Neonatal
Circumcision
and Penile
Problems:
An 8-Year
Longitudinal
Study
D. M. Fergusson,
BA Hons,
J. M. Lawton,
BSc
Hons,
and
F. T.
Shannon,
FRCP,
FRACP
From the Christchurch Child Development Study, Department of Paediatrics,
Christchurch School of Medicine, Christchurch Public Hospital, Christchurch,
New Zealand
ABSTRACT. The prevalence ofpenile problems was
ex-amined in a birth cohort ofmore than 500 New Zealand
children studied from birth to 8 years ofage. By 8 years,
circumcised children had a rate of 1 1.1 problems per
100 children, and uncircumcised children had a rate of
18.8 per 100. The majority of these problems were for
penile inflammation including balanitis, meatitis, and
inflammation ofthe prepuce. However, the relationship between risks of penile problems and circumcision sta-tus varied with the child’s age. During infancy, circum-cised children had a significantly higher risk of prob-lems than uncircumcised children, but after infancy the rate of penile problems was significantly higher among the uncircumcised. These associations were not
changed when the results were adjusted statistically for
the effects of a series of potentially confounding social and perinatal factors. Pediatrics 1988;81:537-541; cir-cumcision, penis.
During the last two decades there has been
mounting opposition to the practice of routine
neonatal circumcision. The extent of the opposi-tion is well illustrated by thejoint statement from
the American Academy of Pediatrics and the
American College of Obstetricians and
Gynecol-ogists which concluded that “there is no absolute
medical indication for routine circumcision.”
However, this strong conclusion has been
chal-lenged by recent evidence that has suggested that there is a higher rate of urinary tract infection
among uncircumcised male infants24 and that
uncircumcised children are more susceptible to
Received for publication April 6, 1987; accepted July 1, 1987. Reprint requests to (D.M.F.) Christchurch Child Development Study, Dept. of Paediatrics, Christchurch School of Medicine, Christchurch Public Hospital, Christchurch, New Zealand. PEDIATRICS (ISSN 0031 4005). Copyright © 1988 by the American Academy of Pediatrics.
penile problems.5 Although the evidence for a
pos-sible link between circumcision and reduced rates
of urinary tract infection in infancy is
controver-sial,69 the general trends in the research
evi-dence suggest that circumcised and
uncircum-cised children may differ with respect to their
medical history.
To cast further light on this issue, we studied
longitudinally a birth cohort of more than 500
New Zealand boys from birth to 8 years of age.
The aims of this research were twofold: (1) to
ex-amine the association between the child’s
neo-natal circumcision status and risks ofpenile
prob-lems during early and middle childhood and (2)
to adjust any apparent correlation between
neo-natal circumcision status and risks ofpenile
prob-lems for the potentially confounding effects of a
number of social and perinatal factors.
METHODS
The data were collected during the first nine
stages of the Christchurch Child Development
Study in which a birth cohort of 1,265 children
born in the Christchurch (New Zealand) urban
region was studied at birth, 4 months, and annual intervals until the age of 8 years. At each time, information about the health, family conditions,
and social background of the children was
col-lected by a structured interview with the child’s
mother and supplemental information was
ob-tamed from other sources including hospital
med-ical records, general practitioner notes, and a
diary record of the child’s medical attendances kept by the mother. The method of data collection and quality control ofthe data has been described
in previous papers.’#{176}” The following measures
Neonatal
Circumcision
When the child was 4 months of age,
informa-tion concerning his circumcision status was
col-lected by maternal report and from existing
records.
Penile
Problems
During the period from birth to 8 years, infor-mation about the child’s history of medical at-tendance for penile problems was collected
rou-tinely from maternal reports, supplemented by
information from a diary record kept by the
mother and from medical records. From this
in-formation, the child’s history of medical
attend-ance was reconstructed and the following
mea-sures of penile problems were obtained: (1) the
number of episodes of inflammation of the penis experienced by the child. Penile inflammation in-cluded balanitis, meatitis, inflammation of the
prepuce, and conditions in which the penis was
described as sore or inflammed without any fur-ther diagnostic elaboration; (2) the number of
ep-isodes of phimosis experienced by the child. These
episodes included all times the child sought
mcd-ical attention for phimosis and associated
symp-toms. However, episodes for which the child was
brought to medical attention for “tight” or “non-retractable” foreskin but was not treated were not
classified as phimosis because it was likely that
most of these attendances were the result of
pa-rental anxiety or uncertainty about the
develop-ment of the foreskin rather than any pathologic
condition in the child; (3) inadequate circumcision
requiring repair or recircumcision; and (4)
post-operative infection following circumcision.
