Risks
From
Circumcision
During
the First
Month
of Life Compared
With Those
for
Uncircumcised
Boys
LTC Thomas
E. Wiswell,
MC,
USA,
and
COL
Dietrich
W. Geschke,
MC, USA
From the Medical Research Fellowship, Wafter Reed Army Institute of Research, Washington, DC
ABSTRACT. The records of 136,086 boys born in US
Army hospitals from 1980 to 1985 were reviewed for indexed complications related to circumcision status dur-ing the first month of life. For 100,157 circumcised boys, there were 193 complications (0.19%). These included 62 local infections, eight cases of bacteremia, 83 incidences of hemorrhage (31 requiring ligature and three requiring
transfusion), 25 instances of surgical trauma, and 20
urinary tract infections. There were no deaths or reported
losses of the glans or entire penis. By contrast, the
complications in the 35,929 uncircumcised infants were all related to urinary tract infections. Of the 88 boys with such infections (0.24%), 32 had concomitant bacteremia, three had meningitis, two had renal failure, and two died. The frequencies of urinary tract infection (P < .0001)
and bacteremia (P < .0002) were significantly higher in
the uncircumcised boys. Serious complications from rou-tine prepuce removal are rare and relatively minor. Cir-cumcision may be beneficial in reducing the occurrence of urinary tract infections and their associated sequelae. Pediatrics 1989;83:1011-1015; circumcision, foreskin, pre-puce, urinary tract infection.
Circumcision is the most commonly performed surgical procedure in the United States.”2 The rou-tine removal of the foreskin has long been a contro-versial issue. The American Academy of Pediatrics
Ad Hoc Task Force on Circumcision concluded,
“There is no absolute medical indication for routine circumcision ofthe newborn.”3”’” However, recent
data suggest that circumcision protects against un-nary tract infections during infancy4’5 and against acquired immunodeficiency syndrome.6 Addition-ally, intriguing reports abound linking sexually transmissible diseases and the uncircumcised penis.7’8 Furthermore, cancer of the penis is the only malignancy in humans that can be prevented almost categorically by neonatal circumcision.9 Fi-nally, the majority of male infants are circumcised for social considerations.’#{176} For these reasons, we believe that the procedure will continue to be corn-monly performed during the neonatal period.
Physicians who perform circumcisions are re-sponsible for furnishing information regarding the risks and benefits of the procedure. However, to date there are limited data concerning the compli-cations of circumcision compared with those of the
uncircumcised penis. Herzog and Alvarez”
re-viewed the subject among older infants and children (aged 4 months to 12 years) and found a higher frequency of penile problems in uncircumcised boys. It is generally accepted that earlier compli-cations from the operation occur more frequently than those of the intact prepuce; however, there are no reports verifying this belief. We hypothesized that there would be no more serious complications in circumcised compared with uncircumcised boys during the first month of life. This study was de-signed to test our premise.
Received for publication Jan 6, 1988; accepted March 16, 1988. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
Reprint requests to (T.E.W.) 9016 First Aye, Silver Spring, MD 20910.
PEDIATRICS (ISSN 0031 4005). Copyright © 1989 by the American Academy of Pediatrics.
MATERIALS
AND
METHODS
The hospital records of all boys born in US Army facilities between Jan 1, 1980, and Dec 31, 1985,
were reviewed to determine the total number of
se-quelae, those that were specifically reported in the neonatal records or required subsequent hospitali-zation during the first month of life. The results may be an underestimation the actual frequency of adverse sequelae in both circumcised and uncircum-cised boys. During the neonatal hospitalization, minor complications, such as slight oozing from the circumcision site, may not have been indexed. After discharge, lesser problems were likely to have been treated on an outpatient basis. However, the focus ofthis investigation was to examine the more severe consequences of the circumcision decision. Finally, a small number of children may have been admitted to civilian, rather than military, facilities. These records would not have been available for review.
Some of the complications that were indexed (such as pneumothorax and bacteremia) may not have been a direct consequence of either being circumcised or “intact.” However, because these have been previously described as potential2’225 complications, all such episodes were included in our analysis.
Data were analyzed for significance with
x2
analysis.
