TABLE 3.
Characteristics of literature searches, physicians questionnaires and society recommendations
| Lead author | Year | Country | Study description | Types of complication | Major findings/conclusions |
|---|---|---|---|---|---|
| Sorokan | 2015 | Canada | Canadian Pediatric Society position statement on newborn male circumcision. | Infection (minor and major) | While there may be a benefit for some boys in high‐risk populations and circumstances where the procedure could be considered for disease reduction or treatment, the Canadian Pediatric Society does not recommend the routine circumcision of every newborn male. |
| Death (from unrecognized bleeding) | |||||
| Unsatisfactory cosmetic results including uncircumcised appearance | |||||
| Brook | 2016 | USA | A literature search was conducted through June 25, 2015. The following search terms were used: circumcision, infections (all types), complication, wound infection, bacteremia, tetanus and guidelines. | Infection (minor and major) | Infectious complications following circumcision should be reduced with trained and competent practitioners performing the procedure using sterile techniques. |
| Morris | 2016 | Canada | A risk–benefit analysis of the Canadian Academy of Pediatrics Position Statement on newborn male circumcision. | Infection (minor and major) | The 2015 Canadian Pediatric Society position statement on early infant (newborn) male circumcision is at odds with the evidence. The Canadian Pediatric Society conclusions stem from errors in its risk–benefit analysis. In light of our findings, we recommend the Canadian Pediatric Society issue a revised statement. |
| Partial penile/glans amputation | |||||
| Haemorrhage/bleeding (outside of a genetic deficiency) | |||||
| Meatal stenosis | |||||
| Death (from unrecognized bleeding or infection) | |||||
| Krill | 2011 | USA | Description of how/when circumcisions are performed and various complications that can arise. | Infection (minor and major) | A thorough and complete preoperative evaluation, focusing on bleeding history and birth history, is imperative. Proper selection of patients based on age and anatomic considerations as well as proper sterile surgical technique are critical to prevent future circumcision‐related adverse events. |
| Necrosis | |||||
| Partial penile/glans amputation | |||||
| Phimosis (secondary) | |||||
| Haemorrhage/bleeding (outside of a genetic deficiency) | |||||
| Meatal stenosis | |||||
| Meatitis | |||||
| Trapped/buried/concealed/inconspicuous penis | |||||
| Urethrocutaneous fistula | |||||
| Iatrogenic hypospadias | |||||
| Insufficient foreskin removal/redundant foreskin | |||||
| Pain | |||||
| Skin bridges (penile skin adhesion) | |||||
| Implantation dermoid/epidermal inclusion cysts/penile implantation cyst | |||||
| Chordee | |||||
| Suture sinus tracts | |||||
| Schofer | 2015 | Germany | Electronic databases were searched for articles about the infection risks of foreskin surgery, and the efficacy of circumcision in reducing the risks of sexual transmission of HIV, herpes viruses, HPV, Treponema pallidum, chlamydia, Hemophilus ducrey and Neisseria gonorrhoeae. | Infection (minor and major) | Neonatal circumcisions (and circumcision in early childhood) are irreparable interventions in the physical integrity, with very few medical indications. The risk of complications is dependent on the education of the circumciser (ritual and medical), analgesia and hygiene. Circumcisions should be performed under optimal surgical and hygienic conditions in informed and self‐determined young men only. In adolescents and adults, circumcision reduces the risk of the transmission of viral STIs (HIV, HSV and HPV), and there is also probably some effect on the sexual transmission of T. pallidum and Haemophilus ducreyi (insufficient, controversial data). The role of circumcision as an effective procedure to reduce the transmission of STIs is still under discussion, because important additional factors like sexual risk behaviour (e.g., unprotected sexual intercourse and promiscuity) have a strong influence on STI epidemiology. |
| Haemorrhage/bleeding (outside of a genetic deficiency) | |||||
| Meatitis | |||||
| Koren | 2013 | Israel | A review of the medical records of neonatal herpes simplex virus infection looking for cases who were born between January 2001 and December 2007 in five medical centres located in central Israel to determine the incidence and the clinical characteristics of neonatal herpes simplex virus infection in Israel. | Penile herpes simplex virus type 1 infection (after Jewish ritual circumcision) | The incidence of neonatal herpes simplex virus infection in Israel was found to be similar to the lower part of the scale reported in the United States, however, higher than the incidence reported in Canada or in Europe. Similar to more recent reports, our series demonstrates the shift toward the predominance of HSV‐1 in neonatal herpes simplex virus infection. In addition, none of the mothers in our series had a previous history of genital herpes. This study emphasizes the need for awareness of HSV infection in Israeli neonates. |
| Svoboda | 2017 | USA | Article discussing the ethics of Nontherapeutic Circumcision of Minors. | Necrosis | A comparison of benefits and risks is not ethically sufficient in an analysis of a nontherapeutic procedure performed on patients unable to provide informed consent; and that circumcision violates clinicians' imperatives to respect patients' autonomy, to do good, to do no harm and to be just. When due consideration is given to these values, the balance of factors suggests that NTC should be deferred until the affected person can perform his own cost–benefit analysis, applying his mature, informed preferences and values. |
