Risks in Infants

Having described the benefits, let's look at the risks. Surgical complications for large published series range from 0.2% to 0.6% [Wiswell & Geschke, 1989; Cilento et al., 1999; Christakis et al., 2000]. Higher rates of 2–10% have been reported in much older and smaller studies [Kaplan, 1983; Griffiths et al., 1985; Frank, 2000].

One large study, conducted in US Army hospitals from 1980 to 1985, found that for 100,157 boys who were circumcised in the first month of life, there were 193 complications (0.19%) [Wiswell & Geschke, 1989]. These included 62 local infections, 83 instances of  hemorrhage (31 requiring ligatures and 3 requiring transfusion), 25 instances of surgical trauma, 20 urinary tract infections (com,pared with 88 UTIs in the 35,929 boys in this study who had not been circumcised), and 8 cases of bacteremia (compared with 32 in the uncircumcised). There were no deaths or reported losses of the glans or entire penis. However, in the uncircumcised boys, 3 developed meningitis, 2 got renal failure and 2 died.

The largest study, of 354,297 male infants born in Washington State from 1987–1996, noted a complication rate in the 130,475 who were circumcised during their newborn hospital stay of only 0.21% (1 in 476) [Christakis et al., 2000]. It was then calculated that 6 UTIs could be prevented for every circumcision complication, and 1 penile cancer could be prevented for every 2 complications.

Of 9,668 neonatal circumcisions performed in Kaiser Permanente Northern California hospitals none resulted in complications [Schoen et al., 2006].

In a small study of 500 New Zealand boys followed over a longer period, namely from birth to 8 years of age, the rate of penile problems was almost 2-fold higher in those who were not circumcised (19% versus 11%). Moreover, if both minor and more serious problems had not been lumped together, this study would have shown a much higher rate of problems in the uncircumcised [Fergusson et al., 1988].

In a small study of 500 New Zealand boys followed over a longer period, namely from birth to 8 years of age, the rate of penile problems was almost 2-fold higher in those who were not circumcised (19% versus 11%). Moreover, if both minor and more serious problems had not been lumped together, this study would have shown a much higher rate of problems in the uncircumcised [Fergusson et al., 1988].

An old study, spanning 1963 to 1972, in a US hospital in which circumcision rate was 94%, reported 111 of 5,521 newborns incurred a complication of any degree [Gee & Ansell, 1976]. Thus total complication rate was 2.0% (1 in 50). This included easily treatable outcomes as well as serious ones. For only 0.2% were adverse outcomes serious (a single case of a life-threatening hemorrhage, 4 systemic infections, 8 circumcisions of infants with hypospadias, and one complete denudation of the penile shaft). Thus risk was very low even in an old study like this one.

A study in 2005 of 19,478 circumcisions in Israel (on day 8 after birth), and made up of 83% ritual circumcisions and 17% involving a physician, found a complication rate of 0.34% [Ben Chaim et al., 2005]. The breakdown is shown below, to which has been added comments by Dr Sam Kunin, a urological surgeon from Los Angeles who is very experienced in the field of circumcision.

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Excess skin left 0.19%. This can be illusory. Dr Kunin says that if a baby is chubby, has an abundant prepubic fat pad or scrotal swellings from hydrocele or hernia it may look like not enough skin has been removed, when in reality the circumcision has been a good one. One can test this by seeing whether the glans penis is apparent in the erect state. To do this one can depress the fat surrounding the penis at the 3.00 and 9.00 o’clock positions to the pubic symphysis. If the glans is seen the circumcision is satisfactory. If the inner layer of foreskin is not completely freed up before circumcision there may be uneven inner skin left. This can lead to ‘buried penis’, which is when the penis retracts into the fat pad. It can occur with the Mogen method and is avoided by Gomco. Adhesions can develop between the glans penis and the remnant of the foreskin. To avoid this, parents must be instructed to routinely push the skin off the glans. Buried penis after newborn circumcision is not permanent, however, and, in most cases, resolves as the infant becomes older and begins to walk [Erog˘lu et al., 2009]. Thus surgery for buried penis is not recommended in boys less than 3 years [Erog˘lu et al., 2009].

