The carcinogenicity of smegma: debunking a myth.

BACKGROUND: Smegma is widely believed to cause penile, cervical and prostate cancer. This nearly ubiquitous myth continues to permeate the medical literature despite a lack of valid supportive evidence. METHODS: A historical perspective of medical ideas pertaining to smegma is provided, and the original studies in both animals and humans are reanalysed using the appropriate statistical methods. RESULTS: Evidence supporting the role of smegma as a carcinogen is found wanting. CONCLUSIONS: Assertions that smegma is carcinogenic cannot be justified on scientific grounds.

Effect of confounding in the association between circumcision status and urinary tract infection.

OBJECTIVES: To estimate the impact of confounding in the association between circumcision status and urinary tract infection from epidemiological factors, sample collection, and health-seeking behaviors in the first year of life. METHODS: Beginning with the assumption that true urinary tract infection occurred equally regardless of circumcision status, a Markov model incorporating the differences in the rates of prematurity, of urine collection, of false positive urine specimens, and of health-seeking behaviors in infant boys based on circumcision status was developed. Using this model, the rates of false-positive urine cultures, asymptomatic bacteriuria, and true urinary tract infection detected in the first year of life were estimated and contrasted. Error of the model was estimated using Monte Carlo simulations. RESULTS: Keeping the incidence of true urinary tract infection constant between groups, the factors included in the model could account for urinary tract infection being diagnosed 4.27 times more frequently in non-circumcised males under a year of age. CONCLUSIONS: Previously reported differences in the rate of urinary tract infection by circumcision status could be entirely due to sampling and selection bias. Until clinical studies adequately control for sources of bias, circumcision should not be recommended as a preventive for urinary tract infection.

Prophylactic interventions on children: balancing human rights with public health.

Bioethics committees have issued guidelines that medical interventions should be permissible only in cases of clinically verifiable disease, deformity, or injury. Furthermore, once the existence of one or more of these requirements has been proven, the proposed therapeutic procedure must reasonably be expected to result in a net benefit to the patient. As an exception to this rule, some prophylactic interventions might be performed on individuals "in their best interests" or with the aim of averting an urgent and potentially calamitous public health danger. In order to invoke these exceptions, a stringent set of criteria must first be satisfied. Additionally, where the proposed prophylactic intervention is intended for children, who are unlikely to be able to provide a meaningfully informed consent, a heightened scrutiny of any such measures is required. We argue that children should not be subjected to prophylactic interventions "in their best interests" or for public health reasons when there exist effective and conservative alternative interventions, such as behavioural modification, that individuals could employ as competent adolescents or adults to avoid adverse health outcomes. Applying these criteria, we consider the specific examples of prophylactic mastectomy, immunisations, cosmetic ear surgery, and circumcision.

Circumcision and HIV infection: review of the literature and meta-analysis.

Thirty-five articles and a number of abstracts have been published in the medical literature looking at the relationship between male circumcision and HIV infection. Study designs have included geographical analysis, studies of high-risk patients, partner studies and random population surveys. Most of the studies have been conducted in Africa. A meta-analysis was performed on the 29 published articles where data were available. When the raw data are combined, a man with a circumcised penis is at greater risk of acquiring and transmitting HIV than a man with a non-circumcised penis (odds ratio (OR)=1.06, 95% confidence interval (CI)=1.01-1.12). Based on the studies published to date, recommending routine circumcision as a prophylactic measure to prevent HIV infection in Africa, or elsewhere, is scientifically unfounded.

PIP: This article reviews the literature on circumcision and HIV infection. Recent studies show raw figures suggesting circumcised men to be at greater risk for HIV infection. Circumcised men have been found to also have more sexual partners. Findings explain that circumcision may be responsible for the increased number of partners, and therefore, the increased risk. In Africa, the use of dirty instruments and mass ritual events, including group circumcision, may increase the number of young boys developing HIV infections. Based on the studies published in the scientific literature, it is incorrect to assert that circumcision prevents HIV infection. Moreover, even if studies showing circumcision to be beneficial are accurate, the risk from circumcision outweighs any small benefit it may have. Thus, promoting circumcision as protection against HIV infection would lead to the belief that circumcised men are being protected from contracting AIDS, which would result in increased HIV infections.

Case management in managed care: past, present, and future.

Case management (CM) has undergone radical, rapid change during the past 20 years and, from all appearances, shows no signs of slowing down. This article attempts to lay out the factors that will lead to the future of CM from three perspectives: patients, providers, and payers--the trilogy of the health care industry. The content of this article is rather provocative, intentionally designed to kindle thought and generate alternative ways to approach CM programs.

Cost-effective treatment of phimosis.

OBJECTIVE: To determine the most cost-effective treatment for phimosis. DESIGN: The costs of three treatment strategies for treating phimosis were evaluated using a decision-tree analysis. Three therapeutic approaches were considered: circumcision, preputial plasty (the use of plastic surgical techniques to enlarge the preputial opening without removing tissue), and topical therapy with steroids and nonsteroidal antiinflammatories. Published failure and complication rates were used to calculate the cost per case. Outcome Measures. Cost in dollars to treat each case of phimosis. RESULTS: Topical steroid therapy was the most cost-effective strategy, costing between $758 and $800 per case. Preputial plasty cost between $2515 and $2580 per case. Circumcision cost between $3009 and $3241 per case. CONCLUSIONS: The most cost-effective management for treating phimosis is to initiate topical therapy. Daily external application from the tip of the foreskin to the glandis corona with betamethasone 0.05% cream for 4 to 6 weeks has been demonstrated to be very effective, resulting in a 75% savings compared with circumcision. Surgical intervention should not be considered until topical therapy has been given an adequate trial. When contemplating surgery, the lower morbidity, lower costs, and tissue preservation of preputial plasty may make it preferable.