumcision.

RESULTS

The ICory-Circumcision study was carried out from March 2019 to January 2020 and comprised 2 mobile apps, BuddyCare app and Triumf Health mobile game app. The former provides a day-by-day perioperative guide for parents whose children are undergoing circumcision, while the latter provides emotional support and distraction to children. In total, 6 participants were recruited to use the apps and interviewed to evaluate the program. In total, 4 main categories and 10 subcategories were generated from content analysis.

CONCLUSIONS

ICory-Circumcision seemed to lean toward being useful. Revisions to ICory-Circumcision are necessary to enhance its contents and features before advancing to the randomized controlled trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04174404; https://clinicaltrials.gov/ct2/show/NCT04174404.

Neonatal Male Circumcision: Clearly Beneficial for Public Health or an Ethical Dilemma? A Systematic Review

Contrasting ethical and legal arguments have been made concerning neonatal male circumcision (NMC) that merit the first systematic review on this topic. We performed PRISMA-compliant keyword searches of PubMed, EMBASE, SCOPUS, LexisNexis, and other databases and identified 61 articles that met the inclusion criteria. In the bibliographies of these articles, we identified 58 more relevant articles and 28 internet items. We found high-quality evidence that NMC is a low-risk procedure that provides immediate and lifetime medical and health benefits and only rarely leads to later adverse effects on sexual function or pleasure. Given this evidence, we conclude that discouraging or denying NMC is unethical from the perspective of the United Nations Convention on the Rights of the Child, which emphasizes the right to health. Further, case law supports the legality of NMC. We found, conversely, that the ethical arguments against NMC rely on distortions of the medical evidence. Thus, NMC, by experienced operators using available safety precautions, appears to be both legal and ethical. Consistent with this conclusion, all of the evidence-based pediatric policies that we reviewed describe NMC as low-risk and beneficial to public health. We calculated that a reduction in NMC in the United States from 80% to 10% would substantially increase the cases of adverse medical conditions. The present findings thus support the evidence-based NMC policy statements and are inconsistent with the non-evidence-based policies that discourage NMC. On balance, the arguments and evidence reviewed here indicate that NMC is a medically beneficial and ethical public health intervention early in life because it reduces suffering, deaths, cases, and costs of treating adverse medical conditions throughout the lifetimes of circumcised individuals.

The Effect of Distraction Techniques on Pain, Fear, and Anxiety in Children Undergoing Circumcision: A Meta-Analysis of Randomized Controlled Trials

Circumcision is a common pediatric operation, and distraction technique can be used as an adjunct analgesic method during the perioperative period. The study aims to explore the effect of distraction techniques on reducing pain, fear, and anxiety in children undergoing circumcision. The PubMed, ClinicalTrials.gov, and Embase databases were searched for articles published from January 1, 2000, to December 31, 2023. Only randomized controlled trials (RCTs) were included. Meta-analysis and forest plots were carried out using Review Manager 5.4.1 software, and outcomes were reviewed by two authors independently. We used the Risk of Bias assessment form (ROB2) developed by the Cochrane Collaboration to assess the quality of included studies. PRISMA 2020 guidelines were used in this article to achieve the quantitative and qualitative synthesis of data. A total of seven RCTs were included. The intervention group consisted of 417 patients, while the control group had 245 patients. The meta-analysis and sensitivity analysis results showed that the distraction technique could significantly relieve pain (MD -1.3, 95% confidence interval [CI]: [-1.61 to -0.99], p < .00001), fear (SMD -1.04, 95%CI -1.68 to -0.4, p = .001), and anxiety (SMD -1.07, 95%CI [-1.64 to -0.51], p = .0002). Similarly, therapeutic play significant could significantly relieve fear (MD -0.4, 95%CI [-0.71 to -0.1], p = .01) and anxiety (SMD -1.31, 95%CI [-2.59 to -0.04], p = .04), virtual reality (VR) could significantly relieve anxiety (SMD -0.67, 95%CI [-0.98 to -0.37], p < .0001). Distraction techniques can alleviate perioperative pain, fear, and anxiety in children undergoing circumcision.

Comments by opponents on the British Medical Association's guidance on non-therapeutic male circumcision of children seem one-sided and may undermine public health

The British Medical Association (BMA) guidance on non-therapeutic circumcision (NTMC) of male children is limited to ethical, legal and religious issues. Here we evaluate criticisms of the BMA's guidance by Lempert et al. While their arguments promoting autonomy and consent might be superficially appealing, their claim of high procedural risks and negligible benefits seem one-sided and contrast with high quality evidence of low risk and lifelong benefits. Extensive literature reviews by the American Academy of Pediatrics and the United States Centers for Disease Control and Prevention in developing evidence-based policies, as well as risk-benefit analyses, have found that the medical benefits of infant NTMC greatly exceed the risks, and there is no reduction in sexual function and pleasure. The BMA's failure to consider the medical benefits of early childhood NTMC may partly explain why this prophylactic intervention is discouraged in the United Kingdom. The consequence is higher prevalence of preventable infections, adverse medical conditions, suffering and net costs to the UK's National Health Service for treatment of these. Many of the issues and contradictions in the BMA guidance identified by Lempert et al stem from the BMA's guidance not being sufficiently evidence-based. Indeed, that document called for a review by others of the medical issues surrounding NTMC. While societal factors apply, ultimately, NTMC can only be justified rationally on scientific, evidence-based grounds. Parents are entitled to an accurate presentation of the medical evidence so that they can make an informed decision. Their decision either for or against NTMC should then be respected.