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Acute bleeding 0.08%. Although rare, this is more prone to occur with a ritual shield. It cannot occur with the Plastibell.

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Penile torsion 0.03%. This is congenital, but can be revealed by circumcision. It does not affect function

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Skin shortage 0.02%. This is unlikely to occur if the circumciser is experienced

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Wound infection 0.01%. Although rare, this can be more common with Plastibell, if instruments are not sterilized adequately, or if in a ritual Jewish ceremony the mohel performs metzitza b’ pe (the sucking of blood from the would by mouth – which can also lead to herpes simplex type 1 infection).

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Partial amputation 0.005% (n = 1). Partial amputation cannot occur with the Plastibell or Gomco clamp, but is a remote possibility for Mogen clamps or, in Jewish ritual circumcisions, shields.

Inclusion cysts can occur, most often with the Mogen procedure, since freeing up the foreskin from the glans is blind and does not include cleaning out smegma, which becomes trapped in the line of the clamp to form a cyst. In Gomco and Plastibell a dorsal slit in the foreskin is made after clamping and at this time all inner connections can be released and smegma removed.

Dr Kunin is acknowledged for the clinical explanations and advice above. He says that it is important to equate a given complication with what tool is used, but overall complications should approach zero for an experienced operator.

Thus, in this study, complications were rare, mild and virtually all easily correctable, with little difference in rate between ritual and medical circumcisions.

An overall summary of the various complications of circumcision in infancy and the rates of each appears below. This information is taken from references: [Wiswell & Geschke, 1989; Wiswell, 1992; Wiswell, 1995; Wiswell, 1997a; Alanis & Lucidi, 2004].

Excessive bleeding: Occurs in 1 in 1,000. This is treated with pressure or locally-acting agents, but 1 in 4,000 may require a ligature, and 1 in 20,000 may need a blood transfusion because they have a previously unrecognized bleeding disorder. Hemophilia in the family is of course a contra-indication for circumcision.

Infection: Local infections occur in 1 in 100-1,000 and are easily treated with local antibiotics. Systemic infections may appear in 1 in 4,000 and require intravenous or intramuscular injection of antibiotics.

Subsequent surgery: Needed for 1 in 1,000 because of skin bridges, or removal of too much or too little foreskin. Repair of injury to penis or glans required for 1 in 15,000. Loss of entire penis: 1 in 1,000,0000, and is avoidable by ensuring the practitioner performing the procedure is competent. Injuries (rare) can be repaired [Baskin et al., 1997; Thompson et al., 2006; Shaeer et al., 2008] and in the extraordinarily remote instance of loss of the penis it can be reattached surgically [Ozkan & Gurpinar, 1997] and reconstruction is also possible [Beniamin et al., 2008; Shaeer, 2008]. (Successful reattachment can also follow adult self-inflicted penile amputation [Landström et al., 2004].)

Local anesthetic: The only risk is when the type of anesthetic used is a dorsal penile nerve block, with 1 in 4 having a small bruise at the injection site. This will disappear.

