[Penile glans amputation during circumcision: causes, treatments and preventive measures].

INTRODUCTION: Penile glans amputation during circumcision is a rare but potentially devastating complication. The mechanism and causes are poorly understood and incomprehensible. It is important to identify the causes of these complications, to suggest a mechanism and to propose prevention measures. MATERIALS: Between 2005 and 2019, six patients with penile glans amputationafter circumcision were analyzed. All were operated without medical evidence, for religious reasons. THE RESULTS: The operations were performed by local anesthesia, at home - in 5 patients, in 1 child - at polyclinic. All children were circumcised by scalpel with guillotine method, without visualization of glans. Partial amputation of penile glans was observed in 2 children (33.3%). Complete cut-off of the glans at the level of the coronal sulcus was revealed in 4 boys (66.6%). Meatoplasty with urethral mobilizations was performed 2 patients (33.3%) with partial amputation. The tops of corpus cavernous was covered of with the remnants of the skin of penile shaft in two boys (33.3%). Glansplasty was performed in 2 other patients (33/3%), using a labial mucosa graft to reconstruct the shape of glans and glanular groove. The follow up have showed meatostenosis in two boys (33.3%) in the first 2 months after surgery. One child required repeated meatoplasty (16.6%), another had a recovery of normal urine flow rates after urethral dilatation and stenting (4 weeks). CONCLUSION: Visual control of the glans position during circumcision will prevent the amputation. "Guillotine" techniques including, Mogen clamp-type devices, are considered potentially dangerous. Circumcision in newborns, without general anesthesia, in the presence of swelling of the foreskin have an increased risk of glans damage. Preliminary examination of the glans and adequate release of preputial adhesions help to prevent complication of circumcision and to identify combined malformations (hypospadia, epispadia, concealed penis.).

Male Circumcision Reduces Penile HPV Incidence and Persistence: A Randomized Controlled Trial in Kenya.

BACKGROUND: Male circumcision reduces the risk of human immunodeficiency virus infection in men. We assessed the effect of male circumcision on the incidence and natural history of human papillomavirus (HPV) in a randomized clinical trial in Kisumu, Kenya. METHODS: Sexually active, 18- to 24-year-old men provided penile exfoliated cells for HPV DNA testing every 6 months for 2 years. HPV DNA was detected via GP5+/6+ PCR in glans/coronal sulcus and in shaft samples. HPV incidence and persistence were assessed by intent-to-treat analyses. RESULTS: A total of 2,193 men participated (1,096 randomized to circumcision; 1,097 controls). HPV prevalence was 50% at baseline for both groups and dropped to 23.7% at 24 months in the circumcision group, and 41.0% in control group. Incident infection of any HPV type over 24 months was lower among men in the circumcision group than in the control group [HR = 0.61; 95% confidence interval (CI), 0.52-0.72]. Clearance rate of any HPV infection over 24 months was higher in the circumcision group than in the control group (HR = 1.87; 95% CI, 1.49-2.34). Lower HPV point-prevalence, lower HPV incidence, and higher HPV clearance in the circumcision group were observed in glans but not in shaft samples. CONCLUSION: Male circumcision reduced the risk of HPV acquisition and reinfection, and increased HPV clearance in the glans. IMPACT: Providing voluntary, safe, and affordable male circumcision should help reduce HPV infections in men, and consequently, HPV-associated disease in their partners.

Does Lowering Hemoglobin A1c Reduce Penile Prosthesis Infection: A Systematic Review.

