This document has been developed at the instigation of the Paediatrics
& Child Health Division of the Royal Australasian College
of Physicians (formerly the Australian College of Paediatrics)
following critical analysis of the literature by a working party
consisting of representatives of the Royal Australasian College
of Physicians, Australasian Association of Paediatric Surgeons,
New Zealand Society of Paediatric Surgeons, Urological Society
of Australasia and the Royal Australasian College of Surgeons.
The policy represents an agreed position adopted by the following
The purpose of this document is to assist clinicians in their
discussions with parents who are considering having this procedure
undertaken on their male children, and for doctors who are asked
to advise on or undertake it. A separate parents' brochure is
available from the Paediatrics & Child Health Division Regional
Office, ph (02) 9256 5409.
Routine Circumcision Of Normal Male Infants
And Boys - Summary Statement
The Paediatrics & Child Health Division, Royal Australasian
College of Physicians (RACP) has prepared this statement on routine
circumcision of infants and boys assist parents who are considering
having this procedure undertaken on their male children and for
doctors who are asked to advise on or undertake it. After extensive
review of the literature the RACP reaffirms that there is no
medical indication for routine male circumcision.
Circumcision of males has been undertaken for religious and cultural
reasons for many thousands of years. It remains an important ritual
in some religious and cultural groups. In Australia and New Zealand,
the circumcision rate has fallen considerably in recent years
and it is estimated that currently only 10 percent of male infants
are routinely circumcised. It is now generally performed with
some form of local or general anaesthesia, and usually outside
the neonatal period. The best recognised indication for circumcision
There have been increasing claims over recent years of health
benefits from routine male circumcision. The most important other
conditions where some benefit may result from circumcision are
urinary tract infections, HIV and later cancer of the penis.
- Urinary tract infections in boys are uncommon, affecting at
most 1%-2%, and may be about 5 times less frequent in circumcised
boys, whilst circumcision has a complication rate of 1% to 5%.
Routine neonatal circumcision can not be supported as a public
health measure on this basis.
- While there is some evidence, particularly from sub-Saharan
Africa, that male circumcision reduces the risk of acquisition
of HIV, evidence is conflicting and clearly this can not be
seen as an argument in favour of universal neonatal circumcision
in countries with a low prevalence of HIV.
- Penile cancer is a rare disease with an incidence of around
1 per 100,000 in developed countries. Even though the evidence
suggests neonatal circumcision may reduce the risk 10-fold,
the rarity of the condition is such that universal circumcision
is clearly not justified on these grounds.
The complication rate of neonatal circumcision is reported to
be around 1% to 5% and includes local infection, bleeding and
damage to the penis. Serious complications such as bleeding, septicaemia
and meningitis may occasionally cause death.
The possibility that routine
circumcision may contravene human rights has been raised because
circumcision is performed on a minor and is without proven medical
benefit. Whether these legal concerns are valid will be known
only if the matter is determined in a court of law.
If the operation is to be performed, the medical attendant should
ensure this is done by a competent operator, using appropriate
anaesthesia and in a safe child-friendly environment.
In all cases where parents request a circumcision for their child
the medical attendant is obliged to provide accurate information
on the risks and benefits of the procedure. Up-to-date, unbiased
written material summarising the evidence should be widely available
Review of the literature in relation to risks and benefits shows
there is no evidence of benefit outweighing harm for circumcision
as a routine procedure.
[NOCIRC comment: When there is no evidence
that potential (unproven) benefits exceed the known risks and
harm of an operation, good medical practice dictates that the
operation not be done. The RACP et al. says below
that there are no medical indications for circumcision. It has
also endorsed the position of the Australian College of Paediatrics
and the Australasian Association of Paediatric Surgeons that
"Neonatal circumcision has no medical indication," and it has
endorsed the position of the Canadian Paediatric Society that
"Circumcision of newborns should not be routinely performed."
A routine procedure is one that is performed without
medical indication. This means that the RACP and other represented
medical societies are saying "Circumcision of newborns should
not be performed without medical indication and that there are
no medical indications for circumcision of the newborn." The
RACP and other medical societies seem to be saying, in effect,
that neonatal circumcision should not be done at all.]
1. Recent Literature and Policy Statements
There is an extensive literature on circumcision in general,
and male neonatal circumcision in particular. This includes a
number of books1,2 and recent reviews3
including those by the Canadian Paediatric Society (CPS)4
and the American Academy of Pediatrics (AAP)5,6.
