Circumcision Cut It or Leave It West Virginia

Circumcision: Cut It or Leave It. ! West Virginia Chapter on AAP, 4/15/2016 OSAMA AL-OMAR, MD. FEBU. FACS. ASSISTANT PROFESSOR OF SURGERY WEST VIRGINIA UNIVERSITY (WVU) CHAD MORLEY, MD CHIEF RESIDENT OF UROLOGY WEST VIRGINIA UNIVERSITY (WVU)

Introduction: • Medical organizations’ position on circumcision. • Advantages. • Disadvantages/Complications. • Costs. • Closing statement.

Disclosure: • Both presenters have neutral position for circumcision, and neither one is pro or against routine neonatal circumcision. • This presentation is an attempt to provide evidence based for two side of long standing argument about circumcision. • The balance of this presentation is mainly tilted toward neonatal circumcision (NC), as non-neonatal circumcision is mostly done as treatment for underlying conditions, which is beyond the scope of this presentation. • Dr. George Kaplan: “There probably is no procedure that has produced as much emotion and rhetoric as circumcision”

Medical Organizations’ Position: • American Academy of Pediatric (AAP): Ø On August 27, 2012, the AAP released its most recent Policy Statement on Circumcision: * “New scientific evidence shows the health benefits of newborn male circumcision outweigh the risks of the procedure, but the benefits are not great enough to recommend routine circumcision for all newborn boys” *AAP: August 27/2012

Medical Organizations’ Position: Continue… 1 • American Academy of Family Medicine (AAFM): Ø The American Academy of Family Physicians (AAFP) position of 2001, and reaffirmed in 2012, is similar in context and tone to the AAP statement: * “The potential health benefits from circumcision justify it being a covered medical service by third-party payers, and it should be an available service for those who desire it” *http: //www. aafp. org/about/policies/all/neonatal-circumcision. html

Medical Organizations’ Position: Continue… 2 • American College of Obstetricians and Gynecologists (ACOG): Ø ACOG endorsed the policy statement that was issued by AAP in 2012: * “We support the idea that parents choosing circumcision should have access to the procedure” said Sabrina Craigo, MD, the College’s liaison to the AAP task force on circumcision. *http: //www. acog. org/About-ACOG/Announcements

Medical Organizations’ Position: Continue… 3 • American Urological Association (AUA): Ø The (AUA) policy statement of 1989 with a final revision in 2012, is in favor of nonroutine neonatal circumcision after proper counseling, and states that: * “AUA believes that neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks. Neonatal circumcision is generally a safe procedure when performed by an experienced operator…. Nevertheless, when performed on healthy newborn infants as an elective procedure, the incidence of serious complications is extremely low” *https: //www. auanet. org/education/policy-statements/circumcision. cfm

Medical organizations’ position: Continue… 4 • World Health Organization (WHO): Ø WHO took a neutral position on this subject in its published report “Neonatal and child male circumcision: Global review”, 2010: * “Our review of the published literature shows that there is relatively little literature on this very common surgical procedure, but that neonatal, infant and child circumcision is generally a safe procedure when conducted by trained and experienced providers in hygienic conditions” Ø However, WHO is recommending adult male circumcision in areas with HIV epidemic, especially the region of sub-Saharan Africa: ** *http: //www. who. int/hiv/pub/malecircumcision/neonatal_child_MC_UNAIDS. pdf **World Health Organization. Global health sector strat- egy on HIV/AIDS 2011– 2015. 2011.

