Trends in pediatric circumcision in Belgium and the Brussels University Hospital from


Mid-year estimate 0-15 year old boys in Belgium



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Mid-year estimate 0-15 year old boys in Belgium

Number of pediatric circumcisions in Belgium

Circumcision rate (/1000 boys/year)

Circumcision by age 16 (%)

2002

983814.50

13,016.43

13.23

21.17

2003

982907.00

13,313.90

13.55

21.68

2004

982350.00

14,041.13

14.29

22.86

2005

983321.50

14,552.90

14.80

23.68

2006

985249.00

15,097.00

15.32

24.51

2007

986333.00

16,984.00

17.22

27.56

2008

989458.50

17,607.00

17.79

28.46

2009

995850.50

19,048.00

19.13

30.61

2010

1005449.50

19,028.00

18.92

30.27

2011

1016288.50

20,145.00

19.82

31.71

Table 2 Pediatric circumcision rates (/1000 boys/year) over time in Belgium
The yearly percentages of the indications to circumcise in the Brussels University Hospital are extrapolated to a national level. The circumcision rate for phimosis remains relatively stable, at an average of 4.91 per 1000 boys per year. The circumcision rate for parental request increased by about 91.66 %, from 8.33 per 1000 boys per year in 2002 to 15.97 per 1000 boys per year in 2011.

If the 2011 circumcision rate remains stable, 5.88% of boys will undergo a circumcision by their 16th birthday to treat phimosis in Belgium.




Year

Circumcision rate for phimosis (/1000 boys/year)

Circumcision rate for parental request (/1000 boys/year)

Circumcision rate for balanoposthitis (/1000 boys/year)

Circumcision rate for UTI (/1000 boys/year)

Circumcision rate for other reasons (/1000 boys/year)

2002

4.64

8.33

0.26

0.00

0.00

2003

5.11

8.03

0.24

0.16

0.00

2004

5.01

8.40

0.65

0.24

0.00

2005

5.76

8.24

0.79

0.00

0.00

2006

4.41

10.32

0.33

0.13

0.13

2007

5.03

11.31

0.30

0.52

0.07

2008

4.79

11.94

0.81

0.08

0.16

2009

6.25

12.42

0.23

0.23

0.00

2010

4.82

13.73

0.22

0.07

0.07

2011

3.92

15.33

0.14

0.36

0.07

Table 3 Pediatric circumcision rates (/1000 boys/year) per indication over time extrapolated to a national level
The increase in the circumcision rate is most notable in boys aged less than 5 years. In the 10-year study interval, the circumcision rate in this age group rose by 62.23%, from 32.79 per 1000 boys per year to 53.20 per 1000 boys per year. The circumcision rate remains relatively stable in boys aged 5 to 9 years old and 10 to 15 years old at a mean circumcision rate of respectively 9.04 and 2.20 per 1000 boys per year.

Figure 9 Pediatric circumcision rate (/1000 boys/year) over time stratified by age group


The indications to circumcise stratified by age group are extrapolated to a national level. The circumcision rate for parental request increased by about 111.82 % in boys aged 0 to 4 years, from 21.48 per 1000 boys per year in 2002 to 45.50 per 1000 boys per year in 2011.

Figure 10 Pediatric circumcision rate (/1000 boys/year) per indication over time in boys aged 0 to 4 years old


A total of 48,491.28 circumcisions were performed to treat phimosis. Overall, 58.16% of these circumcisions were performed in 0 to 4 year old boys, 32.07% in 5 to 9 year olds and 9.78% in 10 to 15 year olds. The circumcision rate for phimosis increased by 9.18% in 5 to 9 year old boys, from an average of 4.90 per 1000 boys per year in 2002-2006 to an average of 5.35 per 1000 boys per year in 2007-2011. In 0 to 4 year olds, this rate decreased by 22.47%, from an average of 10.45 per 1000 boys per year in 2002-2006 to an average of 8.10 per 1000 boys per year in 2007-2011. The circumcision rate for phimosis increased in 10 to 15 year olds by 73.78%, from 0.91 per 1000 boys per year in 2002-2006 to 1.59 in 2007-2011.

Figure 11 Pediatric cirumcision rate (/1000 boys/year) for phimosis over time stratified by age group


The circumcision rate for parental request (P R) remained relatively stable in 5 to 9 year olds and 10 to 15 year olds at an average of respectively 3.59 per 1000 boys per year and 0.86 per 1000 boys per year. The trends in the circumcision rate for medical indications (M I) were similar to the trends in the circumcision rates for phimosis.

