Page 6 - Canadian Urological Association guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants (Abridged Version)

guideline: neonatal circumcision and foreskin care

CI 0.82‒1.13) or HSV-2 infections (OR 0.86; 95% CI 3. Recognition and treatment of phimosis during regu-
0.62‒1.21). 61 lar health visits is recommended to decrease the
risk of penile cancer (Level 5, Grade D). A geni-
Non-ulcerative and ulcerative STIs in female partners tourinary exam during puberty is recommended
Gray et al followed HIV-negative women married to men to ensure preputial retractability and hygiene, and
randomized to circumcised and non-circumcised groups. 62 counsel regarding HPV vaccination and safe sexual
Adjusted analyses suggested a 22% circumcision efficacy for practices (Grade D).
GUD (95% CI 0.61‒0.99), a 45% efficacy for Trichomonas
(95% CI 0.34‒0.89), and a 18% efficacy for bacterial vagi- Circumcision and prostate cancer
nosis (95% CI 0.74‒0.91). In the Ugandan RCT on HIV-
negative men, MC did not reduce the risk of HSV-2 acquisi- A recent case-control study showed no protective effect
tion in women partners. 63 of MC on prostate cancer (OR 0.87; 95% CI 0.74‒1.02). 69
Recommendations (circumcision and ulcerative/non- Another population-based study from Montreal also dem-
ulcerative STIs): onstrated no significant overall protective effect of MC (or
1. Currently, there is no significant evidence to sup- infant MC), but the results where significant for men circum-
port the protective role of MC in the acquisition of cised at ≥36 years of age (OR 0.55; 95% CI 0.30, 0.98). A
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non-ulcerative STIs, although there may be a protec- U.K. study did not find any significant correlation between
tive effect on acquisition of Trichomonas infections MC and prostate cancer. 71
(Level 2a‒b, Grade B). Recommendations (circumcision and prostate cancer):
2. Currently, there is no significant evidence to support 1. There is no convincing evidence to suggest any pro-
the protective role of MC for males and females in the tective effect of MC against prostate cancer (Level
acquisition of ulcerative STIs (Level 2‒4, Grade C). 3‒4, Grade B).
3. There is weak evidence of a partial protective effect
of MC against HSV-2 infections in adult men follow- Role of the foreskin in sensation and sexual function
ing MC (Level 2a‒b).
There is ongoing controversy regarding the impact of
Circumcision and penile cancer circumcision on penile sensitivity and sexual satisfaction.
The primary question is whether loss of sensory nerves
In a MA of eight studies, Larke et al showed that MC <18 years in the foreskin or a possible decrease in glans sensitivity
of age was protective against invasive penile cancer (OR 0.33; impacts sexual satisfaction, after accounting for several
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95% CI 0.13‒0.83). In a matched case-control study, Tsen et confounders.
al showed that phimosis was a strong risk factor for invasive A recent meta-analysis included 10 studies to assess the
penile cancer. The protective effect of neonatal MC was impact of MC on sexual function. There were no signifi-
65
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not statistically significant when the analysis was restricted to cant differences in sexual desire, dyspareunia, premature
those who did not have a history of phimosis (OR 0.79; 95% ejaculation, ejaculation latency time, or erectile dysfunction
CI 0.29‒2.6). In another case-control study from Denmark, between circumcised and uncircumcised men. A secondary
penile cancer was associated with phimosis (OR 4.9; 95% CI analysis of the Ugandan RCT showed no long-term differenc-
1.85‒13.0), but not childhood circumcision (p=0.33). Daling es in 4456 men for sexual desire, satisfaction, and erectile
66
et al also showed that after excluding patients with phimosis, dysfunction. A similar trial from Kenya found contradictory
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lack of childhood MC was not a risk factor for penile cancer. 67 results where uncircumcised men reported an increase in
Penile cancer is strongly associated with other risk factors like sexual satisfaction. In a study multinational study, a stop-
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smoking, sexual practices, and HPV infection, which can be watch and a blinded timer were used to measure intravaginal
modified, as opposed to universal MC. 68 ejaculation latency time (IELT); results showed that MC and
Recommendations (circumcision and penile cancer): condom use did not impact IELT. 75
1. Circumcision decreases the risk of penile cancer
(Level 2‒3). Sexual function in partners
2. However, given the low incidence of invasive penile
cancer, the partial protective effect of MC, and the In an analysis of self-reported sexual experience in women
availability of other preventive strategies (like HPV partners of men before and after circumcision, Kigozi et al
vaccination, condom usage, and smoking cessation showed no changes in 57% and improved sexual satisfaction
programs), it is difficult to justify universal neonatal in 40%. In a study comparing uncircumcised and circum-
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circumcision as a preventive strategy for preventing cised homosexual men, Mao et al noted no differences in
penile cancer (Grade B). sexual difficulties or type of anal sex practiced. 76

CUAJ • February 2018 • Volume 12, Issue 2 23