Pediatric ultrasound-guided dorsal penile nerve block and sedation in spontaneous breathing: a prospective observational study

Background

Worldwide, one of the most common surgical procedures in the pediatric population is circumcision. There is no consent on the best anesthesiologic approach. This study aimed to investigate ultrasound-guided dorsal penile nerve block (DPNB) plus sedation in spontaneous breathing as a time-saving, safe, effective, and opioid-sparing technique.

Aims

The primary outcome was the assessment of the time from the end of surgery and the discharge to the post-anesthesia care unit. Secondary outcomes were to evaluate the cumulative dosages of opioids, differences in pain levels between the two groups, and complications at the awakening, 4 h and 72 h after surgery, respectively.

Methods

This was a prospective study with a retrospective control group, approved by the Friuli-Venezia Giulia Ethics Committee. Children in the intervention group received an ultrasound-guided DPNB under sedation and spontaneous breathing. With the probe positioned transversally at the base of the penis using an in-plane approach with a modified technique, local anesthetic was injected under the deep fascia of the penis.

Results

We recruited 70 children who underwent circumcision at the University Hospital of Udine, Italy, from 1 January 2016 to 1 October 2021: 35 children in the ultrasound-guided DPNB group and 35 children in the control group. Children who received ultrasound-guided DPNB had a statistically significant lower time to discharge from the operating room, did not require mechanical ventilation, maintained spontaneous breathing at all times, received fewer opioids, had lower mean intraoperative arterial pressures, and lower pain levels immediately after surgery.

Conclusion

Ultrasound-guided DPNB associated with sedation and spontaneous breathing is a time-saving, opioid-sparing, safe, and effective strategy for the management of intraoperative and postoperative pain in children undergoing circumcision.Clinical trial registration: ClinicalTrial.gov (NCT04475458, 17 July 2020).

The role of circumcision in preventing urinary tract infections in children with antenatal hydronephrosis: Systematic review and meta-analysis

INTRODUCTION

Circumcision has been reported to reduce the risk of urinary tract infections (UTIs) in boys with antenatal hydronephrosis (HN). Our aim was to compare the incidence of UTIs in circumcised vs. uncircumcised boys with antenatal HN by conducting a systematic review and meta-analysis.

STUDY DESIGN

A comprehensive search was performed until December 2022. Comparative studies were evaluated according to Cochrane collaboration recommendations. Assessed measures included: UTIs, continuous antibiotic prophylaxis (CAP) use, renal outcomes, and circumcision complications. Odds ratios (OR) and mean difference with 95% confidence interval (CI) were extrapolated from available data. Random-effects meta-analysis were performed.

RESULTS

Twenty-three studies describing 9093 boys with antenatal HN were identified, including 4677 uncircumcised and 4416 circumcised boys. Overall effect estimates demonstrate that circumcised boys have significantly reduced odds of developing any UTI [OR 0.26, 95%CI 0.21, 0.32; p < 0.001]]. In addition, there a significantly reduced odds of developing UTI when circumcised and on CAP [OR 0.19, 95% CI 0.13, 0.30; p < 0.001]. When stratifying by etiology, circumcision reduced the odds of UTI in boys with isolated HN [OR 0.33, 95% CI 0.16, 0.68; p = 0.003], vesicoureteral reflux [OR 0.23, 95% CI 0.13, 0.42; P < 0.00001], or with posterior urethral valves [OR 0.29, 95% CI 0.13, 0.64; p = 0.002].

DISCUSSION

Circumcision reduces the incidence of UTIs in boys with antenatal HN. This review is limited by the varied definitions of UTIs and inconsistent reporting on HN etiology, renal outcomes, and circumcision complications.

CONCLUSIONS

Circumcision should be considered in boys with antenatal HN to prevent the risk of developing UTI. Further research is warranted to individualize the prophylactic role of circumcision for patients with HN.

Nationwide epidemiology and clinical practice patterns of pediatric urinary tract infections: application of multivariate time-series clustering

BACKGROUND

The nationwide epidemiology and clinical practice patterns for younger children hospitalized with urinary tract infections (UTIs) were unclear.

METHODS

We conducted a retrospective observational study consisting of 32,653 children aged < 36 months who were hospitalized with UTIs from 856 medical facilities during fiscal years 2011-2018 using a nationally representative inpatient database in Japan. We investigated the epidemiology of UTIs and changes in clinical practice patterns (e.g., antibiotic use) over 8 years. A machine learning algorithm of multivariate time-series clustering with dynamic time warping was used to classify the hospitals based on antibiotic use for UTIs.

RESULTS

We observed marked male predominance among children aged < 6 months, slight female predominance among children aged > 12 months, and summer seasonality among children hospitalized with UTIs. Most physicians selected intravenous second- or third-generation cephalosporins as the empiric therapy for treating UTIs, which was switched to oral antibiotics during hospitalizations for 80% of inpatients. Whereas total antibiotic use was constant over the 8 years, broad-spectrum antibiotic use decreased gradually from 5.4 in 2011 to 2.5 days of therapy per 100 patient-days in 2018. The time-series clustering distinctively classified 5 clusters of hospitals based on antibiotic use patterns and identified hospital clusters that preferred to use broad-spectrum antibiotics (e.g., antipseudomonal penicillin and carbapenem).

CONCLUSIONS

Our study provided novel insight into the epidemiology and practice patterns for pediatric UTIs. Time-series clustering can be useful to identify the hospitals with aberrant practice patterns to further promote antimicrobial stewardship. A higher resolution version of the Graphical abstract is available as Supplementary information.

