Grand Rounds 2:18

Thanks, KevinMD for the welcome and mention on this week's Grand Rounds! There are links to more than 60 articles this week with topics ranging from PSA tests to doctor phobias, written by health professionals from all around the blogosphere.

Technorati Tags: medicine, medical blogosphere

The Never-ending Circumcision Debate

To cut or not to cut - the debate rages on...

Early in my training, as a young and eager medical student on my first OB rotation, I was called into the nursery with two other med students. There we were told by the intern that several infant boys needed circumcisions, and that we would be doing these. Excited but afraid, I asked if it was appropriate for us to be doing these without any experience. Not to worry, we were told. Then, after observing just one, we were set free to go do our own. The old, "see one, do one, teach one" philosophy was alive and well. Fortunately, we were a conscientious group and our outcomes looked just fine. But how many I wondered would turn out horrible? Who should be doing these? Surely not medical students.

Somehow this young boy's foreskin would be foreshadowing of my future profession. Jump ahead many years, here I am in private practice, after completing a rigorous general surgery training at the world famous Mayo Clinic and my urologic residency at Tufts/New England Medical Center in Boston. Pediatricians are screaming that circumcision has a high complication rate and is tantamount to torture and child abuse of the worse kind. Urologists are struggling to keep their penile cancer patients alive after diagnosis of a rare but very aggressive killer, after horrible surgery. Then more studies start to appear - circumcision may reduce risks for STD's and HIV as adults.

Here we are today, and the debate continues. So what, if any, is the advantage to a newborn circ? First, to have any advantage the circumcision must be preformed by a skilled and experienced doctor. As a urologist, I prefer that urologists perform the circumcision and if possible pediatric urologists. In all my years I have never seen a complication from a skilled urologist. I have seen real problems from circumcisions done by other doctors who may only do an occasional circumcision. It is my guess that the majority of these complications and problems we all read about serve as the basis for the anti-circumcision hysteria. Like anything in life, if you take the time to seek out the best skilled specialist, you will get better results with fewer problems. You don’t take your new Buick to a bicycle shop mechanic for a reason. This is not rocket science.

Second, the risks from an uncircumcised boy only exists if he has poor hygiene during his life, usually associated with scarring of the foreskin so that it cannot be pulled back, called phimosis. The risks go up if he smokes. These guys are the ones that have a higher risk for penile cancer. It all comes down to regular washing away of the cancer-causing irritating substances that normally build up under the foreskin.

This is the end of the debate in my eyes. Preventing a devastating cancer has never been so easy - soap and water. To follow are a number of scientific papers (opinions of urologists, as we are the only ones I think who have any legitimate right to comment on foreskins. We see the problems from birth to death. I personally don't pay much attention when a pediatrician or OB or internists writes about something that they only read about.)

Should you circumcise your newborn son? It is up to you. There are pros and cons of both sides. If he will be clean, then he can do just fine with his foreskin. My personal preference is for the son to match the dad. And if you do choose to have him circumcised, take the time to find the best doctor in your area to do it. It will be worth it.


Cancer of the penis.

Mosconi AM, Roila F, Gatta G, Theodore C.

Ospedale Policlinico Monteluce, Perugia, Italy. amarmosc@unipg.it

Cancer of the penis is rare in Europe, accounting for less than 0.5% of all cancers. Phimosis and poor hygiene are strong risk factors whereas neonatal circumcision is a contributing factor in the prevention of this disease.

Penile carcinoma: a challenge for the developing world.

Misra S, Chaturvedi A, Misra NC.

Department of Surgical Oncology, King George's Medical College, Lucknow, India.

Although rare in developed countries, carcinoma of the penis is an important problem in the developing world. Circumcision done in childhood offers the greatest protection against this disease. Poor penile hygiene and phimosis are strong risk factors for development of penile carcinoma.

Scand J Urol Nephrol Suppl. 2000;(205):189-93.
Related Articles,

Scand J Urol Nephrol. 2001 Dec;35(6):435; author reply 435-6.

Etiology of squamous cell carcinoma of the penis.
Dillner J, von Krogh G, Horenblas S, Meijer CJ.

Microbiology & Tumor Biology Center, Karolinska Institute, Stockholm.

In a case-control study, circumcision neonatally, but not after the neonatal period, was associated with a 3-fold decreased risk...

Related Topics:
Circumcising Newborns May Prevent Penile Cancer, Ways To Reduce the Risk of Penile Cancer

Technorati Tags: circumcision, penilecancer, cancer

Adult Circumcision

Circumcision is a controversial topic because there is so much misinformation and emotion included as fact. The facts are fairly straightforward. There are some definite biological advantages to circumcision. For example, circumcised men don't develop penile cancer- a rare though deadly (and emotionally difficult) cancer. Circumcised men develop fewer sexually transmitted diseases if promiscuous (the skin is thicker and more resiliant to trauma)

Some men who complain of problems retracting their foreskin are candidates for one of three options. This problem, called phimosis, develops as a result of injury the the circular fibers within the foreskin- usually as a result of a traumatic retraction- often at birth or early in life. This trauma heals with scarring that over time may gradually scar down to total inability to retact the foreskin.

There are 3 main options.

First, is to do nothing. It may not get worse, it may get better or stay the same. Try to avoid forcibly retracting the foreskin as this will make it worse.

The second choice is what is called a "dorsal slit" this opens up the foreskin by simply cutting, under local or general anesthesia, a one or two inch longitudinal cut at the top through the foreskin, across and past the scar. This then allows you to retract the foreskin yet maintains the look and presence.