It is important to recognize that the data on medical attendance for penile problems was col-lected as part of a much larger longitudinal study of child health and development in which the pri-mary concern was not with the issue of the long-term consequences of circumcision. This feature of the data collection process places a number of
restrictions on the quality of the collected data.
Specifically, data relating to immediate
postcir-cumcision problems and penile problems that
were treated at home without medical attention
were not available. Also, diagnostic details of
medical attendances for penile problems were lim-ited. The net result of these imprecisions in the data collection process is that the incidence and prevalence of penile problems probably
underes-timated and the problems can only be described
in terms of broad diagnostic categories.
Nonethe-less, we believe that the trends that emerge from the analysis are likely to reflect general
differ-ences in the medical histories of circumcised and uncircumcised children.
Family
Social
Background
Information was available about the following aspects of the child’s family social background:
(1)
maternal age; (2) maternal education-thiswas classified as mother lacked formal
educa-tional qualifications, mother had secondary school qualifications (New Zealand school certificate,
university entrance) or, mother had tertiary
qualifications (university degree, professional qualifications); (3) ethnicity-children were clas-sified as Polynesian (ie, Maori or Pacific Islander) or white; (4) family socioeconomic status-this was based on the Elley and Irving’2 scale of so-cioeconomic status for New Zealand. This divides the population into six social classes on the basis
of male
occupation.
Children
whose
parents
were
unemployed or whose family depended on social
welfare benefits for their major support were de-fined as having “unclassified” socioeconomic
sta-tus level.
Perinatal
History
Measures of the child’s birth weight and ges-tational age were obtained from medical records of the birth.
Sample
Size
The present analysis is based on all male chil-dren observed at each year during the period from birth to 8 years. All children studied at each year were used so that all available data could be used and the analysis could have the maximum statis-tical sensitivity.’3 Sample numbers varied from 591 for the group of boys studied at 1 year to 553 for the group of boys studied at 8 years. The sam-plc studied at 8 years represented 87% of the 635
boys who entered the study at birth and 93% of
those boys who were resident in New Zealand at
8 years.
RESULTS
The rates of penile problems per 100 children 0 to 8years of age related to the child’s circumcision
status are given in Table 1. The majority of these
problems related to various forms of penile
in-flammation (75%) with phimosis (16%),
made-quate circumcision (4%), and postcircumcision infections (4%) accounting for the remaining
problems. (A number of children who were not
circumcised during the neonatal period are shown
TABLE 1.
Penile Problems in Boys 0tby Circumcision Status*
o 8 Years of Age
Uncircum-Condition Circumcised cised
Penile inflammation 7.6 (11) 14.4 (62)
Phimosis 0.0 (0) 3.7 (16)
Inadequate 2.8 (4) 0.0 (0)
circumcision
Postcircumcision 0.7 (1) 0.7 (3)
infection
Total 11.1 (16) 18.8 (18)
* The number of problems per 100 boys at risk are in
parentheses.
children who were circumcised after the age of 1 year and thus were at risk for postcircumcision
infection.) By 8 years of age, the uncircumcised
boys had a higher rate of penile problems (18.8 per 100) than the circumcised boys (11.1 per 100). This difference was marginally statistically sig-nificant
(x
= 5.75, P < .10).The comparisons given in Table 1 do not take into account the age at which penile problems oc-curred. This is shown in Table 2, where annual rates of penile problems related to neonatal cir-cumcision status are given. During infancy, cir-cumcised children were at greater risk for penile problems: the circumcised group had a rate of 5.5 problems per 100 children, in contrast to 1.1
prob-lems per 100 for the uncircumcised group
(x
=9.70, P < .01). After infancy, uncircumcised chil-dren were at greater risk for penile problems: the circumcised group had a rate of 5.6 problems per 100 children, in contrast to 17.7 problems per 100 for the uncircumcised boys
(x
=9.97,
P < .01).Collectively, these findings suggest that during
infancy circumcision was associated with
in-creased risks of penile problems but after infancy
with a reduction in these risks. However, the
comparisons given in Table 2 do not take into ac-count the potentially confounding social or pen-natal factors that may have influenced both the child’s neonatal circumcision status and risks of penile problems. To account for these factors the data were reanalyzed using logistic regression methods’4 that related the risks of penile prob-lems to the child’s circumcision status, maternal age, maternal education, family socioeconomic status, ethnicity, birth weight, and gestational age. The results of this analysis are summarized
in Table 3 where adjusted rates ofpenile problems
for circumcised and uncircumcised children dun-ing and after infancy are shown. The adjusted rates may be interpreted as the (hypothetical) rate of problems for each series after the come-lated effects of the control factors were taken into account. The effects of the control factors on the
correlations between neonatal circumcision and
risks ofpenile problems were negligible. This
sug-gests that it is unlikely that the apparent come-lation between neonatal circumcision and risks of penile problems can be explained by the presence of common confounding factors which influence both the child’s neonatal circumcision status and risks of subsequent penile problems.