The CPS recommended "Circumcision of newborns should not be routinely
performed" (reaffirmed February 2001: (www.cps.ca/english/statements/FN)
and the AAP concluded "we can not recommend a policy of routine
newborn circumcision". (www.aap.org/mrt/factscir.htm).
Following the present review of the evidence, the RACP concurs
with these statements and endorses the 1996 statement of the Australian
College of Paediatrics (now the Division of Paediatrics and
Child Health of RACP) and Australasian
Association of Paediatric Surgeons that "Neonatal male circumcision
has no medical indication".
2. History of Circumcision
Circumcision of males has been undertaken for religious and cultural
reasons for many thousands of years. It probably originated as
a hygienic measure in communities living in hot, dusty and dry
environments. It remains an important ritual in several religious
and cultural groups.
Medicalisation of male circumcision seems to have occurred in
the 19th century in English speaking countries. Being
circumcised was a sign that the individual had been delivered
by a doctor rather than by a midwife1.
Over the years, circumcision has been seen as a cure or preventative
measure for all manner of conditions including paralysis, insanity,
epilepsy, tuberculosis, enuresis, masturbation and phimosis, through
to the contemporary claims for prevention of urinary tract infections
in boys, and penile cancer and sexually transmitted diseases in
During the last 50-100 years, routine neonatal male circumcision
became widespread in many English speaking countries. Until the
late 1960's or early 1970's, it was generally performed without
any form of anaesthesia.
The rates of circumcision vary from country to country, being
about 60% in the USA (with recent data suggesting falling rates,
particularly amongst the growing Hispanic population), 30% in
Ontario, Canada, 6% in the UK (rates fell when circumcision became
unavailable on the NHS), and less than 2% in Scandinavia. Estimates
for Australia range between 10%-20% (most of which are now performed
under a general anaesthetic in boys older than six months), and
for New Zealand somewhat less than that. The procedure is more
common in Pacific Island communities where traditional circumcisers
are often used.
3. Anatomy of the Foreskin
The foreskin is a redundant fold of penile skin which overlaps
the glans penis7 . It first appears
at eight weeks of fetal life and soon grows forwards over the
glans penis. By 16 weeks it covers the glans. At this stage the
epidermis of the under-surface of the foreskin is continuous with
the epidermis covering the glans. Both consist of squamous epithelium.
The foreskin (prepuce) and glans penis enclose a potential cleft,
the preputial sac. A preputial space is then formed by a process
of desquamation, and the prepuce increasingly separates from the
At the time of birth this process is incomplete in the vast majority
of boys, and the foreskin is non-retractable. Complete separation
of the foreskin with full retractability occurs in almost all
boys by the time of puberty9.
[NOCIRC comment: This description of
the foreskin improperly describes the foreskin as "redundant."
The fold of preputial skin is needed for expansion of the penis
during erection and provides mobility for the gliding mechanisim.
The description omits information about innervation,
vascularity, and the disease
fighting functions of the foreskin.]
3.2 Care of the foreskin
It is normal for the inner surface of the foreskin to be fused
to the glans in newborn males. Separation of the foreskin from
the glans occurs spontaneously during childhood. By five years
of age most of boys are able to retract their foreskin9.
A small percentage of boys are unable to fully retract their foreskin
The foreskin requires no special care during infancy. It should
be left alone10. Attempts to
forcibly retract it are painful, often injure the foreskin, and
can lead to scarring and phimosis.
Later in childhood, the foreskin can be gently retracted to the
point where resistance is met and the distal portion of the penis
and the urethral meatus become visible. The glans and the inner-surface
of the foreskin can be cleaned along with the rest of the body
once separation has occurred and the foreskin is fully retractable11.
By around the time of puberty, all uncircumcised boys should
be able to retract their foreskin and clean underneath it in the
bath or shower. It is important that they always return the foreskin
to its original position after they have finished. If the foreskin
is left retracted behind the glans, it may swell up and become
As the foreskin separates from the glans, dead skin cells will
collect between the two layers. These dead cells appear as white
crumbly or cheesy material and have been termed smegma. Smegma
may produce a noticeable (and often asymmetrical) swelling beneath
the foreskin. This material rarely causes problems and usually
discharges spontaneously. Accumulation of smegma assists the normal
process of separation of the inner surface of the foreskin to
the glans of the penis in the young boy. Infection of smegma as
it is released may cause inflammation.