Prognostic estimation for acute ischemic stroke patients undergoing mechanical thrombectomy within an extended therapeutic window using an interpretable machine learning model

Background

Mechanical thrombectomy (MT) is effective for acute ischemic stroke with large vessel occlusion (AIS-LVO) within an extended therapeutic window. However, successful reperfusion does not guarantee positive prognosis, with around 40-50% of cases yielding favorable outcomes. Preoperative prediction of patient outcomes is essential to identify those who may benefit from MT. Although machine learning (ML) has shown promise in handling variables with non-linear relationships in prediction models, its "black box" nature and the absence of ML models for extended-window MT prognosis remain limitations.

Objective

This study aimed to establish and select the optimal model for predicting extended-window MT outcomes, with the Shapley additive explanation (SHAP) approach used to enhance the interpretability of the selected model.

Methods

A retrospective analysis was conducted on 260 AIS-LVO patients undergoing extended-window MT. Selected patients were allocated into training and test sets at a 3:1 ratio following inclusion and exclusion criteria. Four ML classifiers and one logistic regression (Logit) model were constructed using pre-treatment variables from the training set. The optimal model was selected through comparative validation, with key features interpreted using the SHAP approach. The effectiveness of the chosen model was further evaluated using the test set.

Results

Of the 212 selected patients, 159 comprised the training and 53 the test sets. Extreme gradient boosting (XGBoost) showed the highest discrimination with an area under the curve (AUC) of 0.93 during validation, and maintained an AUC of 0.77 during testing. SHAP analysis identified ischemic core volume, baseline NHISS score, ischemic penumbra volume, ASPECTS, and patient age as the top five determinants of outcome prediction.

Conclusion

XGBoost emerged as the most effective for predicting the prognosis of AIS-LVO patients undergoing MT within the extended therapeutic window. SHAP interpretation improved its clinical confidence, paving the way for ML in clinical decision-making.

Decisional conflict in American parents regarding newborn circumcision

BACKGROUND

Decisional conflict surrounding the topic of circumcision in the newborn male is assumed in some parents but has not been quantified or qualified. It is known that parents often base their decision on cultural and social factors and that physician discussions do affect ultimate decision-making. Information on parents' decision-making surrounding newborn circumcision and ways to mitigate conflict or uncertainty around the decision-making process is needed to better counsel them appropriately.

OBJECTIVES

To identify the presence or absence of decisional conflict in parents-to-be deciding whether or not to circumcise their child as well as to identify determinants of this conflict to direct future educational measures.

STUDY DESIGN

Parents presenting to obstetrics clinic as well as contacted by institutional email were recruited using convenience sampling and completed the validated Decisional Conflict Scale (DCS). A smaller subset of subjects were recruited via institutional email to complete semi-structured interviews regarding the decision-making process and specifically uncertainty regarding the decision. Descriptive statistics and unpaired t tests were used for analysis of survey data. For interview data, an iterative, grounded theory methodology was used.

RESULTS

173 subjects completed the DCS. 12% of all participants had high decisional conflict. Intuitively, those who had not yet decided whether to circumcise had the highest proportion of high DCS (69%), followed by those who had decided to circumcise (9.3%) and those who had decided not to circumcise (1.7%). 24 subjects were interviewed, and based on their DCS scores and interview responses were classified as low, intermediate and high conflict. Three primary themes emerged delineating the high from low conflict groups. There were notable differences in the feelings of subjects regarding knowledge and feeling informed, the importance of particular values and clarity of the roles of these values in decision-making, and feelings of supported decision-making. These themes were used to create a visual model depicting the individual needs of each decision-maker (Fig. 1).

DISCUSSION

This study highlights the need for decision support for parents that is not only information-based but focuses on values clarity and supported decision-making. This study provides a jumping-off point for creation of shared decision-making tools directed at individual needs. The limitations of this study are a single institution design and homogeneous population, so when designing materials, additional unrecognized needs will likely be identified.

CONCLUSION

A small, but real proportion of parents-to-be experience significant uncertainty around the decision to circumcise their newborn boys. Identified needs of parents include feeling informed, feeling supported and clarification of important values related to the problem.

Increasing early infant male circumcision uptake in Zambia: Like father like son

Voluntary Medical Male Circumcision (VMMC) is an effective strategy for HIV prevention in areas with high prevalence of, and risk for, HIV. More than 361,000 male neonates are born each year in Zambia, many of whom could be eligible for Early-Infant Medical Circumcision (EIMC). Building on successful implementation strategies utilized in our Spear & Shield program, this pilot study, "Like Father, Like Son" (LFLS), evaluated the feasibility and acceptability of offering combined EIMC and VMMC services and couple-level behavioral interventions. A total of N = 702 pregnant women and their male partners (n = 351 couples) were recruited and enrolled. Couples were assessed twice pre-birth, 2 weeks post birth, and 6 months post birth. Expectant mothers were an average of 15.05 weeks pregnant (SD = 8.83). Thirty-nine pregnancies did not result in a live birth (11%), 14 couples withdrew from the study or were lost to follow-up prior to delivery (4%), and 148 babies were born female (42%), leaving 150 couples with a male infant in the analytic sample (43%). The LFLS study achieved significantly higher EIMC rates (35%) in comparison with previously observed EIMC study rates in Zambia (11%), and significantly higher than hypothetical comparison rates up to 30%. Relative to baseline rates, odds of VMMC among couples' older sons increased by 31% at post-intervention and by 90% at two-weeks following birth. Overall, this pilot study found the LFLS intervention to be feasible, acceptable, and effective in doubling the rate of EIMC in comparison with a previous longitudinal study in Zambia. Future research should consider a family-centric approach to promotion of male circumcision for infants and adolescents. LFLS may be effective in promoting father-son "bonding" by MC status; a bond that may be a bridge to increase both EIMC and VMMC uptake in newborns and couples' older sons and is a novel leverage point for promotion of this HIV prevention strategy.