Medical Organizations’ Position: � 2010 The Royal Australasian College of Physicians 1 �"After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand. " � 2015 The Canadian Paediatric Society 2 �“The CPS does not recommend the routine circumcision of every newborn male. ” � 2003 Central Union for Child Welfare in Finland 3 �“Circumcision of boys violates the personal integrity of the boys is not acceptable unless it is done for medical reasons to treat an illness. ” 1. Circumcision of Male Infants. Sydney: Royal Australasian College of Physicians, 2010 2. S Todd Sorokan et al. Canadian Paediatric Society, Paediatr Child Health 2015 3. Position Statement on the Circumcision of Boys. Helsinki: Central Union for Child Welfare. 2003

Medical Organizations’ Position: � 2010 Royal Dutch Medical Society 4 � “There is no convincing evidence that circumcision is useful or necessary in terms of prevention or hygiene. Partly in the light of the complications which can arise during or after circumcision, circumcision is not justifiable except on medical/therapeutic grounds. Insofar as there are medical benefits, such as a possibly reduced risk of HIV infection, it is reasonable to put off circumcision until the age at which such a risk is relevant and the boy himself can decide about the intervention, or can opt for any available alternatives. ” � 2006 British Medical Association � “The BMA does not believe that parental preference alone constitutes sufficient grounds for performing a surgical procedure on a child unable to express his own view. Parental preference must be weighed in terms of the child's interests. . The BMA considers that the evidence concerning health benefit from non-therapeutic circumcision is insufficient for this alone to be a justification for doing it. . Some doctors may wish to not perform circumcisions for reasons of conscience. Doctors are under no obligation to comply with a request to circumcise a child. ” 4. Non-therapeutic circumcision of male minors. Utrecht, Royal Dutch Medical Association, 2010.

Medical Organizations’ Position: �American Academy of Pediatrics (AAP) in 2012 �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. �Parents ultimately should decide whether circumcision is in the best interests of their male child AAP policy statement. 201

Medical Organizations’ Position: � The American Academy of Family Physicians recommends physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn son. 5 � The American College of Obstetricians and Gynecologists (ACOG)6 �ACOG cannot and does not recommend elective non- therapeutic circumcision of infant boys for medical reasons or for any other reason. � American Medical Assocation (AMA)7 �In circumstances in which there are potential benefits and AAFP Commission on Position Paper on Neonatal risks, yet the procedure is 5. not essential to. Science. the child's current Circumcision. Leawood, Kansas: American Academy of Family well-being, parents should. Physicians, determine 2002. what is in the best 6. The American College of Obstetricians and Gynecologists interest of the child. (ACOG), 2012 7. Council on Scientific Affairs. Report 10: Neonatal circumcision.

Advantages of Circumcision

Advantages: • Indication: Ø No absolute indication for circumcision, especially in the newborn period…………”ELECTIVE” Ø Surgical indications for circumcision are either: • Preventive (HIV) • Therapeutic (balanitis xerotica obliterans BXO). Ø Majority of cases are done for: • religious, ritual, cultural and cosmetic reasons.

Advantages: Continue… 1 • AAP Task Force Recommendation: “Evaluation of the current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it. ” AAP circumcision policy statement 2012

Advantages: Continue… 2 • Hygiene: Ø Prevent collection of microorganism behind foreskin. Ø Eliminate Smegma. Ø Protect against BXO

Advantages: Continue… 3 • UTI: Ø Lowers the risk of urinary tract infections in the first year of life. 1 Ø A meta-analysis in 2005 noted that circumcision reduced UTI 7. 7 fold (infants)2 Ø In the “Pediatric Research in Office Settings Febrile Infant Study”: being uncircumcised was the strongest multivariate predictor of UTI, with an odds ratio of 11. 6 (95% CI 5. 9– 22. 6)3 Ø In Seattle study: The protective effect of circumcision against UTIs continues into adulthood, with a 5. 6 -fold higher rate of UTI in the uncircumcised (average of men was 32 years)4 1. AAP policy statement. 2012 2. Singh-Grewal D, et al. Arch Dis Child. 2005; 90: 853– 8. 3. Newman TB, et al. Arch Pediatr Adolesc Med. 2002; 156: 44– 54. 4. Spach DH, et al. J Am Med Assoc. 1992; 267: 679– 81.