Although there is evidence that boys who are uncircumcised have
a higher incidence of urinary tract infections, there is no evidence
that the increased incidence of infection is due to poor hygiene.
4. Medical Indications for Circumcision
Pathological phimosis, which needs to be distinguished from the
normal non-retractile foreskin of early childhood12,
is an indication for circumcision13,14.
The condition occurs in at least 1% of boys15,16
, is rare in the first five years of life and may be due to secondary
cicatrisation of the foreskin due to balanitis xerotica obliterans
(BXO)17,18. Topical application
of steroid ointment may resolve phimosis in the majority of boys19,20
except in those with BXO where steroids are rarely successful.
Physiological phimosis (normal narrowing of the foreskin that
may make visualisation of the glans difficult during infancy)
will normally resolve by the age of three to four years and requires
no treatment. If pathological (ie non-physiological) phimosis
fails to respond to steroid cream/ointment applied to the tight
part of the foreskin two to four times a day for two to six weeks,
there is a reasonable probability that it will cause problems
in the future and the child may well benefit from circumcision.
In a proportion of boys the phimosis redevelops after cessation
of applications of steroid treatment.
4.2 Recurrent balanoposthitis
Recurrent balanoposthitis is a relative indication for circumcision.
The condition needs to be distinguished from the more benign ammoniacal
dermatitis13. Balanoposthitis affects
3%-4% of boys, and is recurrent in about 1% of boys21.
Balanoposthitis and balanitis may also occur in adults. Diabetes
may be a risk factor22.
Recurrent paraphimosis is extremely rare and may represent a
relative indication for circumcision. In children, the condition
is usually secondary to forceful retraction of the foreskin and
is associated with a minor degree of phimosis. In adults, paraphimosis
typically occurs in the elderly. Men requiring frequent bladder
catheterisation are particularly at risk23
. Treatment in children involves manipulation of the foreskin
forwards over the glans, and requires some form of analgesia (general
or local). In a minority of children, after reduction of paraphimosis
circumcision may be required, if topical application of a steroid
preparation fails to resolve the underlying phimosis, or if paraphimosis
5. The Role of Circumcision In Preventing
5.1 Urinary tract infections (UTIs)
The cumulative incidence of UTI in boys by the age of about 10
is 1-2%24,25. Ginsburg and McCracken26
first reported a higher incidence of UTIs in uncircumcised boys.
This is biologically plausible because uropathogens have been
shown to bind to the foreskin and then gain access to the renal
tract via the ascending route: removal of the foreskin would abolish
this mechanism. Other factors may be important in determining
the prevalent organisms. For example, rooming in with mother may
favour colonisation with non-pathogenic bacteria4,27,
and breast feeding has been associated with lower rates of UTI
than bottle feeding in one brief report28.
There have now been ten case control and cohort studies published,
which have evaluated the association between circumcision and
UTIs24,29-37, but no randomised
controlled trials have been done. All have demonstrated a statistically
significant reduction in risk of UTI in circumcised males compared
with uncircumcised males, with most data concerning the risk of
UTI during infancy. The magnitude of the reported protective effect
varies from a three-fold reduction to a twelve-fold reduction
in risk of UTI due to circumcision. These data may be used to
assess possible benefits and harm from neonatal circumcision.
Assuming an annual incidence of UTI of 1% during the first year
of life for uncircumcised boys, the risk of UTI may be reduced
from 10 per 1,000 to 1-3 per 1000, a difference of 7-9 per 1,000,
or a need to circumcise between 110 to 140 boys to prevent one
UTI during the first year of life.
On the other side of the equation, taking a mid-range figure
of 2% (20 per 1,000) for major complications from circumcision,
mainly from haemorrhage and infection (see earlier section), for
every 1,000 infants circumcised, about eight fewer will develop
a UTI but 20 will develop a significant complication. Assuming
that the “harm” of a UTI is about the same as a complication,
routine circumcision is difficult to advocate as a public health
Other figures can be used to come to a different conclusion but
even then many parents and caregivers would believe this should
not be the only consideration38.
The benefit-harm trade-off is also sensitive to the baseline
risk of UTI. Assuming the same protective benefits of circumcision
for the prevention of UTI extends to boys at higher risk of UTI,
such as those with underlying renal tract abnormalities, then
is it likely that a small group of boys, who continue to have
symptomatic recurrent UTI despite conventional clinical care such
as chemoprophylaxis, will benefit from circumcision. The risk
of UTI in these boys is not 1% as it is in the general population,
but closer to 30%39,40 so that only
4-5 boys would need to be circumcised to prevent UTI, or 200-270
UTIs prevented for every 1000 circumcisions with about 20 complications.
