Notat om omskæring af drenge - Sundhedsstyrelsen

FROM THE AMERICAN ACADEMY OF PEDIATRICSstudies that show a protective effectare either barely significant or havepoorly defined or self-reported outcomes,thus offering only a fair levelof evidence. 79,88HPVHPV is among the most commonly occurringSTIs in the United States andcan lead to the development of cancers,including cervical cancer. Thepopulation-based data from NHANES2003–2006 indicate that the overallprevalence of high- and low-oncogenicriskHPVtypeswas42.5%amongUSwomen aged 14 to 59 years. Theprevalence of infection was lower forthe 2 viral types with the highest riskof causing cancer, however, at 4.7% forHPV type 16 and 1.9% for HPV type 18. 95There is good evidence that male circumcisionis protective against alltypes of HPV infection (nononcogenicand oncogenic). Two prevalence studieswith good evidence found a 30% to 40%reduction in risk of infection amongcircumcised men. 96,97 These studies failto provide information on the risk ofacquiring HPV and may reflect persistenceof HPV rather than acquisition ofinfection. Four studies provide fair evidencethat male circumcision protectsagainst HPV. 98–101 The selection of anatomicsites sampled may influencethe results. 98Good evidence of the protective effectof male circumcision against HPV isavailable from two of the large randomizedcontrolled trials in Africa. Inthe South African study, the prevalenceof high-risk HPV was 32% lowerin circumcised men. 102 In the Ugandastudy, the risk of oncogenic HPV infection(adjusted for other factors)was 35% lower in circumcised men. 71There is also good evidence that malecircumcision reduces the risk of maleto-femaletransmission of high-riskHPV from HIV-uninfected men. In theUganda randomized controlled trial, theprevalence of high-risk HPV infectionwas 28% lower in female partners ofcircumcised HIV-uninfected men, whilethe incidence was 23% lower. 32 Goodevidence from another Uganda randomizedcontrolled trial of male circumcisionin HIV-infected men indicatesthat a circumcision did not reduce therisk of male-to-female transmission ofhigh-risk HPV from HIV-infected men. 103Male Circumcision and UTIsAccording to the CDC, “A urinary tractinfection (UTI) is an infection involvingany part of the urinary system, includingurethra, bladder, ureters, andkidney.” 104 UTIs are the most commontype of health care–associated infectionreported to the National HealthcareSafety Network among USindividuals. The majority of UTIs inmales occur during the first year oflife. In children, UTIs usually necessitatea physician visit and may involvethe possibility of an invasive procedureand hospitalization.Most available data were publishedbefore 1995 and consistently show anassociation between the lack of circumcisionand increased risk of UTI.Studies published since 1995 havesimilar findings. There is good evidencefrom 2 well-conducted metaanalyses105,106 and a cohort study 107that UTI incidence among boys underage 2 years is reduced in those whowere circumcised compared with uncircumcisedboys. The data from randomizedcontrolled trials are limited.However, there are large cohort andcase-controlled studies with similarfindings. Given that the risk of UTIamong this population is approximately1%, the number needed tocircumcise to prevent UTI is approximately100. The benefits of male circumcisionare, therefore, likely to begreater in boys at higher risk of UTI,such as male infants with underlyinganatomic defects such as reflux orrecurrent UTIs.There is fair evidence from 5 observationalstudies that UTI incidenceamong boys under age 2 years is reducedin circumcised infant boys,compared with uncircumcised boysunder the age of 2. 108–112 The degree ofreduction is between threefold and10-fold in all studies.There is fair evidence from a prospectivestudy that there is a decreased prevalenceof uropathogens in the periurethralarea 3 weeks after circumcision,compared with similar cultures taken atthe time of circumcision. 113 By usingthese rates and the increased riskssuggested from the literature, it is estimatedthat 7 to 14 of 1000 uncircumcisedmale infants will developa UTI during the first year of life, comparedwith 1 to 2 infants among 1000circumcised male infants.There is a biologically plausible explanationfor the relationship betweenan intact foreskin and an increasedassociation of UTI during infancy. Increasedperiurethral bacterial colonizationmay be a risk factor for UTI. 114During the first 6 months of life, thereare more uropathogenic organismsaround the urethral meatus of uncircumcisedmale infants than aroundthose of circumcised male infants(this colonization decreases in bothgroups after the first 6 months). 115 Inaddition, an experimental preparationfound that uropathogenic bacteriaadhered to, and readily colonized, themucosal surface of the foreskin butdid not adhere to the keratinized skinsurface of the foreskin. 116CancerPenile CancerPenile cancer is rare, and rates seemto be declining. In the United States,Surveillance, Epidemiology, and EndPEDIATRICS Volume 130, Number 3, September 2012Downloaded from pediatrics.aappublications.org by guest on June 19, 2013e767