Anthropometric Predictors of Appropriate-Sized Plastibell for Neonatal Circumcision

Background

Using anthropometric parameters to determine the appropriate Plastibell size before circumcision ensures that cumbersome carrying of all the sizes before each procedure is eliminated and also complications reduced.

Methods

Male neonates who presented for routine circumcision by Plastibell method were recruited. Collected on a proforma were their age in days, weight in Kg, stretched penile length (SPL) in cm, penile diameter (PD) in cm and the Plastibell size used by the "circumciser". The routine circumcision was carried out for each neonate according to protocol. P value was set at <0.05.

Results

There were 231 neonates who had Plastibell circumcision. Their mean age, weight, SPL and PD were 15.6(±5.73) days, 3.7(±0.58) Kg, 3.66 (±0.58) cm and 3.79 (±0.64) cm, respectively. Plastibell size 1.3 is the most used (53.6%). There was a positive correlation between weight, SPL, PD, on one hand and Plastibell size , on the other hand with P-values of <0.001, <0.001 and <0.001 respectively. The weight was a weak determinant for Plastibell sizes 1.1 and 1.3: (OR 7.104; 95% CI 1.108 - 45.559; P = .039) and (OR 2.044; 95% CI 1.054 - 3.963; P = .034) respectively. The SPL is also a weak predictor for Plastibell sizes 1.2 and 1.5: (OR 2.176; 95% CI 1.136 -4.136; P = .019) and (OR .043; 95% CI .072 - .984; P = .047), respectively.

Conclusion

The anthropometric parameters correlate well with Plastibell sizes. However, they are not effective in predicting the appropriate sized Plastibell for neonatal circumcision.

Foreskin restorers: insights into motivations, successes, challenges, and experiences with medical and mental health professionals - An abridged summary of key findings

Demographically diverse surveys in the United States suggest that 5-10% of non-voluntarily circumcised American males wish that they had not been circumcised. Similar data are unavailable in other countries. An unknown proportion of circumcised males experience acute circumcision-related distress; some attempt to regain a sense of bodily integrity through non-surgical foreskin restoration. Their concerns are often ignored by health professionals. We conducted an in-depth investigation into foreskin restorers' lived experiences. An online survey containing 49 qualitative and 10 demographic questions was developed to identify restorers' motivations, successes, challenges, and experiences with health professionals. Targeted sampling was employed to reach this distinctive population. Invitations were disseminated to customers of commercial restoration devices, online restoration forums, device manufacturer websites, and via genital autonomy organizations. Over 2100 surveys were submitted by respondents from 60 countries. We report results from 1790 fully completed surveys. Adverse physical, sexual, emotional/psychological and self-esteem impacts attributed to circumcision had motivated participants to seek foreskin restoration. Most sought no professional help due to hopelessness, fear, or mistrust. Those who sought help encountered trivialization, dismissal, or ridicule. Most participants recommended restoration. Many professionals are unprepared to assist this population. Circumcision sufferers/foreskin restorers have largely been ill-served by medical and mental health professionals.

Take the Shot: A Review of Vitamin K Deficiency

Vitamin K is essential for the process of coagulation. In its absence, severe and sometimes fatal bleeding events can occur, especially in newborns. Vitamin K prophylaxis at birth has been shown to prevent morbidity and mortality associated with vitamin K deficiency bleeding (VKDB) and is recommended by multiple organizations including the American Academy of Pediatrics and the World Health Organization. Pediatricians should feel comfortable explaining the risks and benefits of vitamin K prophylaxis to families and should be equipped to recognize signs of VKDB, especially given increasing rates of parental refusal. This article aims to improve understanding of VKDB, including prevention, early recognition, and treatment. [Pediatr Ann. 2023;52(2):e42-e45.].

Building nomogram plots for predicting urinary tract infections in children less than three years of age

BACKGROUND AND PURPOSE

Urinary tract infections (UTIs) are the most common bacterial infection in young children. This study aimed to formulate nomogram plots for clinicians to predict UTIs in children aged <3 years by evaluating the risk factors for UTIs in these children.

METHODS

This retrospective study was conducted at a tertiary medical center from December 2017 to November 2020. Children less than three years of age were eligible for the study if they had undergone both urine culture and urinalysis during the study period. Mixed-effects logistic regression models with a stepwise procedure were used to determine the relationship between outcome (positive/negative UTI) and covariates of interest (e.g., weight percentile, laboratory) for each patient. Nomogram plots were constructed on the basis of significant factors. We repeated the analysis thrice to adapt it to three different medical settings: medical centers, regional hospitals, and local clinics.

RESULTS

In the medical center setting, the two most significant factors were urine leukocyte count ≥100 (OR =8.87; 95% CI (Confidence Interval), 4.135-19.027) and urine nitrite level (OR =8.809; 95% CI, 5.009-15.489). The two factors showed similar significance at the regional hospital and local clinic settings. Abnormal renal echo findings were positively correlated with UTI in the medical center setting (OR =2.534; 95% CI 1.757-3.655). Three nomogram plots for the prediction of UTIs were drawn for medical centers, regional hospitals, and local clinics.

CONCLUSION

Using the three nomogram plots, frontline doctors can formulate the probabilities of pediatric UTIs for better decision-making.

