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. 2017 Feb 8;6(1):89–102. doi: 10.5409/wjcp.v6.i1.89

Table 1.

Risk-benefit analysis for newborn male circumcision

Condition Decrease in risk1 Percent affected2 Study type and ref Quality score3
A: Conditions avoided and risk reduction
Pyelonephritis (infants) – 0.6 OS[24,25] 2+
With concurrent bacteremia – 0.1
Hypertension in early adulthood – 0.1
End-stage renal disease in early adult – 0.06
Urinary tract infections: Age 0-1 yr 90% 1.3 Meta[22] 1+
Urinary tract infections: Age 1-16 yr 85% 2.7 Meta[22] 1+
Urinary tract infections: Age > 16 yr 70% 28 Meta[22] 1+
Urinary tract infections: lifetime 72% 27 Meta[22] 1+
Phimosis4 > 90% 10 OS[33-45,47] 2+
Balanitis 68% 10 Meta[54] 1+
Candidiasis (thrush) 60% 10 OS[19] 2+
High-risk HPV infection 56% 10 Meta[73] 1++
53%-65% 4 Meta[65] 1++
40% 6-10 RCT[61-63,70-72] 1++
HIV (acquired heterosexually) 60% 0.2 OS[90] 2+
70% 0.1 Meta[87] 1++
Genital ulcer disease 50% 1 OS[81,82,160] 2+
Syphilis 47% 1 Meta[67] 1+
40%-55% 1 OS[79,80] 2+
Trichomonas vaginalis 50% 1 RCT[77] 1+
Mycoplasma genitalium 40% 0.5 RCT[78] 1+
Herpes simplex virus type 2 30% 4 RCT[68,69,75,76] 1++
15% 4 Meta[67] 1++
Chancroid 50% < 1 Meta[67] 1+
Penile cancer (lifetime) 67% 0.07 Meta[119] 1+
95%5 0.1 OS[116] 2+
95%6 0.11 OS[117] 2+
99%7 0.07 OS[118] 2+
Prostate cancer: Population-based 17% 2.1 Meta[125] 1+
Black race 42% 17 Meta[125] 1+
Total percentage of uncircumcised males affected = approximately 80%
B: Risks of infant MC
Excessive minor bleeding 0.1-0.2 OS[128,132] 2++
Infection, local 0.06 OS[128,132] 2++
Infection, systemic 0.03 OS[128] 2++
Need for repeat surgery 0.08 OS[128] 2++
Meatal stenosis < 0.1 OS[128-131] 2++
Partial loss of penis 0.0002 OS[128] 2++
Death < 0.000001 OS[132] 2++
Reduced penile function, sensitivity, sexual pleasure 0 SR[133,134,137] 2++
Reduced penile function 0 Meta[134] 1+
Total percentage of adverse events from infant circumcision: About 0.4%
Risk: Benefit
Thus, over the lifetime, the risk to an uncircumcised male of developing a foreskin-related condition requiring medical attention may be up to 80%. In comparison the procedural risk during infant MC of experiencing an easily treatable condition is approximately 1 in 250. The risk of a moderate or serious complication is approximately 1 in 3000. Thus benefit to risk = 1:200.
C: Risks reduced by female partners
Cervical cancer6 58%78 OS[59,60] 2++
28%7 RCT[101] 1++
Herpes simplex virus type 26 55%7 OS[102] 2+
Genital ulceration6 22%7 RCT[103] 1+
Trichomonas vaginalis6 48%7 RCT[103] 1+
Syphilis6 75%7 OS[79] 2++
Bacterial vaginosis6 40%7 RCT[103] 1+
Chlamydia trachomatis6 8279 OS[104] 1++
1

Based on data for circumcised vs uncircumcised males;

2

The percentage of males who will be affected as a result of the single risk factor of retention of the foreskin. Data for STIs were estimated after taking into account the external factor of heterosexual exposure, which is dependent on population prevalence of each STI in North America and risk reduction conferred by circumcision;

3

Quality rating was based on an international grading system[13]. Rating was 1++ or 1+ for well-conducted meta-analysis and RCTs, was 2++ for well-conducted systematic reviews, and was 2++ or 2+ for the original studies cited;

4

Phimosis (tight foreskin) is confined almost exclusively to uncircumcised males;

5

Penile cancer was 22 times more frequent in uncircumcised males in the Californian study cited[116];

6

The last two entries for penile cancer are the references cited by the AAP[2] and CDC[5] in their respective circumcision policy statements;

7

For women with circumcised vs women with uncircumcised sexual partners;

8

For monogamous women whose male sexual partner has had ≥ 6 other female sexual partners;

9

Chlamydia trachomatis was 5.6 times more frequent in female partners of uncircumcised males in a large multinational study[104]. Shown are the reference(s) and type of study. The meta-analyses provide comprehensive lists of references to individual studies relevant to the topic. Meta: Meta-analysis; OS: Original study; RCT: Randomized controlled trial; SR: Systematic review; HPV: Human papillomavirus; HIV: Human immunodeficiency virus.