INTRODUCTION: Hemoglobin A1c (HbA1c), a glycated form of hemoglobin, develops when glucose is elevated in the blood. It is used as a marker of how well a diabetic patient has been controlling their blood sugar over the previous 3-4 months. Some use HbA1c as a predictor of infection risk during prosthetic surgery, and many surgeons require patients to lower it preoperatively. OBJECTIVE: This study was designed to comprehensively review the literature relating HbA1c and penile prosthesis (PP). METHODS: A PubMed search of English-language articles identified studies that investigate the relationship between HbA1c levels and PP infection. Studies were only included if they reported the mean HbA1c of all PP patients and compared patients who did/did not develop a prosthetic infection. References from relevant articles are included. RESULTS: A total of 6 studies, 1992-2020, were identified. 2 studies occurred before the advent of antibiotic-enhanced devices in the early 2000s and have limited applicability to the modern era. Of the 4 studies published after, 2 reported a significant difference in mean HbA1c when comparing patients who developed a prosthetic infection and those who did not (9.1% vs 7.5%, P = .000 and 9.5% vs 7.8%, P < .001). The other 2 studies reported no significant difference in mean HbA1c when comparing patients who developed a prosthetic infection and those who did not (7.0% vs 7.6%, P > .05; and 7.6% vs 7.5%, P = .598). CONCLUSION: Current data regarding HbA1c as a predictor of PP infection are inconclusive, with no consensus. HbA1c is increasingly used as a predictor of postsurgical prosthetic infection, with some urologists requiring patients with elevated HbA1c to acutely lower it before elective surgery. While there are a number of established health benefits of controlling elevated blood sugar, larger randomized controlled trials need to validate whether acutely lowering perioperative HbA1c decreases risk of prosthetic infection. Dick BP, Yousif A, Raheem O, et al. Does Lowering Hemoglobin A1c Reduce Penile Prosthesis Infection: A Systematic Review. Sex Med Rev 2021;9:628-635.

Time-trend of hospitalizations for anogenital warts in Veneto region in the HPV vaccination era: a cross sectional study (2007-2018).

BACKGROUND: Human papillomavirus (HPV) is a common sexually transmitted pathogen and the cause of several cancers and of anogenital warts. With this study, we estimated the trend of hospitalizations for anogenital warts (AGWs) in the Veneto region (Italy) from 2007 to 2018. METHODS: The analysis included all the hospital discharge records of public and accredited private hospitals occurred in Veneto residents in the timespan 2007-2018. The ICD9-CM code 078.11 considered were those associated with condyloma acuminatum and those associated with surgical interventions for vulval/vaginal warts, penile warts anal warts. Annual total and sex- and age-specific hospitalization rates and trends were calculated and correlated with the different HPV vaccine coverage over the study period. RESULTS: We observed an overall reduction of hospitalization rates for AGWs: from 15.0 hospitalizations every 100,000 Veneto residents in years 2007-08 to 10.9 hospitalizations every 100,000 Veneto residents in year 2017-18 (- 37.4%; p < 0.05). Reduction has been caused by a drop in hospitalizations in females - from a rate of 20.4/100,000 in 2007-2008 to a rate of 10.8/100,000 in 2017-18 (AAPC: -7.1; 95%CI: - 10.6;-3.4); while in males, we observed a slight - but not statistically significant - increase in hospitalization rates. CONCLUSION: The marked decline in hospitalization rates for AGWs in Veneto Region is probably attributable to the high coverage rates of HPV vaccination programs implemented since 2008.

Experience and outcomes for PAs in a neonatal circumcision clinic.

OBJECTIVE: To evaluate the outcomes of neonatal circumcision performed by a PA in pediatric urology. METHODS: A retrospective review was performed of infants evaluated for neonatal circumcision by a single PA in pediatric urology over 30 months. Technique, age and weight at circumcision, presence or absence of genital anomalies, and complications were gathered. RESULTS: Of the 371 male infants evaluated for neonatal circumcision, 276 underwent the procedure. Complications included retained Plastibell (2.1%), penile adhesions (1.1%), swelling (1.8%), and cosmetic concerns (0.73%). Eighteen unanticipated postprocedure visits occurred-four in the ED and 14 in the outpatient clinic. No acute procedural complications occurred. One patient (0.3%) underwent lysis of penile adhesions at age 19 months. CONCLUSION: Neonatal circumcisions are commonly performed by nonsurgeons with variable formal circumcision training. These data support that well-trained PAs can perform neonatal circumcisions with low complication rates.