Death: Data in the records show that between 1954 and 1989, during which time 50,000,000 circumcisions were performed in the USA there were only 3 deaths, but during this period there were 11,000 from penile cancer, a disease essentially confined to the uncircumcised [Wiswell & Geschke, 1989; Wiswell, 1997a]. Wiswell found there were 2 deaths in those NOT circumcised, but NONE in the 3 times as many who were circumcised [Wiswell & Geschke, 1989]. The 3 deaths noted by Wiswell for the 35 years to 1989 were in children circumcised at home by a mohel (a Jewish religious circumciser).  Both of them had hemophilia (a new genetic mutation in their families, as there was no family history in either case).  The remaining death was due to infection in a 1.9 kg premature infant. In the largest published series of complications due to circumcision …. Speert's in the 1950s (~500,000 boys) [Speert, 1953], Wiswell’s in 1989 (~100,000 boys) [Wiswell & Geschke, 1989], and Christakis's in 2000 (~135,000 boys) [Christakis et al., 2000] …. there were no deaths from medical circumcisions. One death was reported by Speert, but involved a circumcision performed by a mohel who was not only unqualified, he wasn’t even registered with the New York board of mohelim. In a personal email communication in July 2009, Wiswell states “In the U.SA. I have not read of or heard of any NEONATAL circumcision deaths over the subsequent 20 years since our [1989] publication.” But for later circumcisions, Wiswell states “I am aware of one death in Cleveland just prior to a child's second circumcision at 4 months of age ... the parents did not like the appearance and a urologist agreed to do the second procedure. Prior to even starting, the anesthesiologist inadvertently injected air into the child's vascular system and the child died before even being cleansed for the procedure.” In the U.K., a report in 1949 by Gairdner noted 16 deaths "due to circumcision" during the World War II years, even though “circumcision” and “phimosis” were lumped together on autopsy sheets for cause of death. Jake Waskett points out (personal email communication in July 2009) that this death rate has been used by the anti-circumcision movement to incorrectly claim a “curiously precise figure of 220. The figure does not represent actual, documented deaths. The figure is an estimate, extrapolated from (a) the number of circumcisions performed annually in the USA, and (b) the death rate reported by Gairdner (16 in 90,000) in 1949 in the UK. Applying Gairdner's figures seems wholly inappropriate, given that he didn't study neonatal circumcision, but that of (mostly) older children, and as he noted most of the deaths were due to the complications of general anesthesia (using the now outmoded and more dangerous anesthetics chloroform or ether), which is not required in infancy. The American Academy of Family Physicians quote a figure of 1 in 500,000, citing King who in turn cited the study by Speert. This translates to about 1–2 deaths per year in the U.S.A.  Such deaths are surely outnumbered by the number of deaths due to severe kidney infections that, in turn, are attributable to non-circumcision.”

In Jewish ritual circumcision tightly wrapped gauze is used to stop minor bleeding (as compared to use of local pressure in hospitals), and it is thought that this can cause urinary retention and hence UTI [Harel et al., 2002]. Not surprisingly, complication rates are higher when circumcision is carried out by individuals who are not medically trained [Ozdemir, 1998].

Although very rare, complications from use of the Plastibell method have been reported, and include a higher rate of infection [Gee & Ansell, 1976], proximal migration and tissue strangulation if the Plastibell chosen is too large [Cilento et al., 1999], pressure necrosis of the glans if a Plastibell is used that is too small [Cilento et al., 1999], urinary retention [Mihssin et al., 1999], distended bladder [Ly & Sankaran, 2003], sepsis [Kirkpatrick & Eitzman, 1974; Lazarus et al., 2007] and post-operative bleeding because of failure to ensure that the ligature was tied sufficiently tightly [Lazarus et al., 2007]. In a study in Pakistan, the most common complication was Plastibell impaction, managed by cutting the Plastibell, and occurred in 2.3% of babies under 3 months, increasing gradually to 26.9% for children over 5 years [Samad et al., 2009]. To illustrate the rarity of complication, in a study of 2,000 neonates there were no serious sequelae at all [al-Samarrai et al., 1988]. In the case of the Gomco clamp excessive removal of foreskin tissue can occur [Gee & Ansell, 1976].

A 12-fold higher incidence of methicillin-resistant Staphyloccocus aureus (11 cases) has been seen in circumcised versus uncircumcised neonates during brief periods when there were outbreaks of this bacterium in a nonteaching community hospital [Nguyen et al., 2007]. Contributing factors were longer hospital stay, uncovered circumcision equipment, poor hand hygiene practices, and use of multiple dose lidocaine vials for the local anesthetic used. All of these are avoidable and can be addressed to greatly reduce this risk. None of the infants suffered long-term harm. Moreover, such occurrences are rare.

