But none of these subjective findings are conclusive. Although circumcision appears to have some medical benefits, it also carries potential risks — as does any surgical procedure. These risks are small, but you should be aware of both the possible advantages and the problems before you make your decision. Complications of newborn circumcision are uncommon, occurring in between 0. Of these, the most frequent are minor bleeding and local infection, both of which can be easily treated by your doctor.
One of the hardest parts of the decision to circumcise is accepting that the procedure can be painful. In the past, it wasn't common to provide pain relief. But the American Academy of Pediatrics AAP recommends it and studies show that infants undergoing circumcision benefit from anesthesia, so most doctors now use it.
But because this is a fairly new standard of care, it's important to ask your doctor ahead of time what, if any, pain relief your son will receive. In addition to anesthesia, acetaminophen is sometimes given. This helps reduce discomfort during the procedure and for several hours afterward. Giving a pacifier dipped in sugar water and swaddling a baby also can help reduce stress and discomfort. Following circumcision, it is important to keep the area as clean as possible.
Gently clean with warm water — do not use diaper wipes. Soapy water can be used if needed. This article has been cited by other articles in PMC. Abstract Background: Although male circumcision is a surgical intervention that is frequently performed in children, there is no consensus about the age at which it should be performed. Patients and Methods: This clinical trial was conducted in the affiliated hospital of the Erzincan University of Medical Sciences, Turkey, in Results: A total of children were circumcised, in Group 1, 94 in Group 2, and in Group 3.
Keywords: Circumcision, Age Groups, Anesthesia. Background Circumcision is the surgical removal of the foreskin. Objectives This study was carried out to determine the best age range for performing routine male circumcision with respect to anesthetic approach, complications and costs. Statistics Continuous variables were shown as medians minumum-maximum and categorical data were presented as percentages. Results This study included a total of children.
Table 1. Open in a separate window. Table 2. Anesthesia Complications. Table 3. Surgical Complications. Table 4. Statistical Analyses of Groups a. Discussion Most of the debates about the best age at which to perform male circumcision focus on the following age groups: neonatal and infancy period, phallic stage age and school age 2 , 12 , References 1.
Male circumcision performed with 8-figure non-absorbable suture technique. Can Urol Assoc J. Circumcision in bleeding disorders: improvement of our cost effective method with diathermic knife. Urol J. A review of the current state of the male circumcision literature. J Sex Med. A 'snip' in time: what is the best age to circumcise? BMC Pediatr. Sedoanalgesia in pediatric daily surgery. Int J Clin Exp Med. Ann Fr Anesth Reanim. Comparison of postoperative analgesic efficacy of penile block, caudal block and intravenous paracetamol for circumcision: a prospective randomized study.
Int Braz J Urol. Anaesthesia for day case surgery: a survey of paediatric clinical practice in the UK. Eur J Anaesthesiol. Preanesthetic sedation of preschool children using intranasal midazolam.
Postanesthetic care in the critical care unit. Crit Care Nurse. Allocation of healthcare dollars: analysis of nonneonatal circumcisions in Florida. Am Surg. Circumcision during the phallic period: does it affect the psychosexual functions in adulthood? Try out PMC Labs and tell us what you think.
Learn More. After an extensive evaluation of the scientific evidence, the United States Centers for Disease Control and Prevention CDC released draft policy recommendations in December affirming male circumcision MC as an important public health measure. These recommendations are intended to assist health care providers in the United States who are counseling men and parents of male infants, children and adolescents in decision-making about male circumcision.
Such decision-making is made in the context of not only health considerations, but also other social, cultural, ethical, and religious factors.
Since the release of these trial data, various organizations have updated their recommendations about adult male and infant male circumcision. Systematic evaluation of English-language peer-reviewed literature from through indicates that preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure. Benefits include significant reductions in the risk of urinary tract infection in the first year of life and, subsequently, in the risk of heterosexual acquisition of HIV and the transmission of other sexually transmitted infections.
The procedure is well tolerated when performed by trained professionals under sterile conditions with appropriate pain management. Complications are infrequent; most are minor, and severe complications are rare. Male circumcision performed during the newborn period has considerably lower complication rates than when performed later in life. Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns.
It is important that clinicians routinely inform parents of the health benefits and risks of male newborn circumcision in an unbiased and accurate manner. Parents ultimately should decide whether circumcision is in in the best interests of their male child. They will need to weigh medical information in the context of their own religious, ethical, and cultural beliefs and practices.
The medical benefits alone may not outweigh these other considerations for individual families. Findings from the systematic evaluation are available in the accompanying technical report.