Male circumcision: ritual, science and responsibility.

INTRODUCTION AND OBJECTIVES: In Italy, four minors have died in the last year as a result of male circumcision (MC) procedures performed for cultural and religious reasons by unqualified persons in unhygienic conditions. RESULTS AND DISCUSSION: After illustrating the historical and ethical outlines of the moral admissibility of MC within a comparative perspective, we examine the features of the Italian healthcare system with particular regard both to the heterogeneity of services available in the various Regions and to the risks engendered by excluding MC from the public health setting. CONCLUSION: In order to adequately safeguard public health, particularly that of minors, there is a pressing need for thorough discussion of whether the National Health Service should perform MC on minors free of charge or, at least, for a reduced fee. The implementation of targeted campaigns may raise awareness of the importance of proper safety measures in MC.

[Pathogenesis, prevention and management of edema after prepuce surgery].

Prepuce diseases are very common conditions in urology and andrology, and quite a few cases need to be treated by surgery. Preputial edema is a common complication after prepuce surgery, with a higher incidence rate in children than in adults. Although preputial edema is just moderate symptom and does not affect urination, it worries or even distresses the patient both physically and psychologically. In recent years, rapid achievements have been made in prepuce surgery, as in prepuce circumcision, preputial neoplasm excision, and penile degloving repair, which can now be accomplished with shorter time and higher efficiency. Despite constant improvement in the methods and techniques for prepuce surgery, postoperative edema remains difficult to be totally prevented. Pathogenic factors for postoperative preputial edema vary from disturbance of blood circulation to inflammatory factor-induced change in capillary permeability, lymphatic circulation disorders, and neurogenic edema. Elimination of the pathogenic factors and precautionary measures after surgery count significantly to the prevention and management of postoperative preputial edema. This review focuses on the pathogenesis, prevention and treatment of edema after prepuce surgery.

Suppression of Cavernosal Fibrosis in a Rat Model.

INTRODUCTION: Cavernosal fibrosis is an important pathologic condition leading to erectile dysfunction (ED). The etiologies of cavernosal fibrosis include aging, diabetes mellitus, castration, cavernosal nerve injury during radical prostatectomy, hypertension, and Peyronie disease. AIMS: To summarize published studies investigating suppression of cavernosal fibrosis in rat models of ED of various etiologies. METHODS: A literature search was conducted using PubMed. Relevant studies were identified using search terms such as erectile dysfunction, penis, fibrosis, and rat models. MAIN OUTCOME MEASURES: We reviewed representative literature studies on the mechanisms and suppression of cavernosal fibrosis in rat models of ED. RESULTS: The underlying mechanisms and potential therapeutic strategies suggested thus far for cavernosal fibrosis in rat models of ED were as follows. For age-related ED involving oxidative stress and tumor growth factor-ß1 (TGF-ß1)-driven pathways such as RhoA-ROCK1-LIMK2-cofilin or p42-44 and mitogen-activated protein kinase, proposed therapeutic strategies included phosphodiesterase type 5 inhibitors (PDE5Is), kallikrein-kinin system stimulators, and calorie restriction. For diabetes-related ED involving angiotensin-II- and TGF-ß1-driven Smad and non-Smad pathways, TGF-ß1-Wnt10b, and histone deacetylase (HDAC)-TGF-ß1 pathways, positive therapeutic results were obtained with PDE5Is, TGF-ß1 antagonists, HDAC inhibitors, antioxidants, sphingosine-1-phosphate receptor modulators (fingolimod), angiotensin-II antagonists, stem cell therapy, and antidiabetic drugs. For cavernosal nerve injury-associated ED involving TGF-ß1-driven pathways (Smad or RhoA-ROCK1-LIMK2-cofilin), Sonic hedgehog signaling, angiotensin-II-Smad, and HDAC4-TGF-ß1-Smad signaling triggered by cavernosal hypoxia, PDE5Is, angiotensin-II antagonists, stem cell therapy, HDAC inhibitors, Sonic hedgehog administration, ROCK inhibitors, and LIMK2 inhibitors have shown positive results. For testosterone deficiency-associated ED, TGF-ß1-driven pathways were found to be responsive to testosterone supplementation. For hypertensive ED, positive therapeutic results were obtained with angiotensin-II antagonists. For Peyronie disease involving TGF-ß1 or myostatin signaling, proposed therapeutic strategies included intra-tunical injection of TGF-ß receptor inhibitors or adipose tissue-derived stem cells and HDAC2 small hairpin RNA. CONCLUSION: Several signaling pathways appear to be responsible for the development of cavernosal fibrosis related to ED of various etiologies. Some therapeutic success has been achieved in animal models, but further research focusing on mechanism-specific targeted therapies is needed. Cho MC, Song WH, Paick J-S. Suppression of Cavernosal Fibrosis in a Rat Model. Sex Med Rev 2018;6:572-582.