Figure 12 Pediatric circumcision rate (/1000 boys/year) per indication over time stratified by age group


Discussion


The goal of the study, i.e. the description of the trends in circumcisions of boys aged between 0 and 16 years in the Brussels University Hospital and in Belgium, has been achieved.
Between 1994 and 2012 the total number of circumcisions in the Brussels University Hospital increased by about 59.75 %, from 187.79 in 1994 to 300.00 in 2012. From 2002 to 2011 the national pediatric circumcision rate increased by 49.81%, from 13.23 per 1000 boys per year in 2002 to 19.82 per 1000 boys per year in 2011. If the 2011 circumcision rate remains stable, it is estimated that 31.71% of boys will be circumcised by their 16th birthday.

In England, Scotland, New Zeeland, Australia and the United States of America the circumcision rate is dropping. The studies in New Zeeland, Australia and the United States of America only examine the trends in newborn male circumcision, so post-neonatal circumcisions are not captured (cf. supra “Trends in pediatric circumcision”). From the latter half of the 19th century, the habit of routine neonatal circumcision was accepted in these countries.7 Nowadays this habit is questioned. The Royal Australasian College of Physicians (RACP) stated in 2010 that there is no evidence to warrant routine infant circumcision, but parental choice should be respected.54 The American Academy of Pediatrics Circumcision stated that preventive health benefits of elective newborn male circumcision outweigh the risks of the procedure. These health benefits are not sufficient enough to recommend routine circumcision, but they are sufficient enough to justify access to this procedure for families choosing it and to warrant third-party payment.8 As routine neonatal circumcision is no longer recommended, the number of circumcisions is dropping in these countries. In Belgium routine neonatal circumcision was never a custom.

The decrease in the circumcision rates in England and Scotland was due to a drop in circumcisions performed to treat phimosis.24 57 If the 2003 circumcision rate remains unchanged in England, 3.1% of English boys will undergo circumcision by their 15th birthday.24 If the 2003 circumcision rate remained unchanged in Belgium, 21.68% of Belgian boys will undergo circumcision by their 16th birthday. This is about 7 times the English percentage. In the English study, only medically indicated circumcisions are investigated. In Belgium, all circumcisions performed in a hospital setting are included.
The increase in the total number of circumcisions is due to more circumcisions performed for parental request. Over the 19-year study interval, there is a 382.85% increase in the number of circumcisions performed for parental request in the Brussels University Hospital, from 48.88 in 1994 to 236.00 in 2012. A total of 52.54% of the circumcisions were performed for parental request. From 1994 to 2000, the number of circumcisions performed for parental request remained relatively stable at an average of 45.13 circumcisions per year. From 2000 on, this number increased by 372.05%, from 50.00 in 2000 to 236.00 in 2012. If we extrapolate the percentage of circumcisions performed for parental request in the Brussels University Hospital to the national numbers, there is a 91.66% increase in the circumcision rate for parental request, from 8.33 per 1000 boys per year in 2002 to 15.97 per 1000 boys per year in 2011.

In the English study, there was a decrease in the circumcision rates from 1997 to 2003. Only medically indicated circumcisions were analyzed. Boys who underwent a ritual circumcision were excluded from further analysis. If there was an increase in the number of ritual circumcisions in England, this was not detected in the study.24

In Scotland, the circumcisions performed for non-medical/religious reasons remained stable during the study period. A total of 17.5% of the circumcisions were performed for these indications. This study interval was form 1990 to 2000.57 In the Brussels University Hospital, the number of circumcisions performed for non-medical reasons also remained relatively constant from 1994 to 2000, at 24.09% of the total number of circumcisions. This percentage is 27.36% higher than the percentage in Scotland. The percentage of Muslims in the catchment population of the Brussels University Hospital is higher than the percentage of Muslims in Scotland. The average percentage of Muslims in Scotland was 0.84% in 2001.65 The average percentage of Muslims in Brussels is 25.5% and in Flanders 3.9% in 2005.66 This could explain the dissimilar percentages of circumcisions performed for non-medical reasons.

In Western Australia, the yearly number of circumcisions performed for non-medical reasons was not investigated. From 1981 to 1999, 44% of the total number of circumcisions was performed for non-medical reasons.55 In the Brussels University Hospital, 22.77% of the total number of circumcisions was performed for parental request from 1994 to 1999, about half the Western Australasian percentage. The Western Australasian percentage includes routine neonatal circumcision. This is a habit in Western Australia and not in Belgium and could explain the variations in the percentages.