Advantages: Continue… 4 • STIs: Ø Lower risk for: * • Genital herpes (type 2) (34% decreased risk), • Human papilloma virus (HPV) (30% decreased risk). • Syphilis (39%). ** Ø No decreased risk on Gonorrhea or Chlamydia. *AAP policy statement 2012 **Meta-analysis, 2006. Weiss HA, et al. Sex Transm Infect. 2006; 82: 101–

Advantages: Continue… 5 • Penile Cancer: Ø Circumcision also lowers the risk of penile cancer over a lifetime: • The predicted lifetime risk of penile cancer for an uncircumcised man in the U. S. (1: 600). • 2 case-control studies: showed that the absence of circumcision confers an increased risk of penile cancer (OR 1. 5, CI of 1. 1– 2. 2) 1. Kochen M, et al. Am J Dis Child. 1980; 134: 484– 6. 2. Daling JR, et al. Int J Cancer. 2005; 116(4): 606– 616

Advantages: Continue… 6 • Cervical Cancer: Ø Circumcision reduces the risk of cervical cancer in sexual partners. (AAP statement) • HPV infection with oncogenic types (HPV types 16, 18, 31) is the main prerequisite to developing cervical squamous carcinoma. 1 • There was a lower incidence of HPV detection in circumcised men compared with uncircumcised men (5. 5% and 19. 6%, respectively). 2 • A meta-analysis in 2009 of 14 studies (5. 5 X risk of cervical cancer in women whose male partners are uncircumcised). 3 1. AAP policy statement. 2012. 2. Castellsague X, et al. N Engl J Med. 2002; 346(15): 1105– 1112 3. Bosch FX, et al. J Fam Plann Reprod Health Care. 2009; 35: 5– 7.

Advantages: Continue… 7 • HIV: • Lower risks of acquiring HIV: Ø Several RCTs has shown circumcision reduces risk of heterosexually acquired HIV infection in men by 50– 60% in areas with high HIV prevalence (ie, Africa). 1, 2 • South Africa (published in 2005) • Kenya (published in 2007) • Uganda (published in 2007) 1. AAP policy statement. 2012. 2. http: //www. who. int/hiv/pub/malecircumcision/neonatal_child_MC_UNAIDS. pdf

Advantages: Continue… 8 • Prostate Cancer: Ø 1 in 7 men will be diagnosed with prostate cancer during his lifetime. 1 Ø Prostate cancer is the 2 ed leading cause of cancer death in American men ( lung cancer is 1 st). 1 Ø Risk of prostate cancer has been found to correlate with a history of STIs. 2 Ø Uncircumcised men have a 1. 6 - to 2. 0 -fold higher incidence of prostate cancer (due to higher risk for STIs). 2 1. ACS http: //www. cancer. org 2. Ross RK, et al. J Natl Cancer Inst. 1987; 78: 869– 74.

“Mythical” Advantages �Hygiene – �In 1999, the AAP said, "there is little evidence to affirm the association between circumcision status and optimal penile hygiene. “ �AAP states there is no difference in cleaning of uncircumcised and circumcised penis �Wash with soap and water �Several studies do show more bacteria flora under foreskin and periurethral in uncircumcised boys, but… “the long-term significance of the findings is unclear” AAP policy statement. 20

“Mythical” Advantages �UTI �Boys with real risk of UTI are those with other GU anomalies, like vesicoureteral reflux �Lack of data for those over 2 years old �Incidence in boys under 2 years old 1 �Uncircumcised 1 -2 % �Circumcised 0. 2 -0. 4% Therefore, the NNT is ~ 100, so you must circumcise 99 boys to prevent 1 UTI!2 1. http: //www. circumcision. org/aap. htm 2. AAP Policy statement. 2012

“Mythical” Advantages �STDs, including HIV �Condoms show a better reduction than circumcision � 98 -99% effective against transmission of HIV when used correctly 1 �Reduces the risk of transmission of STDs such as gonorrhea, chlamydia, and trichomoniasis. 2 �The African studies did not seek to determine the source of the HIV infections. Most HIV infections in Africa are transmitted by contaminated injections and surgical procedures 3 �In Europe, where circumcision is rare, there is no increase in the incidence of HIV transmission. 3 1. 2. Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database Systematic Review. 2002; (1): CD 003255. http: //www. cdc. gov/condomeffectiveness/docs/condoms_and_ stds. pdf