How Canadian Law Shapes the Health Care Experiences of Women with Female Genital Mutilation/Cutting/Circumcision and Their Providers: A Disjuncture Between Expectation and Actuality

This study explored how the reproductive health care experiences of women with female genital mutilation/cutting/circumcision (FGC) were shaped. We used Institutional Ethnography, a sociological approach which allows for the study of social relations and the coordination of health care. From qualitatively interviewing eight women with FGC, we learned that they felt excluded within the Canadian health care system because they were unable to access reconstructive surgery, which was not covered by Ontario's universal health coverage (Ontario Health Insurance Plan). We then talked with seven obstetricians/gynecologists (OB/GYNs) and learned that while it was legal to perform certain genital (e.g., female genital cosmetic surgery) and reproductive (e.g., elective caesarean section) surgeries commonly requested by Western-born women, it was not legal for them to perform other genital surgeries often requested by immigrant populations (e.g., reinfibulation), nor were these covered by OHIP (e.g., clitoral reconstructive surgery). From participants' comparison of clitoral reconstructive surgery and reinfibulation to female genital cosmetic and gender confirming surgeries, it became clear that the law and policies within the health care system favored surgeries elected by Western adults over those wished for by women with FGC. We found that the law had an impact on the choices that OB/GYNs and the women they treated could make, shaping their respective experiences. This created ethical dilemmas for OB/GYNs and a sense of exclusion from the health care system for women with FGC.

Characterization of Changes in Penile Microbiome Following Pediatric Circumcision

BACKGROUND

While microbiome and host regulation contribute independently to many disease states, it is unclear how circumcision in pediatric population influences subsequent changes in penile microbiome.

OBJECTIVE

Our study aims to analyze jointly paired taxonomic profiles and assess pathways implicated in inflammation, barrier protection, and energy metabolism.

DESIGN, SETTING, AND PARTICIPANTS

We analyzed 11 paired samples, periurethral collection, before and after circumcision, to generate microbiome and mycobiome profiling. Sample preparation of 16S ribosomal RNA and internal transcribed spacer sequencing was adapted from the methods developed by the National Institutes of Health Human Microbiome Project.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We obtained the predictive functional attributes of the microbial communities between samples using Silva-Tax4Fun and the Greengenes-Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt) approach. The predictive functioning of the microbial communities was determined by linearly combining the normalized taxonomic abundances into the precomputed association matrix of Kyoto Encyclopedia of Genes and Genomes orthology reference profiles.

RESULTS AND LIMITATIONS

Several notable microbiome and mycobiome compositional differences were observed between pre- and postcircumcision patients. Pairwise comparisons across taxa revealed a significant decrease (p < 0.05, false discovery rate corrected) of microbiome organisms (Clostridiales, Bacteroidales, and Campylobacterales) and mycobiome (Saccharomycetales and Pleosporales) following circumcision. A total of 14 pathways were found to differ in abundance between the pre- and postcircumcision groups (p < 0.005, false discovery rate <0.1 and linear discriminant analysis score >3; five enriched and nine depleted). The pathways reduced after circumcision were mostly involved with amino acid and glucose metabolism, while pathways prior to circumcision were enriched in genetic information processing and transcription processes. As expected, enrichment in methyl-accepting chemotaxis protein, an integral membrane protein involved in directed motility of microbes to chemical cues and environment, occurred prior to circumcision, while the filamentous hemagglutinin pathway (a strong immunogenic protein) was depleted after circumcision CONCLUSIONS: Our results offer greater insight into the host-microbiota relationship of penile circumcision and may serve to lay the groundwork for future studies focused on drivers of inflammation, infection, and oncogenesis.

PATIENT SUMMARY

Our study showed a significant reduction in bacteria and fungi after circumcision, particularly anaerobic bacteria, which are known to be potential inducers of inflammation and cancer. This is the first study of its kind showing the changes in microbiome after circumcision, and some of the changes that occur in healthy infants after circumcision that may explain the differences in cancer and inflammatory disorders in adulthood.

Voluntary Medical Male Circumcision for HIV Prevention: a Global Overview

PURPOSE OF REVIEW

With the promise of HIV prevention, there has been a scale-up of voluntary medical male circumcision (VMMC) in high HIV incidence/low circumcision prevalence nations worldwide. Nonetheless, debates over the implementation and the effectiveness and safety of the VMMC in real-world settings persist. We revisit the role of VMMC in HIV prevention to inform health professionals, policymakers, and advocates or opponents in this new era.

RECENT FINDINGS

There has been substantial progress on VMMC scale-up to date, but this has varied considerably by region. The evidence of solid and direct protection of VMMC is available for heterosexual men and older adolescent boys in sub-Saharan Africa. The protective effect in men who have sex with men is suggested by systematic reviews but is not confirmed by clinical trials. Sexual partners, including women, likely benefit indirectly from the increased VMMC coverage through a decreased risk of exposure to infected male partners. Fortunately, the preponderance of studies does not suggest higher sexual risk behaviors among circumcised men, so-called risk compensation. VMMC requires health systems strengthening and continued promulgation of other evidence-based HIV prevention strategies to be successful. Health authorities in high HIV incidence areas that have low circumcision coverage should implement VMMC within a context of complementary biomedical and behavioral prevention strategies.

Impact of Florida Medicaid guidelines on frequency and cost of delayed circumcision at Nemours Children's hospital

INTRODUCTION

In 2003, Florida Medicaid discontinued coverage of routine neonatal circumcision (NC) resulting in an increase in nonneonatal circumcisions. Florida Medicaid is one of 16 state healthcare plans that do not cover NC. Florida Medicaid covers male circumcision in a child ≥3 years for a defined medical indication or persistent phimosis refractory to topical steroid therapy (TST). We sought to assess the economic impact of the evaluation and management of phimosis/circumcision in Florida Medicaid males ≥3 years treated at Nemours Children's Hospital.