P
.05 was considered to be statistically significant.RESULTS
During the study period, 136,086 boys were born in US Army hospitals. Of these, 100,157 (73.6%) were circumcised and 35,929 (26.4%) were not. The complications and relationship to circumcision
sta-tus are described in Tables 1 and 2. The 193 (0.19%)
reported complications in circumcised boys were principally due to infection, surgical trauma, and excessive bleeding. These included 62 local
infec-TABLE 1. Complications Following Circumcision in Boys <1 Month of Age (n = 100,157)*
Complication No.
Local infection/cellulitis 60
Balanitis 2
Bacteremia 8
Too much or too little skin removed 15 Injury to the urethra requiring plastic re- 1
pair
Circumcision in a child with hypospadias 1
Urinary tract infection 20
Wound dehiscence 7
Pneumothorax 1
Excessive blood loss
No ligatures needed 52
Ligatures needed 28
Transfusions/ligatures required 3
Meatal ulcers/meatitis/meatal stenosis 0
Loss of glans or penis 0
Deaths 0
* The total complication rate was 0.19%.
TABLE 2. Complications During the First Month of Life in Uncircumcised Boys (n = 35,929)*
Complication No.
Urinary tract infection 88 Concomitant bacteremia 32
Concurrent meningitis 3 Coexisting renal failure 2
Deaths 2
Balanoposthitis 0
Paraphimosis 0
Phimosis 0
* The total complication rate was 0.24%.
tions, eight cases of bacteremia (five were concom-itant with urinary tract infections), 83 episodes of hemorrhage (31 requiring ligature and three requir-ing transfusion), 25 instances of surgical trauma, and 20 urinary tract infections. Three of the 83 infants with hemorrhage (two of whom required transfusion) were subsequently found to have clas-sic hemophilia. The five episodes of bacteremia in the boys with urinary tract infection were not in-cluded in the total number of complications because the urinary tract infection itself already was noted. All 193 complications were in different boys. There were no reported deaths or losses of the entire glans or penis. Neither meatal ulcers nor meatal stenosis were indexed among the circumcised boys.
In the group of uncircumcised boys, the compli-cations were related to urinary tract infections. Of the 88 (0.24%) infants with such infections, 32 (36.4%) had concomitant bacteremia, three had meningitis with the same organism, two had renal failure, and two died. There were no reports of balanoposthitis, paraphimosis, or phimosis. In all cases of urinary tract infection-associated bactere-mia (for both circumcised and uncircumcised in-fants), the organisms isolated from the urine and the blood were identical.
There was no difference in the overall incidence of complications between the two groups. However, the frequencies of urinary tract infection
(P
<.0001) and bacteremia
(P
< .0002) were signifi-cantly higher in uncircumcised boys.DISCUSSION
There have been a number of reports describing the diverse complications of circumcision.2’1225 The problems range from a small amount of bleeding to
loss of the penis and even death. Most descriptions of serious sequelae, however, appear in isolated case reports. In few publications have the specific fre-quency of complications been addressed.2527 The data in these reports vary considerably.
circum-cised boys and found six “recorded mishaps” (0.06%). In addition, he surveyed the records of the
New York City Health Department and found one
death among 566,483 circumcised infants. The
death was due to hemorrhage following an
“at-home” procedure not performed by a physician. Patel26 interviewed 100 mothers of circumcised boys 7 to 18 months after the procedure. Fifty-five percent of the children were said to have had some type of complication, “varying from slight oozing of blood to phimosis needing recircumcision.”265#{176} Despite the small population size and the methods used, Patel’s study is still widely cited in the lay literature as demonstrating the high rate of com-plications due to circumcision (Newsweek, March 30, 1987, p 74).
Gee and Ansell27 examined the hospital records of 5,521 boys circumcised during a 10-year period. Approximately half of the infants were circumcised with the Plastibell device (Hollister, Inc, Chicago)
and half with the Gomco clamp. The incidence of
serious complications was 0.20%. In neither their investigation nor that of Pate! were there any pa-tient deaths or need for blood transfusions.
The most common adverse sequelae of circumci-sion are hemorrhage, infections, and surgical
trauma.2527 The uncommon complications of the
procedure (glans necrosis, staphylococcal scalded skin syndrome, etc) are atypical and receive note because of their uniqueness. The results of the current study support the infrequent occurrence and relatively mild nature of complications follow-ing prepuce removal. Thus, in several large studies, the incidence of such problems were found to be 0.06% to 0.20%, incidences that are probably less than that of any other surgical procedure.