Decline in hospitalization for genital warts in the Veneto region after an HPV vaccination program: an observational study.

BACKGROUND: Human papillomavirus (HPV) is one of the most common sexually transmitted pathogens. This observational study was conducted to estimate the trend of hospitalization for genital warts (GWs) in the Veneto region (Italy) from 2004 to 2015. METHODS: All patients with GWs were identified in the hospital discharge records of all public and accredited private hospitals that related to Veneto residents and contained the ICD9-CM code 078.11 associated with a genital surgical procedure (vulval/vaginal warts, penile warts and anal warts). Annual total and sex- and age-specific hospitalization rates and trends were calculated and correlated with the different HPV vaccine coverage over the study period. RESULTS: An annual rate of 11.8 per 100,000 population (8.6 per 100,000 males, and 14.8 per 100,000 females) was found, corresponding to 6076 hospitalizations for condyloma (53.3% vulval/vaginal, 35.8% anal, 8.3% penile, and 2.6% both penile or vulval/vaginal and anal). Among females, the rate of overall GWs remained stable to 2007 (19.1 per 100,000), then dropped significantly, reaching a rate of 11.3 per 100,000 in 2015 (average annual percent changes [AAPC]: -6.1%; 95% CI: -8.4; -3.7). For males, the overall rate increased over the study period (from 6.4 per 100,000 in 2004 to 10.8 per 100,000 in 2015; AAPC: 3.8%; 95% CI: 1.2; 6.4). Among the potentially vaccinated females (12- to 20-year-olds) there was a 62.1% decrease in the number of vulval/vaginal warts from the years 2010-2012 to the years 2013-2015 due to an increase in the HPV coverage rate. A similar reduction among males was observed in the same period and the same age group for penile warts (-68.2%). CONCLUSION: GWs have an important impact on the health services and data suggest that GW-related hospitalization rates rapidly decline in a population with a high HPV vaccination coverage (about 75%). Further efforts should be made to better clarify the epidemiological picture regarding HPV-related diseases, with particular regard to sexual behavior.

Parental decision making in male circumcision.

PURPOSE: To study which healthcare professionals (HCPs) firstasked parents about their decision regarding circumcision; whether parents felt they were given enough information by their HCP; and what reasons parents cited for their decision. STUDY DESIGN AND METHODS: Bilingual questionnaires were administered to parents and expecting parents of boys (N = 60). Close-ended survey responses were analyzed through factor analysis to ascertain what types of beliefs parents used in their decision making, whether they felt they had enough information, and who first asked them about their decision. RESULTS: Nurses were most likely to be the first HCPs to ask parents about circumcision. Parental personal and cultural beliefs played an equal or more important role in influencing decision making than medical information received. However, some parents noted that there was a lack of access to accurate information regarding risks and benefits of male circumcision. CLINICAL NURSING IMPLICATIONS: Nurses continue to play a critical role in acquisition of knowledge surrounding male circumcision and serve as important liaisons between parents and the proxy consent process. Nurses, as well as other HCPs, should discuss circumcision early in pregnancy so parents have ample time to ask questions, gather information, and make an appropriate decision.