STUDY DESIGN

We performed an IRB approved retrospective chart review of all male Florida Medicaid patients ≥3 years seen at NCH for phimosis/circumcision from Sept. 2016-Sept. 2019. Data extracted included demographics, age at presentation, prior treatment with TST, response to TST, and surgical interventions. The patients were stratified into three management groups. Total costs for each group were based upon estimated Medicaid reimbursement rates. Data were analyzed using descriptive analysis on SPSS.

RESULTS

Seven hundred and sixty-three males were evaluated. Age at presentation ranged from 3 to 17 years and 59% of patients were 3-6 years at initial presentation. Three hundred and forty patients underwent circumcision. The total estimated cost of care for all patients was $1,345,533.90. This compares to an estimated cost of $171,675 if all individuals underwent NC at 2020 costs.

CONCLUSIONS

The total estimated cost associated with the evaluation and management of 763 patients ≥3 years for phimosis/circumcision was 7.8 times the estimated cost of NC for all these patients and likely is an underestimation of the true difference in cost as we did not account for additional visits outside of the initial consultation and follow-up, post-operative visits outside of the global period, emergency room visits, and returns to operating room. Of the circumcisions performed, only 18.5% met Florida Medicaid defined medical indications. Success rates for TST range from 53.8 to 95% in the literature, however, our success rate was 34.3%. The reason for the variation in response rate between our results and the literature may reflect that caretakers desiring circumcision may be less compliant with TST use. Only 6.6% of patients had a documented failure of TST prior to initial presentation. Further education of PCPs on current Medicaid/MCG guidelines for the evaluation and management of phimosis, as well as PCP adoption of TST, could reduce the number of unnecessary office visits, healthcare costs, and family burden.

Circumcision Knowledge and Opinions of Primary Healthcare Workers: The Case of Turkey

This study evaluates the knowledge levels and opinions of Islamic primary healthcare workers regarding the medical indications of circumcision, its mode of application, contraindications, and possible complications together with the current literature. Our study was conducted with the participation of 400 healthcare personnel having Islamic faith and working in primary healthcare centers in Kahramanmaras. Data were collected through in-person interviews with healthcare workers who completed our questionnaire consisting of 52 questions and designed based on a literature review. SPSS 21 was used to evaluate the collected data statistically. Findings were considered statistically significant if the p-value was lower than 0.05. We evaluated these participants in terms of their levels of knowledge on circumcision. None of the participants had a very high knowledge level. In correlation analysis, it was detected that age (r = 0.194, p < 0.001) and duration of employment in the profession (experience) (r = 0.164, p = 0.001) were positively correlated with knowledge level. Those who found circumcision necessary mostly justified its necessity due to medical benefits (n = 321, 80.3%) and/or religious obligations (n = 242, 60.5%). Our study demonstrates the importance of providing information about circumcision, including the information from the current literature, to primary healthcare workers together with theoretical training and practice both during their formal training and after graduation in Turkey.

Potentially under-recognized late-stage physical and psychosexual complications of non-therapeutic neonatal penile circumcision: a qualitative and quantitative analysis of self-reports from an online community forum

The removal of non-pathogenic foreskin from the penis of healthy neonates and infants for non-religious reasons is routinely practiced in many parts of the world. High level data from well-designed randomized controlled trials of circumcision in neonates and infants does not guide clinical practice. Reliable counts of immediate and short term circumcision complications are difficult to estimate. Emerging evidence suggests routine neonatal circumcision could lead to long term psychological, physical, and sexual complications in some men. The stigma associated with discussing circumcision complications creates a prevalence paradox where the presence of significant circumcision complications is higher than reported. Prior to the Internet, there were very few forums for men from diverse communities, who were troubled about their circumcision status, to discuss and compare stories. To investigate the long term consequences of circumcision, we reviewed 135 posts from 109 individual users participating in a circumcision grief subsection of Reddit, an internet discussion board. We identified three major categories of complications: physical such as pain during erections and lost sensitivity, psychological such as anxiety and violation of autonomy, and sexual such as feeling that the sexual experience was negatively altered or being unable to complete a sexual experience. We also identified a "discovery process" where some men described coming into awareness of their circumcision status. These findings suggest that neonatal circumcision can have significant adverse consequences for adult men. The removal of normal foreskin tissue should be limited to adult men who choose the procedure for cosmetic reasons or when medically indicated.

The effects of sound-and-light toy as a distraction method on pain and physiological parameters in infants regarding circumcision procedure

Background/Aim: Circumcision is a common surgical procedure and a cause of pain and stress for infants. Nurses are in a key role for providing pain relief through implementation of non-pharmacological practices for pain management. This study aimed to assess the impact of distraction using a sound- and light-producing toy on pain and physiological parameters in infants regarding circumcision procedure. Methods: This randomized controlled study was conducted with infants between six months and two years of age who presented to a private circumcision clinic. The sample consisted of 60 infants randomly allocated into intervention (n = 30) and control (n = 30) groups. During the procedure, the mothers of the infants in the intervention distracted the infants with the toy for 15 min. Infants in the control group were accompanied by their mothers during the procedure and did not receive any additional intervention other than the standard care. Data were collected using a questionnaire and the face, legs, activity, cry, consolability (FLACC) pain scale. Data were assessed using descriptive statistical analyses and parametric tests. Results: Infants in the intervention and control groups were similar in terms of current and gestational ages, lengths, weights, and maternal and paternal ages and showed no differences in terms of physiological parameters before and after the procedure (P > 0.05). Post-operative pain scores were lower in infants exposed to the toy with light- and sound than that in the infants in the control group; however, no significant difference between groups was found (P > 0.05). Conclusion: Considering the effect of sound- and light-producing toys on causing a reduction in pain severity, it may be recommended to use distracting practices by nurses to reduce/relieve pain associated with circumcision.