In summary, routine circumcision in boys cannot be justified
on the basis of preventing a UTI. On the other hand, there may
be a role for circumcision in boys with recurrent symptomatic
UTI and/or underlying renal tract abnormalities.
5.2 Sexually transmitted diseases (STDs)
The published evidence concerning the relationship between circumcision
and STD is often conflicting41.
An Australian study from 198342
suggested herpes genitalis, candidiasis, gonorrhoea and syphilis
were all more common in uncircumcised men. A more recent Australian
study43 , however, suggested that
circumcision has no significant effect on the incidence of common
STD’s. One study has suggested a higher risk of non-gonococcal
urethritis among circumcised men than among uncircumcised men44.
Genital ulcer disease, on the other hand, has been reported as
being more common among uncircumcised men, and those with a genital
ulcer are more likely to contract HIV.
There is increasing evidence, particularly from sub-Saharan Africa,
which suggests an increased risk of female to male transmission
of HIV in uncircumcised men45-48
. However, how much circumcision could contribute to ameliorate
the current epidemic of HIV is uncertain49.
Whatever the future direction of this debate it can not be seen
as an argument in favour of universal neonatal circumcision in
countries with a low prevalence of HIV.
5.3 Human papilloma virus and carcinoma of
A recent international study reported an increased risk of human
papilloma virus (HPV) infection in uncircumcised men who indulged
in high-risk behaviours, compared with circumcised men50.
Monogamous women whose male partners had six or more sexual partners
and were circumcised had a lower risk of cervical cancer than
women whose partners were uncircumcised. Public health measures
aimed at early detection have been shown to decrease cervical
cancer fatalities; targeting sexually promiscuous men to decrease
risk taking and increase condom use may inhibit sexual transmission
of HPV and prophylactic vaccination against HPV is being developed.
At present there are no data to suggest advocating neonatal circumcision
would be of additional benefit to these strategies51.
5.4 Carcinoma of the penis
Carcinoma of the penis is a rare condition, with an annual incidence
of approximately 1:100,000 men in developed countries, regardless
of whether there is a high or a low circumcision rate4,5.
There is evidence that neonatal circumcision confers protection
from carcinoma of the glans penis but not of the penis shaft52-56.
Even though the evidence suggests neonatal circumcision does reduce
the risk of carcinoma 10-fold, universal circumcision is clearly
not justified on these grounds46.
Other risk factors for penile cancer include phimosis (which
is limited to uncircumcised men), genital warts, increased number
of sexual partners and cigarette smoking57,58.
It has been hypothesised that good penile hygiene may help prevent
both phimosis and penile cancer59.
6. Complications of circumcision
Apart from pain and distress, and the side effects of local anaesthesia,
there have been many complications of circumcision reported5,60,61.
Most complications are minor, but some can be more severe, such
as penile amputation and even death. The overall reported rate
of complications after circumcision varies between 0.06%62
to 55%63 depending on the situation
in which it is performed and the precise definition of complication.
Most series describe a complication rate of about 2%-10%64-66.
A detailed summary of complications has been provided by Williams
and Kapila61, and includes the following:
- Glanular ulceration
- Meatal stenosis
- Inadvertent injury of the urethra (fistula)
- Too much skin removed
- Anaesthetic complications
- Psychological trauma
- Secondary phimosis
- Secondary chordee
The true incidence of major complications after newborn
circumcision is unknown but is reported to be from between 0.2%
and 0.6%5 to 2%-10%61.
The most frequent acute problem is haemorrhage, and may indicate
an underlying vitamin K deficiency or haemophilia. Infection is
usually minor, but rarely septicaemia and meningitis may occur.
Longer term complications include meatal stenosis, cutaneous tags,
poor cosmetic appearance, and psychological trauma. Children with
prominent prepubic fat may have a concealed penis following surgery
which tends to resolve at puberty.
6.1 Absolute contraindications to neonatal
Contraindications to routine neonatal circumcision include:
- Hypospadias and other congenital anomalies
of the penis, eg epispadias
- Chordee (ventral angulation of the penis)
- Buried penis
- Sick and unstable infants
- Family history of a bleeding disorder or
an actual bleeding disorder
- Inadequate expertise and facilities.