“Mythical” Advantages �Penile Cancer �The incidence of penile cancer is 0. 58 cases in 100, 000 in the United States, where circumcision is common �The incidence of penile cancer is 0. 82 case in 100, 000 in Denmark, where circumcision is rare. �Rates are declining in both countries �It is thought that socioeconomic and economic development factors (including effects on hygiene habits) may have an important role (NOT Circumcision) According to studies cited in the report, between 909 and 322, 000 circumcisions would be required to prevent one case of penile cancer

“Mythical” Advantages �Cervical Cancer �More Condoms! �Reduces HPV transmission by approximately 70%1 �Gardasil and Cervarix �HPV vaccination has been found to prevent nearly 100 percent of the precancerous cervical cell changes that would have been caused by HPV 16/182 “Thus, the contribution of male circumcision to prevention of cervical cancer is likely to be small. ” (2012 AAP Policy Statement) 1. 2. Winer, R et al. (2006). "Condom use and the risk of genital human papillomavirus infection in young women". N Engl J Med "Human Papillomavirus (HPV) Vaccines". National Cancer

“Mythical” Advantages �Prostate Cancer �Condoms, again!! �IF…the “association” is due to an increased risk of STDs �Several studies shows real benefit is if circumcision occurs before sexually active, therefore the patient could decide to be circumcised �Ross et al paper in 1987 did not take into account family history, which is a known risk factor 1 �“It’s still premature to say go ahead with circumcision to prevent prostate cancer, ” said lead author Marie-Elise Parent 1 1. Wright, J. L. , Lin, D. W. and Stanford, J. L. (2012), Circumcision and the risk of prostate cancer. Cancer, 118 2. Spence, A. R. , Rousseau, M. -C. , Karakiewicz, P. I. and Parent, M. -É. (2014), Circumcision and prostate cancer: a population-based case-control study in Montréal, Canada. BJU

Disadvantages of Circumcision

Disadvantages – Pain �Circumcisions are Painful!!

“In less than 30 seconds, a nurse can immobilize the struggling infant securely in the correct position with Circumstraint. The immobilizer works on a proven principle of positive 4 -point restraint. Soft wide Velcro straps encircle the infant's elbows and knees, depriving him/her of leverage. The child is held safely and securely without danger of escape. Circumstraint's comfortable contoured shape positions the infant, hips elevated, perfectly presenting the genitalia. The platform between the infant's legs provides support for a circumcision clamp. Without pins, towels, plastic shells or the threat of strangulation, Circumstraint snugly and securely immobilizes the infant with their entire torso visible. ” http: //www. quickmedical. com/olympicmedical/circumstraint/immobo lizer. html

Disadvantages �Circumcisions are Painful!! �AAP update in Feb 2016 – �“Preventing or minimizing pain in neonates should be the goal of pediatricians and other health care professionals who care for neonates. ” �Exposure to repeated painful stimuli early in life is known to have short- and long-term adverse sequelae. �Physiologic instability, �Altered brain development �Abnormal neurodevelopment, somatosensory, and stress response systems Anand KJ, Aranda JV, Berde CB, et al. Summary proceedings from the neonatal pain-control group. Pediatrics. 2006; 117(3 Suppl 1): S 9– S 22 pmid: 16777824

http: //www. circumstitions. com/Pain. html

Disadvantages �Other acute complications �Bleeding �Hematoma �Infection �Penile amputation �Urinary retention

Disadvantages �Too much skin removed �Tissue epithelizes causing unacceptable cosmesis �Increases likelihood of concealed penis �May require skin grafting �Too little skin removed �Increases likelihood for penile adhesions �Requires circumcision revision under general anesthesia �Dr. AL-Omar has revised 106 circumcisions since March 2013 �Hundreds of other outpatient visits

