CUA 2018 GL on Circumcision

Question 1

What does the most recent american academy of pediatrics say about male circumcision?

Answer 1

The recent American Academy of Pediatrics (AAP) guideline on male circumcision (MC) reversed its prior stand, stating that the “health benefits of newborn male circumcision outweigh the risks,” and justify access to the procedure if the parents so choose

Question 2

T or F: At birth, the inner foreskin is usually fused to the glans penis

Answer 2

T and should not be forcibly retracted unless it is possible to retract it with gentle traction.

Question 3

What eventually causes the retraction of foreskin?

Answer 3

Collection of smegma bw glans and inner prepuce and regular erections of infant. by 3 years 90% of boys have retractile foreskin. but can happen at varying ages

Question 4

when would physiologic phimosis require treatment?

Answer 4

If it is pathological(scarring) Recurrent UTI balanoposthitis genital lichen sclerosis

Question 5

Is ballooning of foreskin an indication for circumcision?

Answer 5

No

Question 6

At what point you may want to consider steroid therapy for phyiologic phimosis?

Answer 6

8-10 years

Question 7

What is this?

Answer 7

Pathological phimosis

It has lichen sclerosis

Question 8

what is this?

Answer 8

Balano-posthitis

Question 9

What should neonatal examination of penis and foreskin include?

Answer 9

Neonatal examination of the foreskin and urethral
meatus should be part of routine clinical assessment
of all newborn boys. Continued examination of the
foreskin without forcible retraction is recommended
during yearly physical examinations to rule out pathological
phimosis and document natural preputial
retraction

Question 10

Is persistent physiologic phimosis an indication for circumcision?

Answer 10

NO, not if asymptomatic

Persistent physiological phimosis in an asymptomatic
child should not be an indication for circumcision

Question 11

What is the first line treatment for persistent physiologic phimosis?

Answer 11

Topical steroids are the first-line treatment for persistent
physiological phimosis requiring treatment
with good success rates and low risk of complications

Question 12

Are low poteny steroids as effective as low potency ones?

Answer 12

Yeah

Moderately low-potency steroid (triamcinolone, clobetasone,
hydrocortisone, mometasone) may have
similar success compared to a highly potent steroid
(betamethasone)

• Patient selection to ensure compliance, demonstrating the technique of gentle retraction of the foreskin and continued retraction after initial success is important to achieve continued success to topical steroid therapy

Question 13

How common is reccurence of physiologic phimosis after topical steroid therapy?

Answer 13

common

Recurrence of physiological phimosis is common
and normally responds to another course of topical
steroids

Question 14

Males under…… age had the
highest prevalence of UTI

Answer 14

three months of

Question 15

How does circumcision prevent UTIs?

Answer 15

by reducing periurethral bacterial
colonization secondary to reduced adherence of bacteria to
keratinized surfaces and by removing the growth-promoting
moist preputial environment

Question 16

Name 3 urological conditions associated with higher risk of UTI than baseline?

Answer 16

high grade VUR,

PUV

primary megatureters

Question 17

Does neonatal Cricumcision decrease the risk of UTIs?

Answer 17

yes

Neonatal circumcision decreases the risk of UTI

Question 18

True or False?

The risk of UTI is low in infant males and decreases
further beyond infancy

Answer 18

Yes,

it is highest from birth to 3 months

Question 19

Does CUA guideline recommend universal circumcision?

Answer 19

NO

There is paucity of Level 1 evidence to justify recommending
universal circumcision to prevent UTIs
in normal males.

Question 20

Is circumcision recommended in boys with urologic abnormalities?

Answer 20

Should be discussed with parents

A stronger effect of neonatal circumcision in preventing UTIs in boys with urological abnormalities has been demonstrated and, therefore, it is recommended that a discussion with the parents is advisable for this subgroup of neonates(VUR, megaureter, PUV and UPJO)

Question 21

Who has HIV?

Answer 21

MSM> IVDU> heterosexual individuals

Question 22

What are the proposed mechanisms of higher HIV transmission in uncicumcised male?

Answer 22

more microabrasions with foreskin

langerhans cells of inner prepuce have HIV (circ would remove most of these)

proinflammatory anerobes supported by foreskin environment support the virus

lack of keratanization of inner prepuce

Question 23

Circumcision reduce the risk of HIV acquision by heterosexual men …..%

Answer 23

38-66%

Question 24

What does CUA say about the benefits of MC in preventing FtoM HIV transmission?

Answer 24

Female to male transmission: There is compelling evidence that MC reduces the risk of HIV transmission from female partners to male (Level 1 a, Grade A). The magnitude of the effect is debatable and cannot be extrapolated to Canada from the African RCTs.

Question 26

What does CUA say about the benefits of MC in preventing MtoM HIV transmission?

Answer 26

Based on current evidence, MC does not provide protection for men who have sex with men

Question 27

What about male circi to protect women from HIV?

Answer 27

Women partners: Based on current evidence, MC is not protective for female partners

Question 28

Is there a role in universal male circ to prevent HIV infection?

Answer 28

Universal infant circumcision cannot be recommended to prevent HIV infection based on current evidence (Grade B).

Question 29

what are the oncogenic usbtypes of HPV?

Answer 29

16,18 low risk 6 and 11 cause genital warts

Question 30

Who should get the HPV vaccine?