Incidence of circumcision among insured adults in the United States

Purpose

Although circumcision is the most commonly performed surgery in males, less is known about the incidence and indications of adult circumcision. In this study, we aim to present the incidence of adult circumcision across the United States.

Methods

Using IBM MarketScan^® Commercial Database from 2015 to 2018, we obtained claims for circumcision in men between 18 and 64 years of age. We calculated the incidence of adult circumcision over the study period and across the United States. We also collected data on indications for surgery using International Classification of Diseases codes.

Results

We identified a total of 12,298 claims for adult circumcisions. The mean age was 39 (±12.9) years. The average incidence rates remained relatively constant from 98.1 per 100,000 person-years in 2015 to 98.2 per 100,000 person-years in 2018 (Δ+0.1%). The age-standardized incidence rates varied significantly across the United States (from 0 to 194.8 per 100,000 person-years) with South Dakota having the highest rate. The most common indications for adult circumcision were phimosis (52.5%), routine/ritual circumcision (28.7%), phimosis + balanitis/balanoposthitis (6.8%), balanitis (3.8%) and balanoposthitis (2.6%), and significantly varied by age groups.

Conclusion

This study suggested a wide geographic variation in rates of adult circumcision between states with highest incidences in the Northeast United States. Future studies can identify the underlying causes for the observed variations.

Serious and Fatal Complications after Neonatal Circumcision

Neonatal circumcision (NNC) is the most frequently performed surgical procedure worldwide and is generally considered safe in Western societies. Deaths attributed to NNC are seldom reported and are mostly explained by lack of adherence to medical standards. We reviewed our emergency department database for circumcision-related emergency admissions. During 2000-2013, 19 previously healthy neonates were admitted for acute complications after circumcision. Four were admitted for bleeding, with hemophilia identified in two cases and von Willebrand disease in one. Eight boys required emergency surgery, three for severe bleeding. Four boys with amputation of the glans underwent immediate surgical reconstruction. One infant was taken to the operating room to remove an obstructing Plastibell ring. Seven boys were admitted to the intensive care unit with severe bleeding or sepsis, three of whom ultimately progressed to hemorrhagic or septic shock. Two of these children died of their complications. We estimate that the annual incidence of severe complications requiring hospitalization after NNC in the Greater Toronto Area was approximately 0.01%, and the incidence of fatalities over the 14-yr review period was approximately 0.0012%. Our results indicate that the risk of serious complications and death as a result of NNC is greater than generally assumed.

Infant Circumcision for Sexually Transmitted Infection Risk Reduction Globally

Population-based studies in high-income countries have failed to find that male circumcision protects against sexually transmitted infections. Using evidence from several sources, we show that male circumcision does protect against HIV during insertive intercourse for men who have sex with men.

Penile Lichen Sclerosis: A Surgical Perspective of its Aetiology and Treatment

Penile lichen sclerosis is a longstanding inflammatory disease of the skin with a controversial aetiology. Penile lichen sclerosis (PLS) is a growing, inflammatory dermatitis of the anogenital region, which involves the meatus, prepuce, penile shaft, and glans penis. Although the accurate aetiology of PLS is contentious, multiple factors including genetics, autoimmunity, infections of human papillomavirus, hepatitis C, Epstein-Barr virus, risk factors (hormonal and trauma), etc., can be considered to be a part of the etiopathogenesis of PLS. The initial clinical presentations of penile lichen sclerosis are white plaques, atrophied skin, erythema, erosions, and sclerosis in the anogenital region. When the disease advances, the following can occur, including meatal constraints, telangiectasia, petechiae, soreness, papular lesions, tightness of the foreskin, difficulties in passing urine, itching, tenderness on erections, pain, cracking, bleeding, redness, rashes, tightness at frenulum, and dysuria. This disease has a dangerous course of action and if untreated it may be linked with severe urologic and sexual morbidities. PLS is usually treated with medical and surgical interventions like topical or intralesional steroids and circumcision. The role of circumcision is very critical in the course of action and prognosis of PLS, and its treatment is dependent on the stage of the disease. This review brings up the knowledge regarding epidemiology, etiopathology, clinical presentation, and management of PLS with an emphasis on the role of circumcision.

Trends in Incidence, Mortality, and Survival of Penile Cancer in the United States: A Population-Based Study

Purpose

The aim of this study is to investigate the trends in incidence and mortality, and explore any change in survival of penile cancer in the United States.

Methods

We obtained data from the Surveillance, Epidemiology, and End Results (SEER) database (2000-2018) utilizing the SEER Stat software. The joinpoint regression was used to analyze the secular trend of incidence and incidence-based mortality (IBM) stratified by age, race, and summary stage. The 5-year relative survival rate was also calculated.

Result

The age-adjusted rates of penile cancer patients were 0.38 (0.37-0.39) and 0.21 (0.2-0.21) for overall incidence and IBM, respectively. The 5-year relative survival rates were 67.7%, 66.99%, and 65.67% for the calendar periods of 2000-2004, 2005-2009, and 2010-2014, respectively. No significant changes in incidence by era were observed from 2000 to 2018 [annual percentage change (APC) = 0.5%, p = 0.064]. The IBM rate of penile cancer showed an initial significant increase from 2000 to 2002 (APC = 78.6%, 95% CI, -1.7-224.6) followed by a deceleration rate of 4.6% (95% CI, 3.9-5.3) during 2002 to 2018. No significant improvement in 5-year relative survival was observed. The trends by age, race, and summary stage in incidence and IBM were significantly different.