7. Legal and Bioethical Issues
The legal and bioethical issues surrounding male neonatal circumcision
have been discussed in recent legal journal reviews60,67.
Parents have the right, indeed duty, to make informed medical
decisions on behalf of their children. It is equally established
in law that parents may not make decisions about their child's
medical care when such a decision is not in the child's best interests.
Many legal precedents exist to establish that Courts will deny
parents the right to refuse medically indicated procedures required
by their child that are contrary to their religious beliefs.
The difficulty with a procedure which is not medically indicated
is whether it may still be in the child's "best interests" (that
is, in the case of circumcision, decreasing the risk of UTI and
penile cancer, and ensuring acceptance within a religio-cultural
group) on the one hand60 or whether
it may constitute an assault upon the child and be a violation
of human rights on the other67.
Arguments to justify the “best interests” case are based upon
data to suggest a decreased risk of medical conditions later in
life, none of which, with the possible exception of UTI’s in boys,
requires a decision in the neonatal period, and this could be
seen to be an argument to defer a decision until the individual
can express his own preferences. Generally the courts have avoided
jurisdiction in this area60. However,
there has been a 1999
UK case where separated parents disagreed on the question
of circumcision with the court finding circumcision not to meet
the “paramountcy of welfare” standard and not be in the best interests
of the child60. One issue, which
is agreed, is that before parents make a decision about circumcision
they should have access to unbiased and clear information on the
medical risks and benefits of the procedure. Whether this has
always been the case in the past is uncertain, and many parents
make such a decision on cultural and religious grounds alone68.
Until recent times a majority of neonatal circumcisions were
performed without analgesia. Stated justifications for not using
analgesia include a belief that circumcision causes minimal pain,
that rapid expert circumcision causes less pain than that engendered
by local anaesthetic procedures and that newborns have no memory
of pain. There are good experimental data to refute the first
two of these contentions and, even though the third suggestion
can not be considered a sufficient reason to withhold analgesia,
there is an emerging body of evidence to show that painful neonatal
experiences do have long term consequences, even if not rooted
in conscious memory69. Taddio reported
that circumcised boys had higher pain and cry scores during routine
immunisation at 4-6 months of age than uncircumcised boys70
and scores were again higher if circumcision was unaccompanied
by analgesia compared with those receiving topical anaesthesia71.
Newborn infants subjected to a variety of noxious stimuli have
hormonal, physiological and behavioural responses72.
There have been two recent consensus statements on the prevention
and management of pain in the newborn73,74
which should be used to guide the clinical approach to analgesia
for circumcision if such an operation should be deemed necessary.
Both statements emphasise that compared with older age groups
newborns may experience a greater sensitivity to pain, such pain
may have long term consequences, and a lack of behavioural response
(for example lack of crying) does not necessarily indicate a lack
Whilst general anaesthesia will often be used for circumcision
beyond the neonatal period it has rarely been considered as an
option for newborn circumcision. Local or regional anaesthesia
for newborn circumcision has been provided by local application
of a eutectic mixture of local anaesthetics (EMLA cream), dorsal
penile nerve block (DPNB), penile ring block (PRB) and caudal
Recent trials have demonstrated that combined analgesia and local
anaesthesia (for example, pre- and post-operative paracetamol,
EMLA cream to the abdomen and foreskin, oral sucrose, and DPNB
or PRB75), are more effective than
either alone74,76,77. In Australia,
most circumcisions are undertaken in boys older than six months
under a general anaesthetic, with local anaesthetic often being
administered during the general anaesthetic.
9. Technique of Circumcision
When a circumcision is performed in an older child it is usually
performed under general anaesthesia and regional block78.
There are numerous descriptions of circumcision but in most,
the following steps are undertaken78.
- Any residual adhesions between the inner surface of the foreskin
and the glans are separated until the coronal groove is fully
exposed circumferentially. Any smegma is removed.
- The foreskin is returned to its normal position and a dorsal
slit is made, stopping short of the coronal groove.
- A similar manoeuvre is performed on the ventral surface as
far as the frenulum.
- The foreskin is excised around each side leaving a rim of
inner surface adjacent to the coronal groove.
- The edges of the foreskin are retracted to enable haemostasis.
Usually the vessels are ligated with absorbable suture, or diathermied.
- The edges of the foreskin are sutured around the circumference
with interrupted absorbable sutures.
