Lerman S E, Liao J C
Division of Pediatric Urology, Department of Urology, University of California Los Angeles School of Medicine, Los Angeles, California, USA.
Pediatr Clin North Am. 2001 Dec;48(6):1539-57. doi: 10.1016/s0031-3955(05)70390-4.
The merits of neonatal circumcision continue to be debated hotly. Some argue that circumcision is a "uniquely American medical enigma." Most of the world's male population remains uncircumcised; however, most boys born in the United States continue to undergo neonatal circumcision. Review of existing literature supports that most children who are uncircumcised do well from a medical standpoint and, thus, the question of whether US health care practitioners are subjecting neonates to an unnecessary surgical procedure remains. The medical benefits of circumcision are multiple, but most are small. The clearest medical benefit of circumcision is the relative reduction in the risk for a UTI, especially in early infancy. Although this risk [figure: see text] is real, the absolute numbers are small (risk ranges from 1 in 100 to 1 in 1000), and one investigator has estimated that it may take approximately 80 neonatal circumcisions to prevent one UTI. In the case of a patient with known urologic abnormalities that predispose to UTI, neonatal circumcision has a clearer role in terms of medical benefit to the patient. Most of the other medical benefits of circumcision probably can be realized without circumcision as long as access to clean water and proper penile hygiene are achieved. Proper penile hygiene should all but eliminate the risk for foreskin-related medical problems that will require circumcision. Moreover, proper hygiene and access to clean water has been shown to reduce the rate of development of squamous cell carcinoma of the penis in the uncircumcised population. Proper techniques on the care of the foreskin are illustrated in the American Academy of Pediatrics pamphlet titled "How to care for the uncircumcised penis." Regarding the relationship between STDs and circumcision, patient education and the practice of low-risk sexual behavior make a far greater impact than does routine circumcision in hopes of reducing the spread of HIV and other STDs. Nevertheless, in areas where safe sexual practices are poorly adhered to, circumcision can have a relative protective effect against the transmission of HIV and other STDs. The medical harms of circumcision lie mainly in the 1% acute complication rate and the additional patients who require revision of their initial circumcision for cosmetic or medical reasons. Anecdotally, the authors see far fewer complications in the acute and long-term phase when the circumcision has been performed by someone with expertise and experience with the procedure. Thus, the authors routinely recommend to parents that, if they choose to have their newborns circumcised, they should seek out an experienced practitioner. A negative psychologic and sexual impact of circumcision has been argued, but solid, scientific data are lacking. Special interest groups have argued that perhaps the greatest harm of circumcision is in performing an operation without a clear indication. Many of these groups have claimed that performing a routine neonatal circumcision is akin to performing a surgical procedure without a clear medical benefit, and in an infant, that is akin to surgery without informed consent. Although this is an extreme posture, the clinician can understand the emphasis on trying to provide invasive medical services only when a clear medical benefit is expected, especially when treating an infant or child. Deciding whether or not to circumcise an infant continues to challenge many new parents. Clearly, the procedure provides potential medical benefits and potential risks. It is difficult to say whether the benefits outweigh the risks for all male infants. Further complicating the decision for many American parents is that, in some areas of the United States, there exists an unexplained positive cultural connotation with neonatal circumcision. For these reasons, parents who actively choose to keep their sons uncircumcised need to be encouraged to make this decision forthrightly. Parents who choose to have their children circumcised also should be encouraged to actively seek an experienced practitioner who can afford the child adequate local analgesia.
新生儿包皮环切术的利弊仍在激烈争论中。一些人认为包皮环切术是“美国特有的医学谜题”。世界上大多数男性未行包皮环切术；然而，大多数在美国出生的男孩仍接受新生儿包皮环切术。对现有文献的回顾表明，从医学角度来看，大多数未行包皮环切术的儿童情况良好，因此，美国医疗从业者是否让新生儿接受了不必要的外科手术这一问题依然存在。包皮环切术的医学益处有多个，但大多都很小。包皮环切术最明显的医学益处是相对降低了泌尿道感染（UTI）的风险，尤其是在婴儿早期。尽管这种风险是真实存在的，但绝对数字很小（风险范围从1/100到1/1000），而且有一位研究者估计，大约需要80例新生儿包皮环切术才能预防一例UTI。对于已知有易患UTI的泌尿系统异常的患者，新生儿包皮环切术对患者的医学益处更明显。包皮环切术的大多数其他医学益处，只要能获得清洁用水并保持阴茎适当卫生，即便不行包皮环切术也可能实现。适当的阴茎卫生几乎可以消除需要进行包皮环切术的与包皮相关的医学问题的风险。此外，已表明适当的卫生和获得清洁用水可降低未行包皮环切术人群中阴茎鳞状细胞癌的发病率。美国儿科学会题为《如何护理未行包皮环切术的阴茎》的宣传册中说明了护理包皮的正确方法。关于性传播疾病（STD）与包皮环切术的关系，患者教育和低风险性行为的实践对减少HIV和其他STD传播的影响远比常规包皮环切术大得多。然而，在安全性行为执行情况不佳的地区，包皮环切术对HIV和其他STD的传播可产生相对的保护作用。包皮环切术的医学危害主要在于1%的急性并发症发生率，以及另外一些因美容或医学原因需要对初次包皮环切术进行修正的患者。据传闻，作者发现当由有该手术专业知识和经验的人进行包皮环切术时，急性和长期阶段的并发症要少得多。因此，作者通常向家长建议，如果他们选择让新生儿进行包皮环切术，应该寻找有经验的从业者。有人认为包皮环切术会产生负面的心理和性影响，但缺乏确凿的科学数据。一些特殊利益集团认为，包皮环切术最大的危害可能在于在没有明确指征的情况下进行手术。许多这类团体声称，进行常规新生儿包皮环切术类似于在没有明确医学益处的情况下进行外科手术，而对于婴儿来说，这类似于未经知情同意的手术。尽管这是一种极端的立场，但临床医生能够理解强调仅在预期有明确医学益处时才提供侵入性医疗服务的重要性，尤其是在治疗婴儿或儿童时。决定是否给婴儿进行包皮环切术仍然让许多新父母感到困扰。显然，该手术有潜在的医学益处和潜在风险。很难说对所有男婴来说益处是否大于风险。让许多美国父母的决定更加复杂的是，在美国的一些地区，新生儿包皮环切术存在一种无法解释的积极文化内涵。出于这些原因，需要鼓励那些积极选择不给儿子进行包皮环切术的父母坦率地做出这个决定。选择给孩子进行包皮环切术的父母也应该被鼓励积极寻找一位能给孩子提供充分局部镇痛的有经验的从业者。