Disadvantages – Meatal Stenosis � Thought to be secondary to glans irritation causing meatitis or ischemia from damage to frenular artery during circumcision � Incidence �Allen et all in 1973 reported an incidence of 32%1 �Joudi et al in 2011 found the rate to be 20. 4% after neonatal circumcision 2 � Symptoms �Spraying urine stream �Dysuria, frequency and gross hematuria �UTIs � Dr. AL-Omar has performed 91 meatoplasties since March 2013 1. Allen SJ, Summers JL, Wilkerson JE: Meatal calibration of newborn boys. I Urol 107: 498, 1972. 2. Joudi. J Pediatric Urology. 2011

Disadvantages – Erectile Dysfunction �Circumcised men have a 4. 5 times greater chance of suffering from erectile dysfunction (ED) than intact men �Reduced glans sensitivity due to keratization and excision of perineal nerve endings in the frenulum �Reduced penile sensation by 75%1 �Inability of achieve an erection � 5 x increase in premature ejaculation 2 1. Sorrells, M. L. , Snyder, J. L. , Reiss, M. D. , Eden, C. , Milos, M. F. , Wilcox, N. and Van Howe, R. S. (2007), Fine-touch pressure thresholds in the adult penis. BJU International, 99: 864– 869. 2. Tang WS and Khoo EM. Prevalence and correlates of premature ejaculation in a primary care setting: A preliminary cross-sectional study. J Sex Med 2011; 8: 2071– 2078

Disadvantages �Other late complications �Abnormal healing �Epidermal inclusion cysts �Penile curvature (chordee) �Phimosis �Necrosis of the penis �DEATH

CIRCUMCISION CAUSES AUTISM!!!

Disadvantages – Autism � Analyzed 340, 000 boys born in Denmark between 1994 and 2003. � The overall risk of developing autism before age 10 was almost 50 percent higher for circumcised boys than uncircumcised boys � Why? �“. . . painful experiences in neonates have been shown in animal and human studies to be associated with longterm alterations in pain perception, a characteristic often encountered among children with ASD. . . The present study was carried out to address the hypothesis that ASD might be a rare adverse outcome in boys undergoing ritual circumcision during a vulnerable period in life. ” – Dr. Morten Frisch

Disadvantage…. ? !!.

Disadvantage: Continue… 1 • AUA statement: “The incidence of serious complications is extremely low. The minor complications are reported to be (3%)”. • AAP statement: “Significant acute complications are rare. In general, untrained providers who perform circumcisions have more complications than well-trained providers who perform the procedure”.

Disadvantage: Continue… 2 • Pain: Ø Anyone who has performed circumcisions, knows that newborn babies respond appropriately to painful stimuli. Ø AAP statement: “Analgesia is safe and effective in reducing the procedural pain associated with newborn circumcision” Ø Pain management (Safe and effective)* • Dorsal penile nerve block (DPNB). • Ring Block. • Topical Anesthesia (EMLA, Tetracaine gel). • Sucrose pacifier: is insufficient as a sole agent, but may use in adjacent to local agents. *Lenhart JG, et al. J Am Board Fam Pract. 1997; 10: 310– 1. Lander J, et al. JAMA. 1997; 278: 2157– 62.

Disadvantage: Continue… 3 • Acute Complications (Bleeding, hematoma, infection…etc. ) Ø Wiswell et al. (1989): * • Reviewed the records of more than 100, 000 circumcisions in U. S. Army hospitals. • Overall complication rate was (0. 29%): • Bleeding was (0. 08%) • Infection (0. 06%) • Too much or too little skin removed (0. 01%) • No deaths. Ø Christakis, et al. (2000): ** • Reviewed the hospital discharge records of over 130, 000 circumcisions from Washington State. • Overall complication rate was (0. 22%): • Bleeding was the most common with an incidence of 0. 18%. • A penile injury occurred in 0. 04%, • Infection was identified in 0. 0008%. *Wiswell TE, et al. Pediatrics. 1989; 83(6): 1011– 5. **Christakis DA, et al. Pediatrics. 2000; 105(1 Pt 3): 246– 9 .