[Male circumcision from an infectiological point of view]. / Zirkumzision des Mannes aus infektiologischer Sicht.

BACKGROUND: In May 2012 a German regional court (Cologne) declared circumcision on religious grounds in minor boys an illegitimate bodily harm. This led to substantial political and religious discussions, because Jews as well as Muslims consider circumcision as an indispensable element of their religion. Still in 2012 a "circumcision law" was passed by the Federal Council of Germany, which continues to allow circumcision in boys "performed under strict medical conditions". OBJECTIVE: How male circumcision is assessed in terms of infectiology (pros and cons)? METHOD: Electronic databases were searched for articles about the infection risks of foreskin surgery, and the efficacy of circumcision in reducing the risks of sexual transmission of HIV, herpes viruses, HPV, treponema pallidum, chlamydia, hemophilus ducrey and Neisseria gonorrhoeae. RESULTS: Contra circumcision: The highest risk of neonatal circumcision is hemorrhage (35 %). Among infections surgical wound infection (10 %), meatitis urethrae (8-20 %) and urinary tract infections (2 %) are frequent (depending on the surgical technique). Severe complications like penile necrosis or lethal sepsis are rare (1:20,000). Pro circumcision: Circumcised boys have a reduced risk for urinary tract infections in childhood (1:10). Compared to uncircumcised men circumcised adults have a 50-60 % reduced risk of becoming infected with viral sexually transmitted infections (STIs; HIV, HPV and HSV). This advantage of circumcision is also discussed for the transmission of bacterial STIs (e.g. syphilis and chancroid), but the analysis of different clinical studies is still controversial. DISCUSSION AND CONCLUSION: Neonatal circumcisions (and circumcision in early childhood) are irreparable interventions in the physical integrity, with very few medical indications. The risk of complications is dependent on the education of the circumciser (ritual, medical), analgesia and hygiene. Circumcisions should be performed under optimal surgical and hygienic conditions in informed and self-determined young men only. In adolescents and adults circumcision reduces the risk of the transmission of viral STIs (HIV, HSV, HPV) and there is also probably some effect on the sexual transmission of treponema pallidum and hemophilus ducreyi (insufficient, controversial data). The role of circumcision as an effective procedure to reduce the transmission of STIs is still under discussion, because important additional factors like sexual risk behavior (e.g. unprotected sexual intercourse, promiscuity) have a strong influence on STI epidemiology.

A review of the current state of the male circumcision literature.

INTRODUCTION: Male circumcision is one of the most commonly performed surgical procedures worldwide and a subject that has been the center of considerable debate. Recently, the American Association of Pediatrics released a statement affirming that the medical benefits of neonatal circumcision outweigh the risks. At present, however, the majority of the literature on circumcision is based on research that is not necessarily applicable to North American populations, as it fails to take into account factors likely to influence the interpretability and applicability of the results. AIMS: The purpose of this review is to draw attention to the gaps within the circumcision literature that need to be addressed before significant changes to public policy regarding neonatal circumcision are made within North America. METHODS: A literature review of peer-reviewed journal articles was performed. MAIN OUTCOME MEASURES: The main outcome measure was the state of circumcision research, especially with regard to new developments in the field, as it applies to North American populations. RESULTS: This review highlights considerable gaps within the current literature on circumcision. The emphasis is on factors that should be addressed in order to influence research in becoming more applicable to North American populations. Such gaps include a need for rigorous, empirically based methodologies to address questions about circumcision and sexual functioning, penile sensitivity, the effect of circumcision on men's sexual partners, and reasons for circumcision. Additional factors that should be addressed in future research include the effects of age at circumcision (with an emphasis on neonatal circumcision) and the need for objective research outcomes. CONCLUSION: Further research is needed to inform policy makers, health-care professionals, and stakeholders (parents and individuals invested in this debate) with regard to the decision to perform routine circumcision on male neonates in North America.