Death rarely occurs as a complication of circum-cision. The 16 deaths per year reported from Eng-land during the middle 1940s were chiefly a conse-quence of general anesthesia.23 Of these deaths, 62% were in boys less than 1 year of age and 38% were in boys 1 to 4 years of age. As previously mentioned, Speert found only one death in a pop-ulation of more than one-half million circumcised boys. King8 reported 500,000 consecutive neonatal circumcisions performed without fatality. We have
reviewed the records of more than 300,000 boys
circumcised in US Army hospitals from 1970 to
1986 (unpublished data), and no boys have died as a consequence of the procedure. Finally, there have been no reported deaths due to the operation among more than 650,000 boys circumcised in the state of Texas since 1971 (5. Trevino, Texas Department of Health, Austin, personal communication, March 16, 1987). Although it has been claimed that there
may be as many as several hundred deaths from
circumcision in the United States29 each year (“The
Phil Donahue Show,” NBC Television, June 17,
1987), we can find evidence for no more than two to three deaths per year that can be attributed to the procedure among the more than 1,200,000 boys that are circumcised.
Serious complications of circumcision are rare. Unfortunately, foreskin ablation is regarded as a simple operation and is frequently delegated to the junior members of the medical hierarchy. We have
found that many complications can be traced to
poor technique, infections, and untrained opera-tons. To avert virtually all complications, “one has to comply with the principles of asepsis, adequate removal of the inner and outer preputial layers, hemostasis, and cosmesis.”30M5
Urinary tract infections are recognized as being ten to 20 times as common in uncircumcised boys compared with circumcised infants.4’5’3’ We listed urinary tract infections as complications in both groups of infants. However, we believe there is a causal relationship only in the uncircumcised boy. Urinary tract infections are not without conse-quence. Ginsburg and McCracken3’ reported blood cultures positive for bacteria in 31% of infants less than 30 days of age with urinary tract infection. We found that a similar proportion of boys with urinary tract infection had concomitant bactere-mia. Furthermore, several of the infants concur-rently had meningitis (also with the same orga-nisms), renal failure, and a fatal outcome. There are longer-term sequelae of urinary tract infections. Renal scarring will occur in 10% to 15% of infants after urinary tract infetions.3234 Of those with pa-renchymal scarring, hypertension will develop in approximately 10% and renal insufficiency will de-velop in 2% to 3%32-34 Children with urinary tract infection will eventually make up 25% of all pa-tients with end-stage renal disease.32M Finally, as many as 11% of children may die following a un-nary tract infection during the first month of life.35 In this investigation, we found neonatal circumci-sion to be beneficial in reducing the incidence of urinary tract infection and associated bacteremia.
We do not know how many boys will have
com-plications beyond 1 month of age from either being circumcised (concealed penis, poor cosmesis, etc) or not being circumcised (recurrent balanitis, con-dylomata, etc). Ideally, we would prospectively fol-low up either this cohort of infants or another group from birth. Realistically, however, a large number of these boys’ parents will leave the military during their sons’ early childhood. Furthermore, many fu-tune problems will be treated in an outpatient facil-ity or may not occur until many years later (penile cancer, sexually transmissible diseases, etc).
boys. We have previously discussed the reasons why we do not think this occurned.3 Furthermore,
there does not seem to be any difference in the socioeconomic status of families of circumcised
in-fants compared with uncircumcised boys.37 These latter two factors do not affect the occurrence of urinary tract infections in our described popula-tions.4’5
The mean age of occurrence of the urinary tract infections in uncircumcised boys was 3 weeks. This
is not surprising; uncircumcised boys are far more likely to have uropathogenic organisms at 2 weeks
of age and beyond rather than during the early
neonatal period.39
Herzog and Alvarez’0 recently compared the fre-quency of penile problems in uncircumcised and circumcised boys 4 months to 12 years of age.” The incidence of complications was significantly greater among the uncircumcised boys. These authors did not include urinary tract infection as a complica-tion. We suspect that, if they had done so, their differences would have been substantially greater.
Fergusson et a14#{176}examined the prevalence of penile problems in a cohort of more than 500 boys from birth to 8 years. They found most problems were from penile inflammation and occurred signifi-cantly more often in uncircumcised boys. They, too, failed to take into account urinary tract infections as a consequence of the intact prepuce. Further-more, these authors did not include the immediate sequelae from circumcision during the neonatal period (bleeding, etc). The reports of both Fergus-son et a! and Herzog and Alvarez indicate most penile problems to be relatively minor. Except for the problem of urinary tract infection, we concur with their analysis.
