circumcision dr. grahame smith the childrens hospital at westmead
TRANSCRIPT
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Circumcision
Dr. Grahame SmithThe Childrens
Hospital at Westmead
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Undertaken for many thousands of years
History
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Originally a hygiene measure
A ritual, religious Enhance/
decrease sexual performance
Prevent masturbation (Brigman)
Why
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RACP/RACS 2010 Not recommended routinely
American Academy of Pediatrics 2012 Not recommended routinely Justified for families that choose it
Canadian Pediatric Society 1989 Not recommended
None recommend routine circumcision
Current position statements
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Finland In February 2010, a Jewish couple were fined for causing bodily
harm to their then infant son who was circumcised in 2008 by a mohel brought in from the UK. Normal procedure for persons of Jewish faith in Finland is to have a locally certified mohel who works in Finnish healthcare perform the operation. In the 2008 case, the infant was not anesthetized and developed complications that required immediate hospital care. The parents were ordered to pay 1500 euros in damages to their child
Netherlands Germany
Dec 2012; law passed explicitly permitting non-therapeutic circumcision to be performed under certain conditions (religious)
Strongly opposed
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Risk & cognitive error 1
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Risk & cognitive error 2
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We fear snakes and not cars We fear spectacular, unlikely events
Plane crash versus car crash We underestimate our risk of disease We don’t interpret statistics well
Risk & cognitive error summary
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Thought Hats Religious - faith * Science* - evidence
Thought processes
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Religious, social, “cultural freedom” Prevent
Penile cancer HIV Other STDs UTIs
Arguments for
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Recurrent UTIs – 1% children Foreskin increases UTI risk 5 – 10 times
Phimosis (pathological) – 1% children Recurrent balanitis – 1% children
Medical indications
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Reduced sexually transmitted disease HIV, Herpes, HPV etc.
Safe sex practices cheaper & more effective May be valid in areas with high HIV incidence HPV vaccine a better alternative
Penile cancer (1: 100,000) too rare to worry about
UTIs – example to follow
Invalid reasons
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Assume complication rate 2% (1% - 10%) 1000 well children circumcised
=> 8 less UTIs, 20 complications 1000 Children with UTIs
=> 250 UTIs prevented, 20 complications
Risk benefit analysis for UTIs
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Circumcision may decrease female pleasure during intercourse
O’Hara & O’Hara - surveyed 138 women. Of that group 20 (14.5%) preferred non-intact circumcised sexual partners while 118 or (85.5%) preferred intact non-circumcised sexual partners. This means that about 6 out of 7 women preferred intact non-circumcised partners while about 1 out of seven preferred non-intact circumcised partners
And further risk
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Abnormal penis Hypospadias Epispadias Buried penis
Systemic Coagulopathy Increased anesthetic
risk
Contra indications
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Early Pain Infection Bleeding Fistula Glans amputation Loss of penis Death
Risks
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Late Meatal stenosis Poor cosmetic result Skin tags, suture sinuses Buried penis
Risks
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Theoretical Sued or prosecuted
Legally, parents may not consent for an operation for a child when such a decision is not in the child’s best interest.
Risks
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Care of the normal foreskin
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Nothing required
Forceful retraction may cause injury and phimosis
Infancy and childhood
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Retract and clean each day
After puberty
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Treatment not needed
Responds well to Betnovate ½ cream
Phimosis - physiological
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Responds to Betnovate ½ cream – rarely
Tacrolimus May be
carcinogenic Circumcision
usually curative
Phimosis – pathological
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Phimosis and buried penis
Megaprepuce
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Paraphimosis
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Tight frenulum
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Foreskin adhesions
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Foreskin lumps
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Smegma
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Smegma - more
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Multiple Happen even in the best of hands Incidence = 5 to 10%
Circumcision complications
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Buried penis
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Shaft to glans
adhesions
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Meatal stenosis
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Shortage of skin
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Amputation glans
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Don’t circumcise unless there is a medical indication (benefits outweigh the risk)
If there is an indication, it’s a good operation
Conclusion
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https://www.racp.edu.au/page/paed-policy http://www.cps.ca/documents/position/circumcision http://pediatrics.aappublications.org/content/early/2012/08/22/
peds.2012-1989 http://www.cirp.org/library/legal/brigman/ http://www.circumcision.org/ (against) http://www.circinfo.net/ (pro) O’Hara K, O’Hara J. The effect of male circumcision on the
sexual enjoyment of the female partner. BJU Int 1999;83 Suppl 1:79–84.
References
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