- No circumferential dressing is applied, because of the risk
of making the glans ischaemic if swelling occurs.
Potential intraoperative problems include:
- Removal of excessive skin
- Removal of inadequate skin
- Injury to the urethra
Early postoperative complications include bleeding, infection
and glanular ulceration.
- Gollaher DL. Circumcision: a history
of the world’s most controversial surgery. Basic Books, New
- Denniston GC, Hodges FM, Milos
MF, Eds. Male and female circumcision: medical, legal and ethical
considerations in pediatric practice. Kluwer Academic/Plenum
Publishers, New York, 1999.
- Lerman SE, Liao JC. Neonatal circumcision.
Pediatr Clin North Am. 2001 Dec;48:1539-57.
- Canadian Paediatric Society, Fetus
and Newborn Committee. Neonatal
circumcision revisited. Can Med Assoc 1996 Mar 15;154:769-80.
- American Academy of Pediatrics:
Force on Circumcision. [Circumcision Policy Statement] Pediatrics
- American Academy of Pediatrics:
Task Force on Circumcision. Pediatrics 2000;105:641-2.
- Williams PL, Bannister LH, et al
(eds). Gray’s Anatomy, 38th ed, Churchill Livingstone, New York,
- Williams PL, Bannister LH, et al
(eds). Gray’s Anatomy, 38th ed, Churchill Livingstone, New York,
- Gairdner D. The
fate of the foreskin. A study of circumcision. BMJ 1949;24:1433-37.
- Baskin L. Circumcision. In: Baskin
S, Kogan B, Duckett J, eds. Handbook of Pediatric Urology, 1st
ed San Francisco: Lippincott-Raven, 1997:2-3.
- American Academy of Pediatrics:
Task Force on Circumcision. [Report
of the Task Force on Circumcision.] Pediatrics. 1989 Aug;84:388-91.
- Rickwood AMK and Walter J. Is
phimosis overdiagnosed in boys and are too many circumcisions
performed in consequence? Ann R Coll Surg Eng. 1989 Sep;71:275-77.
- Rickwood AMK. Medical indications
for circumcision. BJU Int. 1999;83(Suppl 1):45-51.
- Stenram A, Malmfors G, Okmian
L. Circumcision for phimosis - Indications and results. Acta
Paediatr Scand 1986 Mar;75:321-26.
- Shankar KR, Rickwood AMK. The
incidence of phimosis in boys. BJU Int. 1999;84:101-02.
- Rickwood AMK, Kenny SE, Donnell
evidence based circumcision of English boys: Survey of trends
in practice. BMJ. 2000;321:792-93.
- Rickwood AMK, Hemalatha V, Batcup
G, Spitz L. Phimosis
in boys. Brit J Urol. 1980 Apr; 52:147-50.
- Clemmensen O, Krogh J, Petri
M. The histological spectrum of prepuces from patients with
phimosis. Arch Dermatol. 1988 Apr;10:104-08.
- Kikiros CS, Beasley SW, Woodward
AA. The response of phimosis to local steroid application. Pediatr
Surg Int. 1993;8:329-32.
- Wright J. The
treatment of childhood phimosis with topical steroid. Aust
N Z J Surg. 1994 May; 64: 327-28.
- Escala JM, Rickwood AMK. Balanitis.
Brit J Urol. 1989 Feb;63:196-97.
- Fakjian N, Hunter S, et al. An
argument for circumcision: Prevention of balanitis in the adult.
Arch Dermatol. 1990 Aug;126:1046-47.
- Williams J, Morrison P, Richardson
J. Paraphimosis in elderly men. Am J Emerg Med. 1995 May;13:351-53.
- Craig JC, Knight JF, Sueshkumar
P, Mantz E, Roy LP. Effect
of circumcision on incidence of urinary tract infection in preschool
boys. J Pediatr. 1996 Jan;128:23-7.
- Hellstrom A, Hanson E, Hansson
S, Hjalmas K, Jodal U. Association
between urinary symptoms at 7 years of age and previous urinary
symptoms. Arch Dis Child. 1991 Feb;66:232-234.
- Ginsburg CM, McCracken GHJ. Urinary
tract infections in young infants. Pediatrics. 1982 Apr;
- Winberg J, Bollgren I, Gothefors
L, Herthelius M, Tullus K. The
prepuce: a mistake of nature? Lancet. 1989 Mar; 1: 598-9.