DISCUSSION
The findings of this 8-year longitudinal study suggest the presence of an interactive relation-ship among the child’s neonatal circumcision sta-tus, age, and risks of penile problems. During in-fancy circumcised children had a significantly higher risk of penile problems, whereas after
in-TABLE 2.
Penil e Proble ms in Bo ys by Ag e and Ci rcumcisi on Statu s”Age (yr)
<1 2 3 4 5 6 7 8
Circumcised Uncircumcised Total 5.5 (146) 1.1 (445) 2.2 (591) 3.5 (141) 3.7 (436) 3.6 (577) 2.1 (138) 4.2 (433) 3.7 (571) 0 (137) 2.3 (430) 1.8 (567) 0 (137) 2.3 (425) 1.8 (562) 0 (137) 2.3 (425) 1.8 (559) 0 (137) 1.5 (417) 1.1 (554) 0 (137) 1.4 (415) 1.1 (553)
* Results are numbers ofproblems per 100 boys at risk. The number ofchildren studied are in parentheses.
TABLE 3.
Unadjusted and Adjusted Rates of Penile ProblemsInfants Children 1- 8 yr of Age Unadjusted Adjusted Unadjusted Adjusted
Circumcised 5.5 5.2 5.6 6.5
Uncircumcised 1.1 1.2 17.7 17.2
fancy these problems were significantly higher among the uncircumcised boys. The net effects of these trends were that by 8 years of age the
un-circumcised boys had experienced more than 1.5
times the rate of penile problems. The apparent
correlations between the child’s neonatal
circum-cision status and risks of penile problems could not be explained by the confounding effects of a range of social and peninatal factors.
The higher rate of problems among circumcised children during infancy may reflect the effects of exposure of the glans to imitation by wet diapers.
This has been noted previously and Kaplan’5”6
argues that meatitis and meatal ulcers occur
a!-most exclusively in circumcised boys for this
reason.
The higher rate of problems in uncircumcised children after infancy is consistent with the
find-ings ofHerzog and Alvarez5 who reported a higher
rate of problems among uncircumcised boys in a
sample of boys 4 months to 12 years of age. These
authors
did
not report higher rates of problemsamong circumcised infants younger than 1 year
of age. However, this difference may be explained
by the fact that Herzog and Alvarez’s data were
collected cross-sectionally and on a sample of chil-dren aged 4 months to 12 years and thus may have failed to provide adequate longitudinal data con-cemning the prevalence of penile problems during
infancy. In common with Herzog and Alvarez’s
findings, the great majority ofpenile problems
oc-curring in our sample were relatively minor and
most (64%) were resolved after a single medical
consulation.
These findings and recent evidence24
suggest-ing a link between urinary tract infection during
infancy and circumcision status inevitably
res-urrect the controversy about whether neonatal circumcision is ajustifiable procedure. On the one hand, it may be argued that the possible link be-tween urinary tract infection and circumcision and the greater rates of penile problems among uncircumcised boys after infancy justify
circum-cision.7 On the other hand, it may be suggested
that the higher rates of penile problems among
circumcised children during infancy coupled with the complications of circumcision including the
small risks of death and mutilation do not justify
the alleged benefits of circumcision.”7’9
This issue has been complicated by the
sugges-tions that circumcision reduces risks of penile
cancer and genital herpes.’9’2’ However, it has
also been argued that the apparent correlations
between circumcision status and these conditions could be due to confounding genetic or
environ-mental 17,22 Additionally, it is unclear
whether good hygiene can offer the alleged
ben-efits ofneonatal circumcision.”2225 Pediatricians and others will remain divided on these issues, but it is doubtful whether the existing evidence
provides unambiguous support for strong
posi-tions in favor of or against routine neonatal
cm-cumcision. However, one thing is clear. The
trends in recent evidence do suggest that the med-ical histories of circumcised and uncircumcised children differ systematically. Whether these dif-ferences are of sufficient magnitude to provide an
unambiguous justification for routine neonatal
circumcision is a matter that probably can only be established by further well-designed long-term
studies of populations of circumcised and
uncir-cumcised neonates.