In the Brussels University Hospital, the number of circumcision performed for phimosis declined by 58.14%, from 133.77 in 1994 to 56.00 in 2012. The Belgian circumcision rate for phimosis remained stable from 2002 to 2010 at an average of 4.91 per 1000 boys per year.

There are two possible explanations. The first is that fewer circumcisions are performed for phimosis, not because there are fewer boys with phimosis, but because there is an improved understanding of the natural history of physiological non-retractile foreskin and the pathophysiology of phimosis. What many surgeons would have considered in the past to be “phimosis” (and treated by circumcision) was in fact physiological non-retractile foreskin. Secondly, there has been a move toward conservative management of phimosis. For more than two decades topical steroids are used to treat phimosis and it has showed good results (cf. supra “Indications for pediatric circumcision - Phimosis”).

In England and Scotland the number of circumcisions performed for phimosis declined as well.24 57

In Western Australia, the circumcision rate for phimosis increased from 1981 to 1999. There were two possible explanations. One is that physicians may be mistaking a physiologic phimosis for a pathologic phimosis. The second theory is that hospital physicians may feel some pressure to encode a medical indication for routine (non-medical) circumcisions, as the Australasian Association of Paediatric Surgeons does not support this practice.55 The number of circumcisions performed for phimosis in the Brussels University Hospital remained relatively stable from 1994 to 1999.


In the year 2000 there was a substantial drop in the number of circumcisions performed in the Brussels University Hospital. This number decreased by 17.35%, from 197.96 in 1999 to 163.62 in 2000.

This was not due to a decrease in the number of 0 to 15 year old boys in the catchment area, as this number increased.

The drop in the number of circumcisions performed in the Brussels University Hospital is most likely due to a drop in the circumcisions performed to treat phimosis. This number decreased by 61.49%, from 142.97 in 1999 to 55.05 in 2002. From 1999 on, the urology department systematically started topical steroid treatment for phimosis. This resulted in a drop in the total number of circumcisions.
It is estimated that 5.88% of boys will undergo a circumcision by their 16th birthday to treat phimosis if the 2011 circumcision rate for phimosis remains stable.

The incidence of pathologic phimosis is 0.4 per 1000 boys per year or 0.64% of boys are affected by their 16th birthday.35 Thus, this circumcision rate is about 9 times higher than the reported incidence of phimosis at that age. This indicates that phimosis currently is still overdiagnosed.

If the English 2003 circumcision rate remains unchanged, 3.1% of English boys would undergo circumcision by their 15th birthday. This number is about 5 times higher than the reported incidence of phimosis.24 If the Australasian 1999 circumcision rate remains stable, it is estimated that 4% of all boys will be circumcised for phimosis by their 15th birthday, a number that is 7 times higher than the estimated rate of pathologic phimosis at that age.55 These percentages are lower than the Belgian 2011 figures and indicate that phimosis is better managed in these countries. It is important to distinguish a physiologic phimosis from a pathologic phimosis. A physiologic phimosis requires no medical treatment and a pathologic phimosis does. This treatment can be either surgical or medical. For more than 2 decades, topical steroids have been used as an alternative for surgical correction and it has showed good results (cf. supra “Indications for pediatric circumcision - Phimosis”).
Mainly boys from 0 to 4 years of age are circumcised to treat phimosis, despite this condition being rare in this age group (cf. supra “Indications for pediatric circumcision - Phimosis”).

This shows that a review of current practice guidelines for the pediatric management of phimosis in Belgium may be warranted. A physiologic phimosis is a very common condition at that age. Only 4% of the newborns have a fully retractable foreskin. In 20% of 2 year olds, the foreskin cannot be retracted over the glans.2 This does not require treatment. A reassurance of normalcy and reinforcement of proper preputial hygiene are required. Young boys with a confirmed diagnosis of phimosis do not necessarily need to be circumcised. Topical steroids have been shown to be a cost-effective treatment for phimosis (cf. supra “Indications for pediatric circumcision - Phimosis”). In Western Australia boys aged 0 to 4 years also had the highest rate to treat phimosis.55 In Belgium this number declined from 1994 to 1999, whereas this number increased in Western Australia from 1981 to 1999.




The number of circumcisions performed for parental request is highest in 0 to 4 years olds.

This is a favorable trend. Infancy is the optimal age to circumcise and complications are less frequent among younger ages (cf. supra “Potential benefits of male circumcision”). If parents choose to circumcise their son, it is in the best interest of the boys to circumcise at a young age.





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