Conclusion

This study, using population-level data from the SEER database, showed an increasing trend in IBM and no significant improvement in the 5-year relative survival rate. Meanwhile, the incidence of penile cancer exhibited a relatively stable trend during the study period. These results might be due to the lack of significant progress in the treatment and management of penile cancer patients in the United States in recent decades. More efforts, like increasing awareness among the general population and doctors, and centralized management, might be needed in the future to improve the survival of this rare disease.

Efficacy of Dexmedetomidine Anesthesia plus Dorsal Penile Nerve Block in Pediatric Circumcision

Objective

To assess the efficacy of dexmedetomidine anesthesia plus dorsal penile nerve block in pediatric circumcision.

Methods

In this retrospective study, 80 children receiving circumcision in our hospital from February 2020 to February 2021 were recruited and assigned via different anesthesia methods at a ratio of 1 : 1 to receive dorsal penile nerve block plus dexmedetomidine anesthesia (combined anesthesia group) or only sevoflurane for total inhalational anesthesia (total anesthesia group). Traditional Chinese medicine (TCM) care was introduced to both groups of patients. Outcome measures included vital signs, operative indices, anesthesia effect, adverse reactions, parent satisfaction, and nursing satisfaction.

Results

There were no significant differences in the heart rate, oxygen saturation, and mean arterial pressure between the two groups of children before anesthesia, after anesthesia, and during the awakening period (P > 0.05). Patients receiving combined anesthesia showed a shorter time lapse before the disappearance of eyelash reflex, longer time lapse before postoperative analgesic use, faster awakening, and shorter operation time and hospital stay versus those receiving total inhalational anesthesia alone (P > 0.05). The combined anesthesia resulted in a lower Induction Compliance Checklist (ICC) score, McGill score, and Richmond Agitation-Sedation Scale (RASS) score and a higher Ramsay score versus total anesthesia (P > 0.05). Patients receiving combined anesthesia showed a significantly lower incidence of adverse events (5.00% (2/40)) versus total inhalational anesthesia (62.50% (25/40)) (X² = 29.574, P > 0.05). The combined anesthesia group had a higher parent satisfaction (92.50% (37/40)) versus the total anesthesia group (75.00% (30/40)) (X² = 4.501, P > 0.05). A total of 80 questionnaires were distributed, with a 100% return rate and a 100% validity rate, and all 80 questionnaires scored 90 points or above. The families of children in both groups were satisfied with the quality of TCM care.

Conclusion

The efficacy of dorsal penile nerve block plus dexmedetomidine anesthesia in pediatric circumcision is better than total inhalational anesthesia with sevoflurane.

Critical evaluation of contrasting evidence on whether male circumcision has adverse psychological effects: A systematic review

OBJECTIVE

To conduct the first systematic review critically examining evidence on whether early male circumcision has short- and long-term adverse psychological effects.

METHODS

We searched PubMed, EMBASE, SCOPUS, Cochrane Library, and Google Scholar.

RESULTS

Twenty-four studies with original data met the inclusion criteria. These comprised 11,173 total males, 4340 circumcised in infancy and 6908 uncircumcised. Nineteen were rated 1+, 2++ or 2+, and 5 were rated 2- by SIGN criteria. Neonatal circumcision, particularly without anesthetic, increased vaccination pain response, but had little effect on breastfeeding or cognitive ability. Studies reporting associations with sudden infant death syndrome, autism, alexithymia and impaired sexual function and pleasure had design flaws and were rated 2-. Sexual arousal, touch, pain, and warmth thresholds measured by quantitative sensory testing were not diminished in neonatally circumcised men. Neonatal circumcision was not associated with empathy in men, contradicting the hypothesis that procedural pain causes central nervous system changes. After correcting all associations with socioaffective processing parameters for multiple testing only higher sociosexual desire, dyadic sexual libido/drive, and stress remained significant. The relatively greater sexual activity found in circumcised men might reflect reduced sexual activity in uncircumcised men overall owing to pain and psychological aversion in those with foreskin-related medical conditions (reverse causality). Most studies employed case-control designs with limited follow-up. Studies beyond childhood were prone to confounding.

CONCLUSION

The highest quality evidence suggest that neonatal and later circumcision has limited or no short-term or long-term adverse psychological effects.

Need for Increased Awareness of International Male Circumcision Variations and Associated Complications: A Contemporary Review

Male circumcision is a prevalent, straightforward procedure. Cultural, religious, and/or social factors are the main determinants in the decision to undergo circumcision. The method of circumcision and age of the patient at the time of circumcision varies, dependent on the deciding determinant: cultural or religious tradition, personal hygiene, preventive health, or medical need. While circumcision is a relatively simple operation for a trained medical professional with low rates of adverse events, the safety of the operation varies when performed by non-medically trained (traditional) practitioners. This review aims to inform physicians of international circumcision variations and associated complications and to provide history-taking considerations during the review of the genitourinary system. The review revealed a wide variety in 1) training of practitioners performing circumcisions, 2) methods of circumcision, and 3) sterility during the procedure contributing to differing rates of complications. Findings suggest circumcisions should not be viewed equally, and greater emphasis should be placed on genitourinary history, especially circumcision, with patients from areas where traditional circumcisions are prevalent.