REFERENCES
1. Guidelines for Perinatal Care. Evanston, IL, American Academy of Pediatrics and American College of Obstetri-cians and Gynecologists, 1983, p 87
2. Ginsberg CM, McCracken Gil Jr: Urinary tract infections in young infants. Pediatrics 1982;69:409-412
3. Wiswell TE, Smith FR, Bass JW: Decreased incidence of urinary tract infections in circumcised male infants. Pe-diatrics 1985;75:901-903
4. Wiswell TE: Futher evidence for the decreased incidence ofurinary tract infections in circumcised male infants. Pe-diatrics 1986;78:96-99
5. Herzog LW, Alvarez SR: The frequency of foreskin prob-lems in uncircumcised children. Am J Dis Child 1986;
140:254-256
6. Roberts JA: Does circumcision prevent urinary tract in-fection? J Urol 1986;135:991-992
7. Fink AJ: In defense of circumcision, letter. Pediatrics
1986;77:265-266
8. Malleson P: Prepuce care, letter. Pediatrics 1986;77:265
9. Cunningham N: Circumcision and urinary tract
infec-tions, letter. Pediatrics 1986;77:267
10. Beautrais AL, Fergusson DM, Shannon FT: Family life events and behavioral problems in preschool-aged chil-dren. Pediatrics 1982;70:774-779
11. Fergusson DM, Horwood U, Shannon FT: Birth place-ment and childhood disadvantage. Soc Sci Med
1981;15E:315-325
12. Elley WB, Irving JC: Revised socio-economic index for New Zealand. NZ J Educ Stud 1976;11:25-36
13. Cutler SJ, Ederer F: Maximum utilisation ofthe life table method in analysing survival. J Chronic Dis 1958;8:699-712
14. Lee J: Covariance adjustment of rates based on the
mul-tiple logistic regression model. JChronicDrs 1981;34:415-426
15. Kaplan GW: Circumcision-An overview. Curr Probi Pe-diatr 1977;7:1-33
16. Kaplan GW: Complications of circumcision. Urol Clin
North Am 1983;10:543-549
17. Canadian Paediatric Society, Fetus and Newborn Com-mittee: Benefits and risks of circumcision: Another view.
Can Med Assoc J 1982;126:1399
18. Gee WF, Ansell JS: Neonatal circumcision: A ten-year
overview: With comparison of the Gomco clamp and the Plastibell device. Pediatrics 1976;58:824-827
19. Burger R, Guthrie TH: Why circumcision? Pediatrics
1974;54:362-364
20. Warner E, Strashin E: Benefits and risks of circumcision.
Can Med Assoc J 1981;125:967-976, 992
21. St John-Hunt D, Newill RGD, Gibson OB: Three English-men favor circumcision and why they do, letter. Pediatrics
22. Thompson HC: The value ofneonatal circumcision: An
un-answered and perhaps unanswerable question. Am J Dis Child 1983;137:939-940
23. Philip AGS: Urologists views challenged, letter. Pediatrics
1975;56:338
24. Krueger H, Osborn L: Effects of hygiene among the
un-circumcised. J Fam Pract 1986;22:353-355
25. Sorrells ML: Still more criticism, letter. Pediatrics 1975; 56:339
FIVE DAYS
IN FINLAND
AT THE AGE OF 55
As I get older, my childhood self becomes more accessible to me, but
se-lectively, in images as stylized and suspect as moments remembered from a
novel read years ago. One’s hotel room is a place one is always trying to leave and yet always returning to. Staying in it, alone with the television set, seems cowardly and a waste of the airplane ticket, and yet leaving it-stepping into the long, windowless, carpeted hail, letting the door click shut as you tap your pocket to make sure the key is there-has a sadness, too: the sadness
of rejecting
a symbolic
mother,
a place
that
would
serve
as home.
Submitted by Student