Answer 30

HPV vaccination is currently available and recommended for males (HPV 4 vaccine, 9‒26 years of age), females (HPV 2 or 4 vaccine, 9‒13 years and 14‒26 years of age) and MSM (HPV 4 vaccine, \>9 years of age) with good evidence (Level 1, Grade A)

Question 31

What are the benenfits of MC for HPV prevalence in men?

Answer 31

Current evidence suggests a modest decrease in HPV prevalence in the glans and coronal sulcus up to two years following MC (Level 1b). The protective effect is partial, does not cover all high- risk types(seem to cover 16 more) and is weaker further away from the glans and coronal sulcus. It is not clear whether this effect will persist into adulthood following neonatal circumcision.

Question 32

Does MC help men clear HPV infections?

Answer 32

There is no evidence (except a single RCT on HIV-negative men) that MC increases HPV clearance (Level 1b‒2b). If it did increase clearance, this may also inflate the impact of the prevalence benefits mentioned.

Question 33

How does MC affect HPV incidence or acquisition?

Answer 33

There is no convincing evidence to suggest that MC decreases HPV acquisition or incident infections in HIVpositive or -negative men (Level 1b‒2b).

Question 34

How does MC affect female partner HPV status?

Answer 34

HPV in female partners: MC lowers prevalence and incidence in partners of HIV-negative men and improves clearance rates As a public health intervention, it is likely that the effect of HPV vaccination and behavioural modification will be more effective than performing universal neonatal circumcisions on all males

Question 35

what are the most common non-ulcerative STIs?

Answer 35

gonorrhea, chlamydia, trichomonas

Question 36

what is the role of circumcision in preventing non-ulcerative STIs?

Answer 36

Currently, there is no significant evidence to support the protective role of MC in the acquisition of non-HPV, non-ulcerative STIs (Level 2a‒b, Grade B).

Question 37

what are common cuases of genital ulcer disease?

Answer 37

HSV1,2 T. Pallidum(syphilis) H. ducreyi(chancroid) K. granulomatis(donovanosis)

Question 38

There is weak evidence of decreased seroconversion for HSV-2 following MC in adult men

Answer 38

Wrong It is kinda right but the statement is only true for AFRICA

Question 39

Does circumcision have a rile for amels and females in preventing acuisition of ulcerative STIs?

Answer 39

Nope

Question 40

What are risk factors for penile cancer?

Answer 40

phimosis balanitis smoking HPV infections , penile oral sex , Lichen slcerosis Premalignant conditions( bowen's disease, erythroplasia of queyrat) priapism, PUVA therapy

Question 41

Does circumcision decease the risk of penile cancer?

Answer 41

yes However, given the low incidence of invasivepenile cancer, the partial protective effect of MC, and the availability of other preventive strategies, such as HPV vaccination, condom use, and smoking cessation programs, it is difficult to justify universal neonatal circumcision as a preventive strategy for preventing penile cancer

Question 42

what are some things CUA recommends to reduce the risk of penile cancer?

Answer 42

Recognition and treatment of phimosis during regular health visits is recommended to decrease the risk of penile cancer (Level 5, Grade D). A genitourinary exam during puberty is recommended to ensure preputial retractibility and hygiene, rule out phimosis, and counsel regarding HPV vaccination and safe sexual practices, as well as to offer the possibility of circumcision as a preventive measure against STIs while specifying the drawbacks and efficacy of other preventive measures

Question 43

Does circumcision protect against prostate cancer?

Answer 43

NO There is no convincing evidence on the protective effect of MC against prostate cancer

Question 44

Neonatal circumcision will impact sexual function or cause a perceptible change in penile sensation in adulthood

Answer 44

Wrong There is lack of any convincing evidence that neonatal circumcision will impact sexual function orcause a perceptible change in penile sensation in adulthood

Question 45

What is the most common presentation of lichen sclerosis( BXO)?

Answer 45

Secondary Phimosis

Question 46

what is koebner phenomenon?

Answer 46

recurrent LS may appear along scar lines of previous surgery; the use of topical steroids is an option in the postoperative period

Question 47

Who should not have a circumcision?

Answer 47

congenital anomolies of the penis(hypospadias, epispadias, penoscrotal webbing, concealed penis, ventral curvature)

Question 48

what are the complicaitons of circ?

Answer 48

early complications: infection, bleeding, glans necrosis, glans amputation,delayed/early slippage of circumcision device, death Late comp: Redundant skin\> meatal stenosis inclusion cysts, suture sinus tracts, ventral curvature, secondary burried penis, phimosis, urethrocutaneous fistula, cosmetic issues Older children at higher risk of complications

Question 49

what is the most effective pain control technique for circ?

Answer 49

dorsal penile block A DPNB with a ring block, using proper technique, is the most effective technique to provide anesthesia during a neonatal circumcision( better than EMLA) - Topical local anesthetics alone are inferior to nerve and ring blocks and require an adequate time intervalfor efficacy; they can be used as an adjunct to penile blocks

Question 50

Can you just give oral stimulation for circ? sucrose, sucking,

Answer 50

Nope also the younger the kid, the lower the pain they experience( \<8days)

Question 51

whar is the complicaiton rate of circ?

Answer 51

around 2% but.... Complication rates post-neonatal circumcision are usually low (around 2%), but given the variability in quoted complication rates and risk of delayed complications not treated by the original physician performing the neonatal circumcision, it is likely that the overall complication rate is slightly high

Question 52

what factors predict complicaitons?

Answer 52

Operator experience and training, recognition of contraindications to circumcision, technique used ( plastibell device better),age, and patient-related variables can impact results and proper reporting and auditing of results is recommended