Disadvantage: Continue… 4 • Late complications (Redundant foreskin, excessive skin removal, adhesions, meatal stenosis, concealed penis, and epithelial inclusion cysts): Ø They usually occur late in childhood. Ø Meatal stenosis: • • Van Howe (2006)*: reported (7. 3%) incidence of meatal stenosis in boys greater than 3 years old. Circumcision and Sexual function, Sensation, Satisfaction: Ø The literature review does not support the belief that male circumcision adversely affects penile sexual function, regardless of how these factors are defined: • Two US studies in 2002 found similar or greater sexual satisfaction in men after circumcision as adults [Collins et al. , 2002; Fink et al. , 2002]. • Uganda study: A randomized controlled trial of 4, 456 sexually-experienced men aged 15 -49 found no difference in sexual satisfaction or clinically significant function between circumcised and uncircumcised men [Kigozi et al. , 2008]. • Kenya study: A large randomized controlled trial, dispelled the myth that circumcision diminishes penile sensitivity. In fact 64% of the men in this trial reported an INCREASE in their penile sensitivity and 55% reported greater ease in reaching orgasm [Krieger et al. , 2008]. Van Howe RS. Clin Pediatr (Phila). 2006; 45(1): 49– 54.

Disadvantage: Continue… 5 CIRCUMCISION CAUSES AUTISM!!! C’MON MAN!!!. .

Disadvantage: Continue… 6 • Dr. Douglas S. Diekema, one of the authors of the AAP Policy Statement: Ø Dr. Frisch is known in Denmark as an outspoken critic of circumcision (bias concern) Ø Correlation does not imply or prove causation. Ø While the rate of circumcision decreased in U. S from 80% to 62. 5% between 1980 and 1999, the rate of Autism increased from 1/150 to 1/60 between 1992 and 2002. Ø Diekema urged parents who wish to have their child circumcised to insist that adequate pain control be provided both during and after the procedure. http: //www. huffingtonpost. com/2015/

Costs of Circumcision

Costs �“It is difficult to get a man to understand something when his salary depends on his not understanding it. ” – Upton Sinclair

Costs �Neonatal Circumcision = $662 �Surgical Circumcision = $585 + ~$400 for anesthesia + Facility fee + OR time ~ $150 for each Plastibell

Costs �Circumcision Revision = $650 �Meatoplasty = $1212 �Lysis or Excision of Post-Circumcision Adhesions = $776 �Foreskin Restoration = at a minimum $7, 000

Costs �What’s the cost of keeping your foreskin? FRE E

Costs: • Is neonatal circumcision cost effective? • AAP Policy Statement: “…. . 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. ” • Indirect cost benefits of circumcision resulted from prevention of infant urinary tract infection, balanoposthitis, phimosis, HIV infection and penile cancer. • I agree with you that Post neonatal circumcision should be avoided as much as possible (unless medically indicated), because it costs 10 X more than neonatal circumcision. * *Schoen et al. J Urol, 2006.

Closing Statement: • Except for the region of sub-Saharan Africa, no call for routine circumcision has been made by any established medical organizations or governmental bodies. • The range of positions is from “some medical benefit/parental choice” in the United States, to “essential no medical benefit/ parental choice” in Great Britain, to “no medical benefit/physical and psychological trauma/parental choice” in the Netherlands. 1 • The preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure (AAP statement). • Parents should be carefully counseled about advantages and disadvantages of circumcision. • When circumcision is being performed on healthy newborn infants as an elective procedure, the incidence of serious complications is extremely low. The minor complications are reported to be 3%. • Adequate anesthesia should be provided during circumcision procedure. • Post neonatal circumcision is not cost effective, as it costs 10 X more than neonatal one. 1 Surgical guide to circumcision. Bolnick et al. 2012

Questions: • Thank You!