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FRCSC 2020 Guidelines > CUA 2018 GL on Circumcision > Flashcards

CUA 2018 GL on Circumcision Flashcards

1
Q

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

A

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

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2
Q

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

A

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

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3
Q

What eventually causes the retraction of foreskin?

A

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

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4
Q

when would physiologic phimosis require treatment?

A

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

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5
Q

Is ballooning of foreskin an indication for circumcision?

A

No

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6
Q

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

A

8-10 years

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7
Q

What is this?

A

Pathological phimosis

It has lichen sclerosis

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8
Q

what is this?

A

Balano-posthitis

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9
Q

What should neonatal examination of penis and foreskin include?

A

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

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10
Q

Is persistent physiologic phimosis an indication for circumcision?

A

NO, not if asymptomatic

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

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11
Q

What is the first line treatment for persistent physiologic phimosis?

A

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

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12
Q

Are low poteny steroids as effective as low potency ones?

A

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
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13
Q

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

A

common

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

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14
Q

Males under…… age had the
highest prevalence of UTI

A

three months of

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15
Q

How does circumcision prevent UTIs?

A

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

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16
Q

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

A

high grade VUR,

PUV

primary megatureters

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17
Q

Does neonatal Cricumcision decrease the risk of UTIs?

A

yes

Neonatal circumcision decreases the risk of UTI

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18
Q

True or False?

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

A

Yes,

it is highest from birth to 3 months

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19
Q

Does CUA guideline recommend universal circumcision?

A

NO

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

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20
Q

Is circumcision recommended in boys with urologic abnormalities?

A

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)

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21
Q

Who has HIV?

A

MSM> IVDU> heterosexual individuals

22
Q

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

A

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

23
Q

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

A

38-66%

24
Q

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

A

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.

25
Q
A
26
Q

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

A

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

27
Q

What about male circi to protect women from HIV?

A

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

28
Q

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

A

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

29
Q

what are the oncogenic usbtypes of HPV?

A

16,18

low risk 6 and 11 cause genital warts

30
Q

Who should get the HPV vaccine?

A

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)

31
Q

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

A

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.

32
Q

Does MC help men clear HPV infections?

A

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.

33
Q

How does MC affect HPV incidence or acquisition?

A

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

34
Q

How does MC affect female partner HPV status?

A

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

35
Q

what are the most common non-ulcerative STIs?

A

gonorrhea, chlamydia, trichomonas

36
Q

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

A

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).

37
Q

what are common cuases of genital ulcer disease?

A

HSV1,2

T. Pallidum(syphilis)

H. ducreyi(chancroid)

K. granulomatis(donovanosis)

38
Q

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

A

Wrong

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

39
Q

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

A

Nope

40
Q

What are risk factors for penile cancer?

A

phimosis

balanitis

smoking

HPV infections , penile oral sex , Lichen slcerosis

Premalignant conditions( bowen’s disease, erythroplasia of queyrat)

priapism, PUVA therapy

41
Q

Does circumcision decease the risk of penile cancer?

A

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

42
Q

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

A

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

43
Q

Does circumcision protect against prostate cancer?

A

NO

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

44
Q

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

A

Wrong

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

45
Q

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

A

Secondary Phimosis

46
Q

what is koebner phenomenon?

A

recurrent LS may appear along scar lines of
previous surgery;

the use of topical steroids is an option in
the postoperative period

47
Q

Who should not have a circumcision?

A

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

48
Q

what are the complicaitons of circ?

A

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

49
Q

what is the most effective pain control technique for circ?

A

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
50
Q

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

A

Nope

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

51
Q

whar is the complicaiton rate of circ?

A

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

52
Q

what factors predict complicaitons?

A

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

FRCSC 2020 Guidelines (49 decks)

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