The American College of Obstetricians and Gynecologists has endorsed this statement. The CDC has a mandate to use the best available evidence to inform the public on interventions for disease prevention. In the case of early infant MC, there are few public health interventions in which the scientific evidence in favor is now so compelling. Here, we critically assess the evidence used by Frisch and Earp to support their thesis and respond to their main criticisms summarized in Box 3.
In a recently published article, Frisch and Earp 6 oppose the draft MC recommendations from the U. Failure to provide a thorough description of the normal anatomy and functions of the penile structure being removed at circumcision i.
Undue reliance on findings from sub-Saharan Africa concerning circumcision of adult males as opposed to infants or children Response: The evidence shows the CDC is correct in concluding that findings from sub-Saharan Africa concerning circumcision of adult males for protection against heterosexually-acquired HIV and certain other STIs also apply to men in the United States.
The findings also apply to boys when they grow up. Moreover, the cumulative lifetime benefit is greatest if circumcision is performed early in infancy since early infant circumcision is simpler, more convenient, and carries lower risk than when performed later, and circumcision confers immediate protection against urinary tract infections, phimosis, balanitis, and, when older, specific STIs and genital cancers.
MC also protects the female partners, as confirmed in randomized controlled trials. Uncritical reliance on a prima facie implausible benefit-risk analysis performed by a self-described circumcision advocate Response: The benefit-risk analysis used by the CDC is based on the best current evidence relevant to the United States, and the results are plausible. Reliance on misreported statistics to downplay the problem of pain in the youngest of boys Response: While procedural pain can occur during circumcision, the evidence cited by the CDC indicates that, with use of local anesthetic, pain is negligible in the first week of a boy's life.
Frisch and Earp misconstrue pain statistics to overplay the issue of pain. Reliance on incomplete register data to assess the frequency of short-term post-operative complications associated with circumcision, leading to a likely underestimation of their true frequency Response: By selective citation and misrepresentation of findings, Frisch and Earp overstate the frequency of short-term postoperative complications associated with MC while ignoring data from large high-quality studies such as those published recently by CDC researchers.
Serious underestimation of the late-occurring harms of circumcision presenting months to years after the operation most notably meatal stenosis. Response: Frisch and Earp selectively cite small, outdated, weak studies, often involving traditional circumcisers, and misrepresent data while ignoring large, high-quality studies.
As a result, they overestimate the frequency of meatal stenosis occurring years after the MC procedure. MC confers immediate and lifelong protection against numerous medical conditions Box 4. Male circumcision confers immediate and lifelong protection against numerous medical conditions. Sexually transmitted infections including high-risk human papillomavirus HPV , genital herpes simplex virus HSV , trichomoniasis, mycoplasma, syphilis, chancroid, and HIV.
Disputing the value of MC's protection against STIs, Frisch and Earp argue that less invasive STI prevention strategies should instead be promoted, such as encouraging safe sex practices. But we argue that public health messages normally include all effective measures for protection against disease, and in the case of STIs, MC complements current safe sex messages. The effectiveness of each approach should, moreover, be considered in real-world settings.
Frisch and Earp also contend that many STIs can be treated effectively if they do occur. We dispute that logic and instead argue that prevention is preferable to treatment, especially for viruses for which there is no cure e. And for bacterial STIs and urinary tract infection UTI , antibiotic-resistant strains mean that infections that were once easily treatable can now be life threatening.
The benefits of medical procedures should always, of course, be weighed with the potential risks. The risk of major surgical mishaps with MC, however, is extremely low and the benefits gained from MC far exceed risks. Systematic reviews have found no adverse effect of MC on sexual function, 28 , 29 , 33 sensitivity, or satisfaction. The survey concluded that MC is not associated with men's overall sexual function.
A risk-benefit analysis 8 cited by the CDC 2 found that benefits of infant MC exceed risks by over A letter 36 questioning this risk-benefit analysis that Frisch and Earp cite contained misunderstandings, as pointed out in the response to the letter.
See critique 40 for further details. But they fail to acknowledge that the healthy foreskin of an uncircumcised male remains vulnerable to adverse medical conditions, infections, and genital cancers.
Moreover, foreskin-preserving preputioplasty had to be repeated in 5. The uncircumcised foreskin remains vulnerable to adverse medical conditions, infections, and genital cancers. Foreskin problems continue into adulthood, as does MC for medical and cosmetic reasons. Since some men might not seek medical attention, especially for sexual or genital conditions, foreskin problems will always be more common than evident in case studies such as the one by Sneppen and Thorup.
Infant MC would prevent later foreskin problems and obviate the need for later MC which is more costly and risky. But most of the studies they cite to support their claim are small, quite old, comprised of MC performed by non-medical personnel, lack a control group of uncircumcised males, and either include no statistical analyses or include P values that were not statistically significant.
