Page 1 - Canadian Urological Association guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants (Full Version)

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CUA GUideline

Canadian Urological Association guideline on the care of the normal

foreskin and neonatal circumcision in Canadian infants (full version)

Sumit Dave, MD ; Kourosh Afshar, MD ; Luis H. Braga, MD ; Peter Anderson, MD 4
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1 Department of Surgery (Urology), Western University, London, ON; Department of Urologic Sciences, University of British Columbia, Vancouver, BC; Department of Surgery (Urology), McMaster University,
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Hamilton, ON; Department of Urology, Dalhousie University, Halifax, NS; Canada
Cite as: Can Urol Assoc J 2017;12(2):E76-99. http://dx.doi.org/10.5489/cuaj.5033 Provincial Ministries of Health in Canada indicate circumci-
sion rates of 51‒67% in 1970. In 2009, the Public Health
Published online December 1, 2017 Agency of Canada reported an overall Canadian circumci-
sion rate of 31.9% for 2006‒2007. This varied across the
provinces, with the rate being highest in Alberta (44.3%) and
Introduction lowest in Nova Scotia (6.8%) (www.circinfo.net).
A Centers for Disease Control and Prevention (CDC)
Circumcision is the oldest planned operative procedure in report showed a decreasing trend in US circumcision rates
the history of the human civilization, but there continues from 1999‒2000 until 2008‒2010 from 60% to 55% of new-
to be a lack of consensus and strong opposing views on born males. In the U.K. between 1997 and 2004, circum-
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whether universal neonatal circumcision should be adopted cision rates declined from 2.6/1000 boys/year to 2.1/1000
as a public health measure. The recent American Academy boys/year; however, a more recent study from the U.S. using
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of Pediatrics (AAP) guideline on male circumcision (MC) the Nationwide Inpatient Sample noted an increasing trend
reversed its prior stand, stating that the “health benefits of of neonatal circumcisions from 48% in 1988‒1991 to 61%
newborn male circumcision outweigh the risks,” and justify in 1997‒2000, reflecting an increase of 6.8% on average
access to the procedure if the parents so choose. This rec- every year.
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ommendation was primarily based on the impressive results A survey of prospective parents in the U.S. was assessed
from African trials demonstrating the protective effect of MC to obtain parental views of circumcision analyzing the effect
against human immunodeficiency virus (HIV) and sexually of the AAP 1999 circumcision guideline and recent HIV
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transmitted infections (STIs). and human papillomavirus (HPV) trials. Individuals with
A review of the literature on MC shows evidence of a previous circumcised sons, those born in the U.S., and those
vehement debate, often clouded by strong personal biases who discussed circumcision with their partner were more
and lack of high-quality evidence. Creation of a guideline likely to request circumcision. There was no change in sup-
specific to the need of Canadian infant males is, therefore, dif- port after reading information on recent HIV/HPV trials from
ficult given the level of evidence provided for each potential Africa. A similar survey in Canada indicated that circumci-
benefit, the lack of data directly applicable to the Canadian sion status of the father significantly influences the child’s
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population, the inability to quantify the true complication circumcision. This study indicates that initial parental views
rate of routine circumcisions accurately, uncertainty about rather than new evidence may continue to be the strongest
the health benefits of a circumcision compared with other determinant for neonatal circumcision.
health interventions, the ethical issues and acceptability of
a surgical procedure done by parental consent for future Aims of the review
benefits, and the costs of training and implementation of any
universal neonatal circumcision policy in Canada. The aim of this guideline is to present the current evidence
on the benefits of circumcision, the optimal anesthesia/anal-
Acceptance and trends of neonatal circumcision gesia requirements of neonatal circumcision, the possible
complications of circumcision, and its effect on sexual func-
Neonatal circumcision rates are declining across several tion and sensation, as well as the care of a normal foreskin in
countries, including Canada, and this may be a reflection early childhood. This guideline is directed towards pediatric
of changing demographic patterns and parental beliefs. The caregivers who routinely examine and follow male infants,

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