Veracity and rhetoric in paediatric medicine: a critique of Svoboda and Van Howe's response to the AAP policy on infant male circumcision.

In a recent issue of the Journal of Medical Ethics,Svoboda and Van Howe commented on the 2012 changein the American Academy of Pediatrics (AAP) policy on newborn male circumcision, in which the AAP stated that benefits of the procedure outweigh the risks. Svoboda and Van Howe disagree with the AAP conclusions. We show here that their arguments against male circumcision are based on a poor understanding of epidemiology,erroneous interpretation of the evidence, selective citation of the literature, statistical manipulation of data, and circular reasoning. In reality, the scientific evidence indicates that male circumcision, especially when performed in the newborn period, is an ethically and medically sound low-risk preventive health procedure conferring a lifetime of benefits to health and well-being.Policies in support of parent-approved elective newborn circumcision should be embraced by the medical,scientific and wider communities.

Incidence of genital warts in adolescents and young adults in an integrated health care delivery system in the United States before human papillomavirus vaccine recommendations.

BACKGROUND: Information on genital wart incidence in adolescents and young adults before human papillomavirus (HPV) vaccination is important for understanding the impact of the vaccine on the epidemiology of this early outcome of HPV infection. METHODS: The study population included 11- to 29-year-old enrollees of Northern California Kaiser Permanente between July 1, 2000, and July 1, 2005, before the availability of the HPV vaccine. We identified genital warts with an algorithm combining genital wart-specific International Classification of Diseases, Ninth Revision, Clinical Modification codes (078.10, 078.11, and 078.19) with physician-recorded anatomic locations. We calculated sex- and age-specific incidence rates of genital warts and described the specific anatomic location of presentation, as well as recurrences of genital warts. RESULTS: We identified 1,682 cases of genital warts among 181,264 individuals. The incidence rate was highest among women (6.3/1000 person-years) and men (2.9/1000 person-years) aged 20 to 24 years old. Among women (n = 96,792), 63.4% of the 1240 incident genital wart cases occurred on the vulva and 21.1% on the cervix. Among men (n = 84,472), 91.6% of the 442 incident genital wart cases did not have a specific anatomic location recorded. Most people with an incident genital wart diagnosis (87.2%) did not have a recurrence during the observation period. CONCLUSIONS: Our study found that the incidence of genital warts was highest among persons aged 20 to 24 years using a unique method to identify the location of the wart. Information on incidence of genital warts before vaccine use provides baseline data that can be used to measure HPV vaccine impact.

[Circumcision in male newborns--update].

Recently, there have been efforts in a number of countries to forbid the circumcision of infants and children. This position, which is based on alleged violation of autonomy and on serious harm to the infant or child, is not supported by the medical literature. Controlled studies have accumulated showing the major health benefits of circumcision of infants; there is a decrease in urinary tract infections, a virtual elimination of cancer of the penis, a reduction in HIV and HPV infections, as well as other sexually transmitted diseases, and perhaps, reductions in prostatic cancer and in uterine cervical cancer. The complications of the procedure are minimal, especially when performed in infancy. Recent studies have not confirmed the alleged reduction in sexual pleasure as a result of circumcision. Therefore, there is no justification, whatsoever, for attempts to forbid circumcision of infants. On the contrary, there seem to be good reasons to encourage such practices.

Male circumcision reduces penile high-risk human papillomavirus viral load in a randomised clinical trial in Rakai, Uganda.