| Partial penile/glans amputation | |||||
| Phimosis (secondary) | |||||
| Meatal stenosis | |||||
| Meatitis | |||||
| Trapped/buried/concealed/inconspicuous penis | |||||
| Urethrocutaneous fistula | |||||
| Iatrogenic hypospadias | |||||
| Implantation dermoid/epidermal inclusion cysts/penile implantation cyst | |||||
| Kearney | 2015 | USA | A survey of paediatric haematologists from Hemophilia Treatment Centers (HTC) across the United States to better understand the attitudes toward and management of neonatal circumcision in haemophilia patients. | Bleeding in the context of a genetic condition: haemophilia, sickle cell trait and factor VII deficiency | The recent shift in policy statements by professional societies in the United States regarding neonatal circumcision may result in more parents requesting this procedure during newborn period for its medical benefits. Paediatric haematologists must be prepared to address this while considering the risks inherent to persons with an underlying bleeding disorder. The study provides a foundation for future research regarding the optimal management and outcomes of neonatal circumcision in haemophilia to develop evidence‐based guidelines for the management of circumcision in this unique population. |
| Simpson | 2014 | USA | Review summarizing historical, cultural and ethical factors in neonatal circumcision and briefly compare common surgical techniques including anaesthesia. | Haemorrhage/bleeding (outside of a genetic deficiency) | We agree with the AAP policy that neonatal circumcision has medical benefits that exceed the medical risks and should be available for families who choose the procedure. We strongly support additional anticipatory guidance and documentation of informed consent. Cultural, religious and ethical family traditions must be respected and supported as physicians counsel these new families. We believe that neonatal circumcision is cost effective. Insurers including state associated Medicaid programmes should cover this procedure with adequate funds to encourage practitioners to perform neonatal circumcisions in appropriate settings. Additionally, we believe that a standardized circumcision curriculum is helpful for all resident training programmes whose graduates may expect to either perform neonatal circumcision or interact with parents during the prenatal and neonatal periods. Finally, physicians performing the procedure have a responsibility to demonstrate ongoing competency, including adequate pain control, during the procedure. |
| Meatal stenosis | |||||
| Unsatisfactory cosmetic results including uncircumcised appearance | |||||
| Skin bridges (penile skin adhesion) | |||||
| Srinivasan | 2011 | USA | Provide a definition and description of inconspicuous penis and then to describe its management including surgical correction. | Trapped/buried/concealed/inconspicuous penis | Inconspicuous penis is a very common condition presenting to a paediatric urologist for surgical correction. Reconstruction is warranted in appropriate cases to avoid future psychosexual issues and provide the child with normal functional anatomy. Although the classification system to an extent is artificial and considerable overlap is present, it is useful in determining the primary anatomic issue and thus determines treatment. Diagnosis should be made on anatomical considerations and treatment individualized to the patients based on residual anatomy, type of deformity and the amount of skin cover available. |
| Cimador | 2015 | Italy | Management of inconspicuous penis in children. | Trapped/buried/concealed/inconspicuous penis | Inconspicuous penis is more common than is usually appreciated and often requires evaluation by a paediatric urologist. This disorder can have iatrogenic causes resulting from adhesions that are secondary to circumcision. If the inconspicuous penis is caused by abnormalities of the surrounding structures, it is essential to identify the primary anatomical issue. Diagnosis should be made on the basis of penile appearance while considering the anatomy of the penis. Treatment should be individualized to each patient on the basis of residual anatomy, type of deformity and the amount of covering skin available. |
| Edler | 2016 | Sweden | Data on significant complications following circumcision on boys under the age of one in Scandinavia over the last 20 years were collected. A systematic review was performed of fatal cases in the literature. Thirty‐two boys had cases that had been reported to the health authorities in the three countries, and a total of 74 complications were identified in these cases. | Infection (minor and major) | Complications following male circumcision in Scandinavia were relatively rare, but serious complications did occur. Based on the analyses of the severe cases, we argue that circumcision should only be performed at hospitals with 24‐h emergency departments. |
| Necrosis | |||||
| Oedema | |||||
| Haemorrhage/bleeding (outside of a genetic deficiency) | |||||
| Nonhealing wound | |||||
| Trapped/buried/concealed/inconspicuous penis | |||||
| Circulatory shock | |||||
| Death (from bleeding or infection) | |||||
| Insufficient foreskin removal/redundant foreskin | |||||
| Pain | |||||
| Excessive skin removal | |||||
| Injury to urethra |