- Pisacane A, Graziano L, Mazzarella
G, Scarpellino B, Zona G. Breast-feeding
and urinary tract infection. J Pediatr 1992 Jan;120:87-9.
- Wiswell TE, Smith FR, Bass JW.
Decreased incidence of urinary tract infections in young infants.
Pediatrics. 1985 May;75:901-03.
- Wiswell TE, Roscelli JD. Corroborative
evidence for the decreased incidence of urinary tract infections
in circumcised male infants. Pediatrics 1986 Jul;78:96-99.
- Schoen EJ, Colby CJ, Ray GT.
Newborn circumcision decreases incidence and costs of urinary
tract infections during the first year of life. Pediatrics 2000
Apr;105(4 Pt 1):789-93.
- Herzog LW. Urinary tract infections
and circumcision. A case-control study. Am J Dis Child 1989;143:348-350.
- Crain EF, Gershel JC. Urinary
tract infections in febrile infants younger than 8 weeks of
age. Pediatrics. 1990 Sep;86:363-7.
- Spach DH. Stapleton AE. Stamm
WE. Lack of circumcision increases the risk of urinary tract
infection in young men. JAMA. 1992;267 Feb 5:679-81.
- Rushton HG. Majd M. Pyelonephritis
in male infants: how important is the foreskin?. J Urol. 1992;148:733-6;
- Kashani IA, Faraday R. The risk
of urinary tract infection in uncircumcised male infants. International
- To T, Agha M, Dick PT, Feldman
W. Cohort study on circumcision of newborn boys and subsequent
risk of urinary-tract infection. Lancet. 1998 Dec 5;352:1813-6.
- Christakis DA, Harvey E, Zerr
M, et al. A
trade-off analysis of routine newborn circumcision. Pediatrics.
- Winberg J. Andersen HJ. Bergstrom
T. Jacobsson B. Larson H. Lincoln K. Epidemiology of symptomatic
urinary tract infection in childhood. Acta Paediatr Scand -
- Panaretto K. Craig J. Knight
J. Howman-Giles R. Sureshkumar P. Roy L. Risk factors for recurrent
urinary tract infection in preschool children. J Paediatr Child
Health. 1999 Oct;35:454-9.
- Van Howe, RS. Does
circumcision influence sexually transmitted diseases?: A literature
review. BJU Int. 1999 Jan;83 Suppl 1:52-62.
- Parker SW, Stewart AJ, Wren M,
et al. Circumcision and sexually transmissible disease. Med
J Aust. 1983 Sep 17;2:288-90.
- Donovan B, Bassett I, Bosworth
circumcision and common sexually transmissible diseases in a
developed nation setting. Genitourin Med. 1994;70:317-20.
- Smith GL, Greenup PR, Takafugi
as a risk factor for urethritis in racial groups. Am J Public
Health. 1987 Apr;97:452-54.
- Cameron DW, Simonsen JN, et al.
Female to male transmission of human immunodeficiency virus
type I: Risk factors for seroconversion in men. Lancet. 1989
- Moses S, Bailey RC, Ronald AR.
Male circumcision: assessment of health benefits and risks.
Sex Transm Inf. 1998 Oct;74:368-373.
- De Vincenzi I, Mertens T. Male
circumcision: A role in HIV prevention? AIDS. 1994 Feb;8:153-160.
- Quigley MA, Weiss HA, Hayes RJ.
Male circumcision as a measure to control HIV infection and
other sexually transmitted diseases. Curr Opin Infect Dis. 2001
- O’Farrell N, Egger M. Circumcision
in men and the prevention of HIV infection: a “meta-analysis”
revisited. Int J STD AIDS. 2000 Mar;11:137-42.
- Castellsagué X, Bosch
FX, Munoz N, et al. Male
circumcision, penile human papillomavirus infection, and cervical
cancer in female partners. N Engl J Med 2002 Apr 11;346:1105-12.
- Adami H-O, Trichopoulos D. Cervical
cancer and the elusive male factor (Editorial). N Engl J Med
2002 Apr 11;346:1160-1.
- Dean A. Epithelioma of the penis.
J Urol 1945;33:252-83.
- Lenowitz H, Graham AP. Carcinoma
of the penis. J Urol. 1946;56,458-84.
- Dagher R, Selzer ML, Lapides
J. Carcinoma of the penis and the anti-circumcision crusade.
J Urol. 1973 Jul;110:79-80.