Our findings show that short-term complications of routine circumcision are rare and mostly minor, whereas urinary tract infection and bacteremia oc-cur with significantly greater frequency in uncir-cumcised boys. Because serious complications of either are rare, informed consent counseling con-cerning the procedure requires an honest and bal-anced discussion of the potential risks both of re-taming and removing the prepuce. Foreskin abla-tion is controversial, to say the least. The literature abounds with emotional defenses for and against circumcision. There are far fewer data-based re-ports. Wilson4””7’6 expressed the sentiment best, “There must be more light and less heat in discus-sions regarding circumcision.”
ACKNOWLEDGMENT
We are grateful to Joseph Whitson of the US Army
Patient Administration Systems and Biostatistics
Activ-ity, Ft Sam Houston, TX, for his help in data retrieval.
REFERENCES
1. Wallerstein E: Circumcision: The uniquely American medi-cal enigma. Urol Clin North Am l985;12:123 to 132 2. Kaplan GW: Circumcision-An Overview. Curr Probl
Pe-diatr 1977;7:1-33.
3. American Academy of Pediatrics, Committee on Fetus and Newborn: Report of the Ad Hoc Task Force on Circumci-sion. Pediatrics 1975;56:610-611
4. Wiswell TE, Smith FR, Bass JW: Decreased incidence of urinary tract infections in circumcised male infants.
Pedi-atrics 1985;75:901-903
5. Wiswell TE, Roscelli JD: Corroborative evidence for the decreased incidence of urinary tract infections in
circum-cised male infants. Pediatrics 1986;78:96-99
6. Simonsen JN, Cameron DW, Gakinya MN, et al: Human immunodeficiency virus infection among men with sexually transmitted diseases. N EngI J Med 1988;319:274-278 7. Parker SW, Stewart AJ, Wren WN, et al: Circumcision and
sexually transmissible disease. Med J Aust 1983;2:288-290 8. Fink AJ: Circumcision and heterosexual transmission of
HIV infection to men. N EngI J Med 1987;316:1545-1547 9. Boczko S, Freed 5: Penile carcinoma in circumcised males.
NY State J Med 1979;79:1903-1904
10. Herzog LW, Alvarez SR: The frequency offoreskin problems in uncircumcised children. Am J Dis Child
1986;140:254-2.56
11. Brown MS, Brown CA: Circumcision decision: Prominence of social concerns. Pediatrics 1987;80:215-219
12. MacDonald MG: Circumcision, in Fletcher MA, MacDonald
MG, Avery GB (eds): Atlas of Procedures in Neonatology. Philadelphia, JB Lippincott Co. 1983, pp 332-338
13. Woodside JR: Necrotizing fasciitis after neonatal
circumci-sion. Am J Dis Child 1980;134:301-302
14. Denton J, Schreiner RL, Pearson J: Circumcision compli-cations. Clin Pediatr 1978;17:285-286
15. Mor A, Eshel G, Aladjem M, et al: Tachycardia and heart failure after ritual circumcision. Arch Dis Child 1987;62:80-81
16. Frand M, Berant N, Brand N, et al: Complication of ritual circumcision in Israel. Pediatrics 1974;54:521
17. Auerbach MR, Scanlon JW: Recurrence of pneumothroax as a possible complication of elective circumcision. Am J Obstet Gynecol 1978;132:583
18. Horwitz J, Schussheim A, Scalettar HE: Abdominal disten-sion following ritual circumcision. Pediatrics 1976;57:579 19. Shiraki 1W: Congenital megalourethra with
urethrocuta-neous fistula following circumcision: A case report. J Urol
1973;109:723-726
20. Kirkpatrick BV, Eitzman DV: Neonatal septicemia after circumcision. Clin Pediatr 1974;13:767-768
21. Rubenstein MM, Bason WM: Complication of circumcision done with a plastic bell clamp. Am JDiS Child 1968;116:381-382
22. Radhakrishnan J, Reyes HM: Penoplasty for buried penis secondary to “radical” circumcision. J Pediatr Surg 1984; 19:629-631
23. Gairdner D: The fate ofthe foreskin. Br Med J
1947;2:1433-1437
24. Shulman J, Ben-Hur N, Neuman Z: Surgical complications of circumcision. Am J Dis Child 1964;107:149-154
25. Speert H: Circumcision of the newborn: An appraisal of its present status. Obstet Gynecol 1953;2:164-172
26. Patel H: The problem of routine circumcision. Can Med Assoc J 1966;95:576-581
27. Gee WF, Ansell JS: Neonatal circumcision: A ten-year over-view: With comparison of the Gomco clamp and the Plas-tibell device. Pediatrics 1976;58:824-827
