Higher incidence of urethral damage in circumcised boys

A large scale, comprehensive study has found that circumcised boys have a far higher incidence of urethral problems such as meatal stenosis than boys who are left genitally intact (uncircumcised). The nationwide study of over 4 million males in Denmark found that meatal stenosis (narrowing and ulceration of the urinary opening of the penis) affected as many as 20 per cent of circumcised boys, about five times the incidence of such problems in uncircumcised boys. They also experience a far higher incidence of other urethral problems. Among other observations, the authors of the article criticise the American Academy of Pediatrics for its uncritical reliance on a flawed study on circumcision complications by El Bcheraoui et al which claimed to find a negligible incidence of urethral disease among boys circumcised in American hospitals. They point out that the data in this study actually show a high relative risk for such problems. The AAP should have paid attention to a warning it published in 1984: “The foreskin shields the glans; with circumcision this protection is lost. In such cases, the glans and especially the urinary opening (meatus) may become irritated or infected, causing ulcers, meatitis (inflammation of the meatus), and meatal stenosis (a narrowing of the urinary opening). Such problems virtually never occur in uncircumcised penises. The foreskin protects the glans throughout life”.** The present study is further evidence that the AAP’s 2012 claim that the “benefits” of circumcision exceed the “risks” is fundamentally false.

** This text was included in the 1984 edition of a leaflet for parents on care of the normal (uncircumcised) penis. When the leaflet was reissued in 1990 the paragraph was deleted, for reasons never explained. Relevant correspondence and a copy of the original leaflet available from Circumcision Resource Center.

The abstract of the paper follows.

Background: Meatal stenosis is markedly more common in circumcised than genitally intact
males, affecting 5-20 per cent of circumcised boys. However, no population-based study
has estimated the relative risk of meatal stenosis and other urethral stricture diseases
(USDs) or the population attributable fraction (AFp) associated with non-therapeutic
circumcision.

Methods: In two nationwide cohort studies (comprising 4.0 million males of all ages and
810 719 non-Muslim males aged 0e36 years, respectively), we compared hospital contact
rates for USD during 1977e2013 between circumcised and intact Danish males.Hazard ratios
(HRs) were obtained using Cox proportional hazards regression, and the AFp estimated the
proportion of USD cases in <10 year-old boys that is due to non-therapeutic circumcision.

Results: Muslim males had higher rates of meatal stenosis than ethnic Danish males,
particularly in <10 year-old boys (HR 3.44, 95 per cent confidence interval 2.42e4.88). HRs
linking circumcision to meatal stenosis (10.3, 4.53e23.4) or other USDs (5.14, 3.48e7.60)
were high, and attempts to reduce potential misclassification and confounding further
strengthened the association, particularly in <10 year-old boys (meatal stenosis: 26.3, 9.37
e73.9; other USDs: 14.0, 6.86e28.6). Conservative calculations revealed that at least 18, 41,
78, and 81 per cent of USD cases in <10 year-old boys from countries with circumcision
prevalences as in Denmark, the United Kingdom, the United States and Israel, respectively,
may be attributable to non-therapeutic circumcision.

Conclusion: Our study provides population-based epidemiological evidence that circumcision
removes the natural protection against meatal stenosis and, possibly, other USDs as well.

Frisch M, Simonsen J. Cultural background, non-therapeutic circumcision and the risk of meatal stenosis and other urethral stricture disease: Two nationwide register-based cohort studies in Denmark 1977-2013, The Surgeon, on-line first, 22 December 2016.