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Male circumcision is the surgical removal of the prepuce, or foreskin, covering the glans of the penis. Over the past decades, cultural changes and new research have led to a closer examination of the practice of circumcision. Although there is no definitive evidence regarding the impact of circumcision on sexual enjoyment, studies suggest a reduction in urinary tract infections among newborns. Neonatal circumcisions significantly reduce the risk of penile cancer later in life, but this benefit may be realized without surgery as the use of the human papillomavirus vaccine increases. Phimosis, paraphimosis, HIV infections, and balanitis are significantly reduced in adults who have been circumcised. The procedure remains controversial among individuals with conflicting cultural or religious beliefs. This activity reviews the indications, contraindications, and techniques involved in circumcision, emphasizing the interprofessional team's role in patient care during this procedure. Collaboration between clinicians in family medicine, obstetrics and gynecology, and internal medicine is essential for the successful completion of circumcision procedures. Objectives: Identify the anatomical structures involved in circumcision and the tools required to complete the procedure. Select the equipment required to perform a circumcision using clinical judgment about patient presentation. Determine the complications of circumcision when utilizing the predominant surgical approaches. Implement an interprofessional team approach to provide effective care to patients undergoing circumcision. Access free multiple choice questions on this topic.

Circumcision is the surgical removal of the foreskin (prepuce) covering the glans of the penis, typically performed on male neonates. Circumcision has been practiced for thousands of years as part of cultural and religious teachings.[1] The procedure was regarded as a ritual of transition to adulthood and a measure of hygiene. Over the past decades, cultural changes and new research have led to a closer examination of the practice. Recent knowledge and outrage over the practice of female circumcision have also fueled discussions on the validity of elective male neonatal circumcisions.[2][3][4][5] As a result, healthcare professionals should provide objective, unbiased, factual information to parents and caregivers about the procedure's potential medical benefits, risks, and complications. Clinicians should emphasize that the procedure is completely elective. The most common reasons for parents in the United States to request an elective circumcision for their newborns were improved hygiene and medical benefits (about 50%), personal or family preference (about 30%), or religious requirements (about 15%).[6][7] Reasons cited by parents who opted against neonatal circumcision included the belief that the procedure was unnecessary, concerns about causing pain to the child, and the father being uncircumcised.[8][9] The prevalence of circumcision among men in the United States is about 80%. In contrast, worldwide, almost 40% of all adult males are circumcised, with a high degree of regional and geographic variability. Worldwide, religious factors accounted for 70% of all circumcisions. The incidence of circumcision is lowest in Armenia, Iceland, the Caribbean, and Central and South America, and highest in Islamic countries and Israel.[10][11] Circumcision reduces the risk of HIV infection by up to 60% and is recommended by the World Health Organization (WHO) for countries with high endemic HIV infection rates.[12][13][14][15][16][17][18][19]

Circumcision does not lower the risk of gonorrhea, chlamydia, or syphilis. However, circumcised heterosexual males experience an average 40% to 60% reduction in acquiring HIV in regions with a high endemic HIV-positive heterosexual population, such as various areas in Africa. A lower prevalence of HPV infection and herpes simplex virus type 2 transmission is observed.[71] Surgical risks include, but are not limited to, pain, bleeding, infection, incision or injury of the glans and urethra, necrosis of the glans, foreskin adhesions, phimosis, wound dehiscence, persistent distal penile edema, urethrocutaneous fistula formation, meatal stenosis, failure to leave enough shaft skin for closure, postoperative trapped penis, or penile loss.[32][39][72] Meatal stenosis is minimized by applying petroleum jelly to the glans, starting immediately after the circumcision.[73] Epidermal inclusion cysts may form if skin folds are buried and sloughed skin is not expressed.[41] Bleeding is the most common complication after neonatal circumcisions, but this typically resolves with manual pressure and topical thrombin.[61] Severe bleeding may occur in patients with previously undiagnosed coagulation disorders such as hemophilia.[74] Wound dehiscence is very common after circumcisions. These typically heal by secondary intention without further intervention. Any remaining redundant foreskin may require a corrective procedure at a later date. Excessive removal of penile shaft skin can result in tethering, loss of effective penile length, pain with erections, or a buried penis. Penile reconstruction with split-thickness skin grafts may be required to repair. Hypersensitivity of the glans is common immediately after circumcision procedures, but this is typically temporary. Meatal stenosis and excessive skin bridging are more common in patients with balanitis xerotica obliterans or lichen sclerosis. Steroid cream applications and regular meatal dilatation can typically control these problems.[75][76][77]

Any remaining redundant foreskin may require a corrective procedure at a later date. Excessive removal of penile shaft skin can result in tethering, loss of effective penile length, pain with erections, or a buried penis. Penile reconstruction with split-thickness skin grafts may be required to repair. Hypersensitivity of the glans is common immediately after circumcision procedures, but this is typically temporary. Meatal stenosis and excessive skin bridging are more common in patients with balanitis xerotica obliterans or lichen sclerosis. Steroid cream applications and regular meatal dilatation can typically control these problems.[75][76][77] Obese patients with a substantial fat pad around the penile base can be advised to evert the penis at least daily for cleaning to minimize the formation of unwanted skin bridges and adhesions. If untreated, this can cause the penis to become imprisoned below skin level, resulting in a trapped or buried penis. Electrocautery should never be used with any metal clamps or instruments. For example, electrocautery with a Gomco clamp in place can cause burning and necrosis of the glans penis.[78] A retained piece of a disposable circumcision device can become a problem. The penile skin can become twisted if adequate attention is not paid to this potential problem during closure. Poor wound healing may occur if too much tension occurs on the incision line from the removal of too much skin or inadequate undermining of the remaining penile shaft skin. A poor cosmetic result is possible. Rare cases of accidental total or partial penile amputations and necrotizing fasciitis have been reported after neonatal circumcision, but these are extremely rare.[79][80][81][82][83] Fatalities after circumcisions are also extremely rare but have been reported.[84][85][86][87]

This review is intended to thoroughly discuss the procedural steps, indications, and current recommendations regarding circumcision. This is a controversial topic, and healthcare team members must be aware of the evolving view of circumcision. The AAP revised the 1999 policy on the procedure to be more pro-circumcision, reigniting the debate. The anti-circumcision papers cite many reasons for not undergoing the procedure. Bringing female circumcision and genital mutilation to the mainstream has placed male circumcision under a similarly focused spotlight. The procedure is sometimes described as a painful ordeal that is needed to push the male into manhood. This trauma can then lead to sexual difficulties. The procedure should be delayed until the individual can decide for himself. However, delaying the procedure overlooks the fact that the procedure is a more significant surgery in adults and loses many known health benefits if conducted outside the neonatal period. Healthcare professionals may hold differing views on the benefits of circumcision and are likely to have individual opinions. Healthcare professionals help families with both the advantages and disadvantages of the procedure to make a well-informed decision.[45][96] For example, HPV transmission can be reduced by circumcision. Clinicians must be educated about and understand religious doctrines, research findings, and cultural circumcision teachings. The data must be provided to each family in an unbiased manner.[88][112][113][114][115][116][117][118] Clinicians must also be able to relate the data to any unique family situation.