28. King LR: Neonatal circumcision in the US in 1982. J Urol
1982;128:1135-1136
29. Enzenauer RW, Smith AG: Circumcision: Needless risks, no medical benefits. RN 1983;46:99-100
30. Kaplan GW: Complications ofcircumcision. Urol Clin North
Am 1983;10:543-549
in young infants. Pediatrics 1982;69:409-412
32. Spencer JR. Schaeffer AJ: Pediatric urinary tract infections.
Urol Clin North Am 1986;13:661-672
33. Roberts JA: Does circumcision prevent urinary tract infec-tions? J Urol 1986;135:991-992
34. Smellie JM, Prescod N: Natural history of overt urinary infection in childhood, in Asscher AW, Brumfitt W (eds):
Microbial Diseases in Nephrology. New York, John Wiley &
Sons, Ltd. 1986, pp 243-255
35. LittlewoodJM: Sixty-six infants with urinary tract infection in first month of life. Arch Dis Child 1972;47:218-226 36. Wiswell TE: Prepuce care, letter. Pediatrics 1986;77:265
37. Wiswell TE: Circumcision and urinary tract infections, let-ter. Pediatrics 1986;77:267-269
38. Wiswell TE: Care of the uncircumcised penis, letter. Pedi-atrics 1987;80:765-766
39. Wiswell TE, Miller GM, Gelston HM, et al: The effect of circumcision status on periurethral flora during the first year of life. J Pediatr 1988;113:442-446
40. Fergusson DM, Lawton JM, Shannon FT: Neonatal circum-cision and penile problems: An eight year longitudinal study.
Pediatrics 1988;81:537-541
41. Wilson RA: Circumcision. Can Med Assoc J
1977;116:715-716
DR CHARLES
WEST
ON THE
PROPER
(1850)
APPROACH
TO THE
ILL CHILD
Charles West (1816-1898), founder of the Children’s Hospital, Great Ormond Street, London, has been described by Fielding H. Garrison, America’ s leading medical historian, as: “The greatest English pediatnist of his time, and perhaps the most genial practitioner ofthe art who ever lived.” West’s pediatric treatise, first published in 1848, opens with this admirable advice on the approach to the ill child.2
The quiet manner and the gentle voice which all who have been ill know how to value in their attendants, are especially needed when the patient is a child. Your first object must be not to alarm it; if you suceed in avoiding this danger, it will not be long before you acquire its confidence; do not therefore, on entering the room, go at once close up to the child, but, sitting down sufficiently near to watch it, and yet so far off as to attract its attention, put a few questions to its attendant. While doing this, you may, without
seeming to notice it, acquire a great deal of important information; you may observe the expression of the face, the character of the respiration, whether slow or frequent, regular or unequal, and if the child utter any sound, you may attend to the character of the cry. All your observations must be made without staring the child in the face, little children,
especially if ill, seem always disturbed by this, and would be almost sure to cry. If the
child be asleep at the time of your visit, your observations may be more minute; the kind of sleep should be noticed, whether quiet or disturbed, whether the eyes be perfectly closed during it, or partly open as they are in many cases where the nervous system is disordered: you may, too, if the sleep seem sound, venture to count the frequency of the respiration, and the beat of the pulse, but in doing this you should be careful not to arouse the child. It should be awoke gently by the nurse or mother, and a strange face should not be the first to meet its eye on awakening. If it were awake when you entered the room, it will probably in a few minutes have grown accustomed to your presence, and will allow you to touch its hand, and feel its pulse.
REFERENCES
Noted by T.E.C., Jr, MD
1. Garrison FH. History ofpediatrics., In: Isaac and Arthur Abt. Abt-Garrison History of Pediatrics.
Philadelphia, PA: WB Saunders; 1965:89