OBJECTIVES: Male circumcision reduces penile high-risk human papillomavirus (HR-HPV) prevalence in randomised trials. The goal of this study was to examine the effect of circumcision on HPV viral load among HPV-infected men in a randomised trial of male circumcision. METHODS: In a randomised trial to assess the efficacy of circumcision on HIV acquisition in Rakai, Uganda, HIV-negative men were randomised to immediate (intervention) or delayed (control) circumcision and followed over 24 months. We performed quantitative-PCR HPV viral load assays on penile swabs which tested positive by Linear Array (LA) for six HR-HPV genotypes and estimated viral load in the remaining types by LA signal strength. RESULTS: At 24 months, circumcision intervention arm men infected with one of the six selected HR-HPV genotypes had a lower viral load and significantly reduced HR-HPV high LA band intensity (PRR=0.61, 95% CI 0.43 to 0.86) compared to infected men in the control arm of the trial. The decreased viral load associated with circumcision was seen among HPV infections acquired after enrolment but not among infections that persisted from trial enrolment to 24 months (p=0.80). CONCLUSIONS: The decreased penile HR-HPV shedding observed among HPV-infected circumcised men may help to explain the protective association observed between circumcision and reduced acquisition of HR-HPV in female partners.

Male circumcision.

Male circumcision consists of the surgical removal of some, or all, of the foreskin (or prepuce) from the penis. It is one of the most common procedures in the world. In the United States, the procedure is commonly performed during the newborn period. In 2007, the American Academy of Pediatrics (AAP) convened a multidisciplinary workgroup of AAP members and other stakeholders to evaluate the evidence regarding male circumcision and update the AAP's 1999 recommendations in this area. The Task Force included AAP representatives from specialty areas as well as members of the AAP Board of Directors and liaisons representing the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention. The Task Force members identified selected topics relevant to male circumcision and conducted a critical review of peer-reviewed literature by using the American Heart Association's template for evidence evaluation. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it. Specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction. It is imperative that those providing circumcision are adequately trained and that both sterile techniques and effective pain management are used. Significant acute complications are rare. In general, untrained providers who perform circumcisions have more complications than well-trained providers who perform the procedure, regardless of whether the former are physicians, nurses, or traditional religious providers. Parents are entitled to factually correct, nonbiased information about circumcision and should receive this information from clinicians before conception or early in pregnancy, which is when parents typically make circumcision decisions. Parents should determine what is in the best interest of their child. Physicians who counsel families about this decision should provide assistance by explaining the potential benefits and risks and ensuring that parents understand that circumcision is an elective procedure. The Task Force strongly recommends the creation, revision, and enhancement of educational materials to assist parents of male infants with the care of circumcised and uncircumcised penises. The Task Force also strongly recommends the development of educational materials for providers to enhance practitioners' competency in discussing circumcision's benefits and risks with parents. The Task Force made the following recommendations:Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it. Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child. Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks and by ensuring that they understand the elective nature of the procedure. Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families. Parents of newborn boys should be instructed in the care of the penis, regardless of whether the newborn has been circumcised or not. Elective circumcision should be performed only if the infant's condition is stable and healthy. Male circumcision should be performed by trained and competent practitioners, by using sterile techniques and effective pain management. Analgesia is safe and effective in reducing the procedural pain associated with newborn circumcision; thus, adequate analgesia should be provided whenever newborn circumcision is performed.Nonpharmacologic techniques (eg, positioning, sucrose pacifiers) alone are insufficient to prevent procedural and postprocedural pain and are not recommended as the sole method of analgesia. They should be used only as analgesic adjuncts to improve infant comfort during circumcision. If used, topical creams may cause a higher incidence of skin irritation in low birth weight infants, compared with infants of normal weight; penile nerve block techniques should therefore be chosen for this group of newborns. Key professional organizations (AAP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Society of Anesthesiologists, the American College of Nurse Midwives, and other midlevel clinicians such as nurse practitioners) should work collaboratively to:Develop standards of trainee proficiency in the performance of anesthetic and procedure techniques, including suturing; Teach the procedure and analgesic techniques during postgraduate training programs; Develop educational materials for clinicians to enhance their own competency in discussing the benefits and risks of circumcision with parents; Offer educational materials to assist parents of male infants with the care of both circumcised and uncircumcised penises. The preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure. The American College of Obstetricians and Gynecologists has endorsed this technical report.