Furthermore, meatal stenosis is seen in uncircumcised males as well. In the Danish study, risk of developing meatal stenosis in uncircumcised boys before 18 years of age was 0. Among the lichen sclerosus patients in the Danish study, Finally, Frisch and Simonsen reported that circumcised boys may be at increased risk for autism spectrum disorder ASD due to MC-related pain. That report has been criticized. A study by Frisch claiming sexual dysfunctions in circumcised men 48 was one-sided and suffered from confounding and statistical flaws.
Sensitivity to vibration not tested by either Bossio et al. Thus, speculation and outdated opinion pieces claiming special properties of the foreskin, such as in penile function and masturbation, should be viewed with skepticism. Larger foreskins place uncircumcised men at increased risk for HIV infection. Arguments by MC opponents disputing the validity of the large African RCTs showing that MC provides substantial protection against heterosexually-acquired HIV infection have been exposed as fallacious.
Comparison of HIV and MC prevalence in high-income countries also suggest MC has a protective effect, providing further support to the applicability of the African MC trials to the United States and other high-income countries.
For example, HIV prevalence in the mostly uncircumcised populations of France and the Netherlands was much higher than in Israel where almost all men are circumcised, despite all other risk factors being comparable.
As well as substantial protection against HIV, data from the African RCTs reinforced the ability of MC to protect against several other STIs in heterosexual males, 10 , 11 , 13 , 16 , 71 , 82 — 90 as well as their female sex partners 10 , 91 — 95 and among MSM who are insertive-only. HIV subtype B arrived in Haiti from Africa between and , reaching the United States in the mids after Haiti became a popular destination for sex tourism.
Because Frisch and Earp dispute the low prevalence of adverse events with MC, they disagree with the conclusions from a cost-benefit study by authors from the Johns Hopkins University. We also contend that if other factors were considered in the model, including medical conditions associated with lack of MC, infections and genital cancers in both sexes, and indirect costs, MC would likely be cost-saving among U.
The U. In , the state withdrew Medicaid health insurance coverage for infant MC. That resulted in a 6-fold increase in medical costs for publicly funded MCs for medical indications, because later MCs are substantially more expensive than early infant MCs. Thus, in contrast to the assertions by Frisch and Earp, the cost-savings estimated by the CDC 77 and Johns Hopkins researchers 74 appear conservative.
Moreover, cost-savings from infant MC apply to whites, blacks, and Hispanics. There are many painful experiences encountered by the child before, during, and after birth. Cortisol levels, heart rate, and respiration have registered an increase during and shortly after infant MC. Most MC procedures can be performed under local anesthesia. General anesthesia involves risks, is usually unnecessary, and is falling out of favor. Frisch and Earp take issue with a study the CDC cited related to the issue of pain associated with the MC procedure, arguing that the figures cited from the study were inaccurate.
However, the error is trivial, resulting in a minor difference of up to 0. In addition, Frisch and Earp highlight that infants may also experience pain from administration of the anesthesia itself before the MC. Pain does occur during injection of local anesthetics, but it can be reduced by prior application of readily available topical anesthetic creams containing lidocaine and prilocaine EMLA, or the more potent LMX4.
In a clinical trial, application of EMLA cream 2 hours prior to Plastibell MC resulted in near absence of evidence of pain during and for 4 hours after infant MC, by which time nerves at the ablation site would have died, meaning a pain-free MC. While infants may experience pain from administration of a local anesthetic before circumcision, the pain can be reduced by prior application of topical anesthetic creams. A small telephone survey, misconstrued by Frisch and Earp, actually found parents' subjective perception of level of discomfort among infants circumcised at 4— days of age mean, Neonatal circumcision also provides some protection from penile cancer, a very rare condition.
Circumcision does, however, pose certain risks , such bleeding and swelling. While they may occur, however, bleeding and swelling are rare. Although the evidence also is clear that infants experience pain, there are several safe and effective ways to reduce the pain. If the baby is born prematurely , has an illness at birth, or has congenital abnormalities or blood problems, he should not be circumcised immediately.
In fact, circumcision should be performed only on stable, healthy infants. At birth, most boys have skin that completely covers, or almost covers, the end of the penis. Circumcision removes some of this foreskin so that the tip of the penis glans and the opening of the urethra, through which the baby urinates, are exposed to air.
Routine circumcisions are performed in the hospital within a few days of birth. When done by an experienced physician, circumcision takes only a few minutes and is rarely complicated. After consultation with you, your doctor will provide local anesthesia to reduce the pain the baby experiences during the procedure; the doctor should inform you in advance about the type of anesthesia she recommends.
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