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Circumcision Dr. Grahame Smith The Childrens Hospital at Westmead.

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Presentation on theme: "Circumcision Dr. Grahame Smith The Childrens Hospital at Westmead."— Presentation transcript:

1 Circumcision Dr. Grahame Smith The Childrens Hospital at Westmead

2 Undertaken for many thousands of years History

3  Originally a hygiene measure  A ritual, religious  Enhance/decrease sexual performance  Prevent masturbation (Brigman) Why

4  RACP/RACS 2010  Not recommended routinely  American Academy of Pediatrics 2012  Not recommended routinely  Justified for families that choose it  Canadian Pediatric Society 1989  Not recommended None recommend routine circumcision Current position statements

5  Finland  In February 2010, a Jewish couple were fined for causing bodily harm to their then infant son who was circumcised in 2008 by a mohel brought in from the UK. Normal procedure for persons of Jewish faith in Finland is to have a locally certified mohel who works in Finnish healthcare perform the operation. In the 2008 case, the infant was not anesthetized and developed complications that required immediate hospital care. The parents were ordered to pay 1500 euros in damages to their childmohel  Netherlands  Germany  Dec 2012; law passed explicitly permitting non-therapeutic circumcision to be performed under certain conditions (religious) Strongly opposed

6 Risk & cognitive error 1

7 Risk & cognitive error 2

8  We fear snakes and not cars  We fear spectacular, unlikely events  Plane crash versus car crash  We underestimate our risk of disease  We don’t interpret statistics well Risk & cognitive error summary

9  Thought Hats  Religious - faith  * Science* - evidence Thought processes

10  Religious, social, “cultural freedom”  Prevent  Penile cancer  HIV  Other STDs  UTIs Arguments for

11  Recurrent UTIs – 1% children  Foreskin increases UTI risk 5 – 10 times  Phimosis (pathological) – 1% children  Recurrent balanitis – 1% children Medical indications

12  Reduced sexually transmitted disease  HIV, Herpes, HPV etc.  Safe sex practices cheaper & more effective  May be valid in areas with high HIV incidence  HPV vaccine a better alternative  Penile cancer (1: 100,000)  too rare to worry about  UTIs – example to follow Invalid reasons

13  Assume complication rate 2% (1% - 10%)  1000 well children circumcised  => 8 less UTIs, 20 complications  1000 Children with UTIs  => 250 UTIs prevented, 20 complications Risk benefit analysis for UTIs

14  Circumcision may decrease female pleasure during intercourse  O’Hara & O’Hara - surveyed 138 women. Of that group 20 (14.5%) preferred non-intact circumcised sexual partners while 118 or (85.5%) preferred intact non-circumcised sexual partners. This means that about 6 out of 7 women preferred intact non-circumcised partners while about 1 out of seven preferred non-intact circumcised partners And further risk

15  Abnormal penis  Hypospadias  Epispadias  Buried penis  Systemic  Coagulopathy  Increased anesthetic risk Contra indications

16  Early  Pain  Infection  Bleeding  Fistula  Glans amputation  Loss of penis  Death Risks

17  Late  Meatal stenosis  Poor cosmetic result  Skin tags, suture sinuses  Buried penis Risks

18  Theoretical  Sued or prosecuted  Legally, parents may not consent for an operation for a child when such a decision is not in the child’s best interest. Risks

19 Care of the normal foreskin

20  Nothing required  Forceful retraction may cause injury and phimosis Infancy and childhood

21  Retract and clean each day After puberty

22  Treatment not needed  Responds well to Betnovate ½ cream Phimosis - physiological

23  Responds to Betnovate ½ cream – rarely  Tacrolimus  May be carcinogenic  Circumcision usually curative Phimosis – pathological

24 Phimosis and buried penis Megaprepuce

25 Paraphimosis

26 Tight frenulum

27 Foreskin adhesions

28 Foreskin lumps

29 Smegma

30 Smegma - more

31  Multiple  Happen even in the best of hands  Incidence = 5 to 10% Circumcision complications

32 Buried penis

33 Shaft to glans adhesions

34 Meatal stenosis

35 Shortage of skin

36 Amputation glans

37  Don ’ t circumcise unless there is a medical indication (benefits outweigh the risk)  If there is an indication, it ’ s a good operation Conclusion

38  https://www.racp.edu.au/page/paed-policy https://www.racp.edu.au/page/paed-policy     (against)  (pro)  O’Hara K, O’Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int 1999;83 Suppl 1:79–84. References

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