- Bissada NK, Morcos RR, El-Senoussi
carcinoma of the penis. 1. Clinical Aspects. J Urol. 1986
- Magoha GAO, Kaale RF. Epidemiological
and clinical aspects of carcinoma of penis at Kenyatta National
Hospital. East Afr Med J. 1995 Jun,72:359-61.
- Hellberg D, Valentin J, Eklund
T, Nilsson S. Penile
cancer: Is there an epidemiological role for smoking and sexual
behaviour? Br Med J (Clin Res Ed). 1987 Nov 21;295:1306-08.
- Brinton LA, Li JY, Rong SV, et
al. Risk factors for penile cancer: Results from a case-control
study in China. Intl J Cancer. 1991 Feb 20;47:504-09.
- Frisch M, Friis S, Kruger Kjaer
S, Melbye M. Falling
incidence of penis cancer in an uncircumcised population (Denmark
1943 - 1990). BMJ. 1995 Dec 2;311:1471.
- Svoboda JS, Van Howe RS, Dwyer
consent for neonatal circumcision: an ethical and legal conundrum.
J Contemp Health Law Policy 2000 Winter;17;61-133.
- Williams N, Kapila L. Complications
of circumcision. Brit J Surg. 1993 Oct;80:1231-6.
- Speert H. Circumcision of the
newborn: An appraisal of the present status. Obstet Gynecol.
- Patel H. The
problem of routine circumcision. Can Med Assoc J. 1966 Sep;95:576-81.
- Fraser IA, Allen MJ, Bagshaw
PF, Johnstone M. A randomised trial to assess childhood circumcision
with the Plastibell device compared to a conventional dissection
technique. Br J Surg. 1981 Aug;68:593-5.
- Kaplan GW. Complications
of circumcision. Urol Clin North Am. 1983 Aug;10:543-9.
- Griffiths DW, Atwell JD, Freeman
prospective study of the indications and morbidity of circumcision
in children. Eur Urol. 1985;11:184-7.
- Boyle GJ, Svoboda JS, Price CP,
Turner JN. Circumcision
of healthy boys: criminal assault? J Law Med 2000;7:301-10.
- Brown MS, Brown CA. Circumcision
decision: Prominence of social concerns. Pediatrics. 1987
- Anand KJS. Pain, plasticity,
and premature birth: a prescription for permanent suffering?
Nat Med. 2000 Sep;6:971-3.
- Taddio A, Goldbach M, Ipp M,
Stevens B, Koren G. Effect
of neonatal circumcision on pain responses during vaccination
in boys. Lancet. 1995 Feb 4;345:291-2.
- Taddio A, Katz J, Ilersich AL,
Koren G. Effect
of neonatal circumcision on pain response during subsequent
routine vaccination. Lancet. 1997 Mar 1;349:599-603.
- Anand KJS, Hickey PR. Pain
and its effects in the human neonate and fetus. New Engl
J Med. 1987 Nov 19;317:1321-1329.
- American Academy of Pediatrics
and Canadian Paediatric Society. Prevention
and management of pain and stress in the neonate. Pediatrics
- Anand KJS. Consensus
statement for the prevention and management of pain in the newborn.
Arch Pediatr Adolesc Med. 2001 Feb;155:173-80.
- Taddio A, Pollock N, Gilbert-MacLeod
C, Ohlsson K, Koren G. Combined
analgesia and local anesthesia to minimize pain during circumcision.
Arch Pediatr Adolesc Med 2000 Jun;154:620-3.
- Taddio A. Pain management for
neonatal circumcision. Pediatr Drugs. 2001;3:101-11.
- Litman RS. Anesthesia and analgesia
for newborn circumcision. Obstet Gynecol Surv. 2001 Feb;56:114-7.
- Beasley SW, Hutson JM, Auldist
AW. Circumcision. In: Essential paediatric surgery. Edward Arnold,
Members of the Working Party
• Professor Spencer Beasley
Department of Paediatric Surgery
Private Bag 4710
• Professor Brian Darlow
Department of Paediatrics
Private Bag 4710
• Dr Jonathan Craig
Department of Nephrology
Children's Hospital at Westmead
Locked Bag 4001
Westmead, NSW 2124
• Mr Des Mulcahy
93 Byng Street
Orange, NSW 2800
• Mr Grahame Smith
Department of Surgery
New Children's Hospital
PO Box 3515
Parramatta, NSW 2124