A claim by Robert Van Howe that circumcision leads to increased meatal stenosis lacks credibility, especially as this “research” study involved personal observations by this renowned anti-circumcision activist [Van Howe, 2006]. The study has been resoundingly criticized, and the conclusion drawn in that study even contradicts the data on which the claim is based [Schoen, 2007a]. Further flaws have been pointed out by an associate professor at The University of Sydney, Guy Cox (personal communication) who notes that the paper states: "a genital examination was performed only if indicated, usually at a well-child visit or for a complaint for which a genital examination would be warranted.  This bias may have slightly increased the estimated incidence of meatal stenosis, but the impact of this potential source of bias is tempered by the predominance of examinations associated with well-child visits." Presumably complaints "for which a genital examination would be warranted" would be mainly urological (the only other condition one might think of would be undescended testes). Such complaints only need to represent 7% of his cases for the whole correlation to disappear!  If well-child medicals gave such a large proportion of his subjects, why did he not confine the study to those?  One can only assume that it was because the statistical significance of the data disappeared.

Topical use of a lubricant (petroleum jelly) on the circumcision site after diaper change for 6 months prevented meatal stenosis in boys aged less than 2 years [Bazmamoun et al., 2008]. In the group not managed in this way, meatal stenosis was 6.6%. The lubricant also reduced infection (by 87%), bleeding (by 84%), and time to recovery (3.8 versus 4.2 days). This study did not include an uncircumcised group for comparison, so frequency of meatal stenosis in the absence of circumcision is not known in this Iranian population.

Not surprisingly, nonmedical, co-called “community circumcision” of infants and children is associated with higher risk of complications, as reported in the U.K. [Corbett & Humphrey, 2003].

It should be stressed that there are contraindications to circumcision in the case of prematurity, family history of bleeding disorders (hemophilia), penile abnormalities (hypospadias, epispadias, micropenis, ambiguous genitalia, megalourethra, webbed penis) in which the foreskin might be required to reconstruct the penis at a later date [Alanis & Lucidi, 2004]. However, the use of tubularized incised plate urethroplasty has virtually eliminated the need for skin flaps in anterior hypospadias repair [Pieretti et al., 2008].

Thus risks in doing a circumcision are exceedingly low.


Circumcision Info

1. What is circumcision?
2. Who in the world gets circumised?
3. The circumcision debate.
4. Circumcision history and recent trends.
5. Position statements by national pediatric bodies.
6. Why the foreskin increases infection risk.
7. Circumcision - 'shapshot' of health benefits + reviews.
8. Different specialists see different things.
9. Circumcision - benefits outweigh the risks.
10. Pain and memory.
11. Penile hygiene.
12. What motivates parents to baby boy circumcision.
13. Rates of circumcision.
14. Physical problems.
15. Inflammatory dermatoses.
16. Urinary tract infections.
17. Sexually transmitted infections.
18. Cancer of the penis.
19. Prostate cancer.
20. Cervical cancer in female partners of uncircumcised men.
21. Breast cancer in female partners of uncircumcised men.
22. Herpes simplex type 2 virus in women.
23. Chlamydia in women.
24. Trichomonas in women.
25. Bacterial vaginosis in women.
26. HIV: the AIDS virus.
27. Circumcision Socio-sexual aspects.
28. Circumcision - sensitivity, sensation & sexual function.
29. Circumcision - societal class distinction.
30. Circumcision prevents infibulation.
31. Circumcision procedure.
32. Circumcision & Anesthesia.
33. Cost of the Circumcision procedure.
34. Cost benefit of Circumcision.
35. Circumcision - how do I find someone to do it?.
36. Circumcision - whose responsibility?...legal
37. Risks in infants.
38. Circumcision - risks in adults & older boys.
39. Circumcision - breastfeeding outcomes and cognitive ability.
40. Circumcision, does it affect penis length?
41. Circumcision - why are human males born with a foreskin?
42. Circumcision - best not to delay til later.
43. Circumcision - what caused many cultures to ritually remove the foreskin?
Summary
SUMMARY
Conclusion
CONCLUSION
References
In Alphabetical Order
(A – I)(J – R)(S – Z)
Brochures
Brochures, circumcision information guide.
Anti Circumcision
Anti-circumcision lobby groups.
Links & Resources
Circumcision websites & online discussion groups.
BOOK: "In Favour of Circumcision".
About the Author - Professor Brian J. Morris.
Adult circumcision stories - testimonials and more.