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Circumcision
Circumcision surgery with hemostats and scissors
ICD-10-PCS	Z41.2
ICD-9-CM	V50.2
MeSH	D002944
OPS-301 code	5–640.2
MedlinePlus	002998
eMedicine	1015820
[edit on Wikidata]

Circumcision is a procedure that removes the foreskin from the human penis. In the most common form of the operation, the foreskin is extended with forceps, then a circumcision device may be placed, after which the foreskin is excised. Topical or locally injected anesthesia is generally used to reduce pain and physiologic stress. Circumcision is generally electively performed, most commonly done as a form of preventive healthcare, as a religious obligation, or as a cultural practice. It is also an option for cases of phimosis, other pathologies that do not resolve with other treatments, and chronic urinary tract infections (UTIs). The procedure is contraindicated in cases of certain genital structure abnormalities or poor general health.

The procedure is associated with reduced rates of sexually transmitted infections and urinary tract infections. This includes reducing the incidence of cancer-causing forms of human papillomavirus (HPV) and significantly reducing HIV transmission among heterosexual men in high-risk populations; its prophylactic efficacy against HIV transmission in the developed world or among men who have sex with men is debated. Neonatal circumcision decreases the risk of penile cancer. Complication rates increase significantly with age. Bleeding, infection, and the removal of either too much or too little foreskin are the most common acute complications, while meatal stenosis is the most common long-term. There are various cultural, social, and ethical views on circumcision. Major medical organizations hold variant views on the strength of circumcision's prophylactic efficacy in developed countries. Some medical organizations take the position that it carries prophylactic health benefits which outweigh the risks, while other medical organizations generally hold the belief that in these situations its medical benefits are not counterbalanced by risk.

Circumcision is one of the world's most common and oldest medical procedures. Prophylactic usage originated in England during the 1850s and subsequently widely spread, becoming predominately established as a way to prevent sexually transmitted infections. Beyond use as a prophylactic or treatment option in healthcare, circumcision plays a major role in many of the world's cultures and religions, most prominently Judaism and Islam. Circumcision is among the most important commandments in Judaism. In some African and Eastern Christian denominations male circumcision is an established practice, and require that their male members undergo circumcision. It is widespread in Australia, Canada, the United States, South Korea, most of Africa, and parts of Asia. It is relatively rare for non-religious reasons in parts of Southern Africa, Latin America, Europe, and parts of Asia. The origin of circumcision is not known with certainty, but the oldest documentation comes from ancient Egypt.

Uses

Elective

Around half of all circumcisions worldwide are performed for reasons of prophylactic healthcare.

Prophylactic usage in high-risk populations

There is a consensus among the world's major medical organizations and in the academic literature that circumcision is an efficacious intervention for HIV prevention in high-risk populations if carried out by medical professionals under safe conditions.

In 2007, the WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) stated that they recommended adolescent and adult circumcision as part of a comprehensive program for prevention of HIV transmission in areas with high endemic rates of HIV, as long as the program includes "informed consent, confidentiality, and absence of coercion" — known as voluntary medical male circumcision, or VMMC. In 2010, this was expanded to routine neonatal circumcision, as long as those undergoing the procedure received assent from their parents. In 2020, the World Health Organization again concluded that male circumcision is an efficacious intervention for HIV prevention and that the promotion of male circumcision is an essential strategy, in addition to other preventive measures, for the prevention of heterosexually acquired HIV infection in men. Eastern and southern Africa had a particularly low prevalence of circumcised males. This region has a disproportionately high HIV infection rate, with a significant number of those infections stemming from heterosexual transmission. As a result, the promotion of prophylactic circumcision has been a priority intervention in that region since the WHO's 2007 recommendations. The International Antiviral Society–USA also suggests circumcision be discussed with men who have insertive anal sex with men, especially in regions where HIV is common. There is evidence that circumcision is associated with a reduced risk of HIV infection for such men, particularly in low-income countries.

The finding that circumcision significantly reduces female-to-male HIV transmission has prompted medical organizations serving communities affected by endemic HIV/AIDS to promote circumcision as an additional method of controlling the spread of HIV.

Prophylactic usage in developed countries

Major medical organizations hold varying positions on the prophylactic efficacy of the elective circumcision of minors in the context of developed countries. Literature on the matter is polarized, with the cost-benefit analysis being highly dependent on the kinds and frequencies of health problems in the population under discussion and how circumcision affects them.

The World Health Organization (WHO), UNAIDS, and American medical organizations take the position that it carries prophylactic health benefits which outweigh the risks, while European medical organizations generally hold the belief that in these situations its medical benefits are not counterbalanced by risk. Advocates of circumcision consider it to have a net health benefit, and therefore feel that increasing the circumcision rate is "imperative". They recommend performing it during the neonatal period when it is less expensive and has a lower risk of complications. The American Academy of Pediatrics and Centers for Disease Control and Prevention stated that the potential benefits of circumcision outweigh the risks.

The World Health Organization in 2010 stated:

There are significant benefits in performing male circumcision in early infancy, and programmes that promote early infant male circumcision are likely to have lower morbidity rates and lower costs than programmes targeting adolescent boys and men.

Pathologies

Circumcision is also used to treat various pathologies. These include pathological phimosis, refractory balanoposthitis and chronic or recurrent urinary tract infections (UTIs).

Contraindications

Circumcision is contraindicated in certain cases.

These include infants with certain genital structure abnormalities, such as a misplaced urethral opening (as in hypospadias and epispadias), curvature of the head of the penis (chordee), or ambiguous genitalia, because the foreskin may be needed for reconstructive surgery. Circumcision is contraindicated in premature infants and those who are not clinically stable and in good health. If an individual is known to have or has a family history of serious bleeding disorders such as hemophilia, it is recommended that the blood be checked for normal coagulation properties before the procedure is attempted.

Technique

The foreskin is the double-layered fold of tissue at the distal end of the human penis that covers the glans and the urinary meatus. For adult medical circumcision, superficial wound healing takes up to a week, and complete healing 4 to 6 months. For infants, healing is usually complete within one week.

Removal of the foreskin

For infant circumcision, devices such as the Gomco clamp, Plastibell and Mogen clamp are commonly used in the USA. These follow the same basic procedure. First, the amount of foreskin to be removed is estimated. The practitioner opens the foreskin via the preputial orifice to reveal the glans underneath and ensures it is normal before bluntly separating the inner lining of the foreskin (preputial epithelium) from its attachment to the glans. The practitioner then places the circumcision device (this sometimes requires a dorsal slit), which remains until blood flow has stopped. Finally, the foreskin is amputated. For older babies and adults, circumcision is often performed surgically without specialized instruments, and alternatives such as Unicirc or the Shang ring are available.

Pain management

The circumcision procedure causes pain, and for neonates this pain may interfere with mother-infant interaction or cause other behavioral changes, so the use of analgesia is advocated. Ordinary procedural pain may be managed in pharmacological and non-pharmacological ways. Pharmacological methods, such as localized or regional pain-blocking injections and topical analgesic creams, are safe and effective. The ring block and dorsal penile nerve block (DPNB) are the most effective at reducing pain, and the ring block may be more effective than the DPNB. They are more effective than EMLA (eutectic mixture of local anesthetics) cream, which is more effective than a placebo. Topical creams have been found to irritate the skin of low birth weight infants, so penile nerve block techniques are recommended in this group.