Uncircumcised Boys May Have Foreskin Problems

(Reuters Health) - When parents choose not to circumcise baby boys, some of the children may later need surgery to address foreskin problems, a Danish study suggests.

Doctors often leave the decision about circumcision up to parents because health benefits such as reduced risk of HIV and other sexually transmitted infections aren’t sufficient to recommend universal adoption of this practice. The risk of complications for newborn circumcision is also low, and the most common problem is light bleeding around the foreskin incision.

Without a medical case for widespread circumcision, the choice often comes down to cultural or religious beliefs. It is a common religious rite among Jews and Muslims.

In Denmark, where circumcision is rare, parents still need to consider the possibility that around 5 percent of boys may have foreskin problems requiring treatment and a third of these may need foreskin surgery for medical reasons, researchers report in the journal Pediatrics.

“Circumcision should be performed at any age if a chronic foreskin inflammation is suspected and when foreskin retraction is not possible around puberty,” said study co-author Dr. Jorgen Thorup of the University of Copenhagen.

At birth, boys have a hood of skin called the foreskin covering the head of the penis, or glans. During circumcision, the foreskin is surgically removed, exposing the end of the penis. When parents choose to do this, the procedure is usually done within a week or two of birth, often before babies go home from the hospital. 

To assess the health reasons that may lead to foreskin surgery, Thorup and co-author Dr. Ida Sneppen, also of the University of Copenhagen, examined medical records for 181 boys who had procedures in Denmark in 2014.

They excluded boys who had circumcisions for nonmedical reasons or procedures to correct complications from these operations. They also left out boys who had a birth defect known as hypospadias, which causes the urethra to form abnormally with an opening for urine anywhere from just below the end of the penis to the scrotum. 

Boys who did have foreskin surgery in the study were around 10 years old on average. 

Overall, the cumulative risk of undergoing foreskin operations by age 18 was 1.7 percent, the study found.

Forty of the patients had what’s known as balanitis xerotica obliterans (BXO), or chronic inflammation of the foreskin. 

Most of the boys who had surgery – 95 percent – had a condition known as phimosis, or an inability to retract the foreskin. Babies are born with a tight foreskin, but it typically loosens over time. If it doesn’t, boys can have bleeding, scarring, infections or difficulty with urination.

The remaining 5 percent of those who had surgery had a condition known as frenulum breve, when the elastic band of tissue under the glans penis that connects to the foreskin and helps it retract over the glans is too short and causes problems during an erection.

To fix medical problems, 44 boys had circumcisions and 137 patients had foreskin-preserving procedures.

While most boys won’t have these problems, the complications are common enough that doctors should discuss them when counseling parents about newborn circumcision, the authors conclude. 

They also caution that the rates of problems needing surgery in countries where infant circumcision is more common may be different from those in Denmark where it is rare.

Even though many parents will decide on circumcision based on cultural and religious beliefs, they should also understand that the medical evidence to date on the procedure is mixed, Dr. Andrew Freedman, a pediatric urologist at Cedars Sinai Medical Center in Los Angeles writes in an accompanying editorial.

“What this study does is ask the question as to the likelihood a child that is not circumcised at birth will go on to need a circumcision for well described medical reasons during their childhood,” Freedman told Reuters Health by email.

“In the non-newborn there are many conditions for which circumcision would be an appropriate treatment,” Freedman added.

SOURCE: bit.ly/1RXQeZW and bit.ly/1TBZPrF Pediatrics, online April 6, 2016.