The third option is formal circumcision. Despite the emotion and hysteria, recent studies have analyzed the sensory input from the glans penis (the end) looking at whether or not circumcised men have more, less or same sensation. The answer is that they feel the exact same thing.

Another way to look at this is by asking men who had adult circumcision about their own personal before and after experience. I know a number of other urologists and surgeons who went though this as an adult. A few liked it before, a few liked it after, most said no difference.

Related Topics: Should Your Son Be Circumcised?, Adult Circumcision Affects Sexual Performance

Technorati Tags: circumcision, adultcircumcision, phimosis

Male Infertility and Testicular Cancer

You'd think that missing the diagnosis of a testicular cancer in a young, healthy male would scare the living daylights out of any doctor. But there exists in today's modern medicine a situation that continues to baffle me,where some bright doctors ignore the facts. Study after study has proven what urologists have known for years: that a significant number of men seeking evaluation for male infertility have a testicular cancer as the cause of their infertility!

Young men with fertility problems (poor or zero sperm counts) usually go to a fertility center. Almost always this is an OB/GYN that specializes in female reproductive issues or an OB/GYN that has done additional training after residency in female reproduction and is called a reproductive endocrinologist (RE). Because so many advances have been made in assisted reproductive techniques for the female, the cause of the husband's infertility is considered irrelevant. Sperm can be retrieved blindly and used to create a baby through the magic of ICSI with IVF. This technique is an amazing advance in helping infertile couples create a baby of their own. However, in the doctor's zeal to move ahead with the "baby making," the cause of the male's infertility is often of little concern . They can get sperm, so what difference does it make whatever the cause?

This is where the facts should help define "standard of care." There are two reasons why a urologist with special interest or training in male fertility should be an integral part of the fertility medical team.

1. There is a real risk that some of these men have a testicular cancer as the cause of their infertility. Without a urologic exam and appropriate studies, he may be able to father a child through IVF, while the undiagnosed cancer continues to grow until it becomes much larger or shows signs of being advanced (as with Lance Armstrong). This is obviously not good for the man, or his new family. Missing an opportunity for an early diagnosis may mean chemotherapy, radical surgery and increased chances for death.
2. Sometimes the urologist is able to diagnose and correct the cause of infertility, such as a varicocele, ejaculatory duct obstruction, or blockage of the vas. This could allow some couples to conceive naturally or without the risks and expense of ICSI with IVF.

So what can be done? First and foremost, couples need to be informed about the causes and treatment options of infertility in the male and female. Second, urologists need to be more involved in their community when it comes to fertility issues. Urologists should also work with the female fertility experts, reminding them of the importance of being included whenever there are male fertility questions. Lastly, doctors that prefer to ignore the potential risks to their infertile male patients need to refer these patients to urologists. This is not rocket science. It is good patient care. If the doctors themselves won't initiate it, then informed patients must demand it!

Related Topics: Infertility Treatment and Support, Fertility Tests for Men

Tags: malefactorinfertility,testicularcancer,IVF,urology,webmd

One step closer to Bin Laden

It had been a long day, and now I was going to the airport to pick up my son. What a nice way to end the day. A difficult vasectomy reversal in the morning, patients in the afternoon, a few phone calls. I was going to relax and spend some quality time driving home with my 20 year old son. Now that he lives out-of-town, these moments are few and far between. Moments to be cherished. As he was here for a week, I knew he would be bringing a few suitcases. Jordan always travels home with gifts for everyone. He's just that kind of kid. With that in mind, I decided to drive the 9 year old plain white, bench seat, hand-crank window pick-up truck, Dorothy. Yes her name is Dorothy. She was driven primarily by friends and family for moves, trips to the dump, hauling furniture, etc. This was exactly why we had her- for those special occasions where a little extra hauling was in order, and I was hoping tonight would be no exception.

As I approached the airport (I do not want to mention the Tucson Airport by name), newly remodeled at I'm sure a cost of many tens of millions of dollars, I received a call from my wife that has become too common - the flight was a bit delayed but he would be here soon. I decided to drive on ahead and do the usual drive around the airport circle until he arrived. The weather was nice, the music was good, and it was only a matter of time. What a great way to relax.

First pass - smiling at the traffic cops (keeping us safe from bad guys, I thought) when I noticed something out of the ordinary. A bright light behind me- almost as if a flashing light. Wait, it was a flashlight held by someone that was approaching me. Could I be going faster than the posted 15 miles an hour? Did I not offer the cursory nod the traffic cop? Was it one of my friends in law enforcement coming to say "Hey Sheldon, how are you?"

I slowly pulled over (you really can't slow down when you are going 15 miles an hour). Then he approached my window. A tall, somewhat muscular Airport policeman in a pressed uniform, asking to see my usual ID, etc. "What seems to be the problem, officer?" I asked. It just so happens, he said, that the tag on the pick-up had expired the previous month.

Was I supposed to get it renewed, or was that my wife's job?

Probably mine. Oh well, no big deal. Just a warning to go get it done, I assumed. Heck, there were people out there who wanted to kill us. To cut off our heads, to damage our economy, to destroy everything we hold dear. And this was just an expired tag, and only one month at that. But wait, there were other armed officers now surrounding the car. One behind me, and another at the passenger door grilling me about the car, tags, licensing, etc. Wow, I laughed at first - "Must be a slow night". Apparently not the thing to say.

There I sat, with armed police around me for 45 minutes, while they checked on everything to be sure that this middle aged, graying, slightly overweight urologist was not some horrible criminal, waiting to do evil deeds at the airport.

It seemed like the time to mention that I am one of the good guys so he can relax. I work with the local SWAT team -- I teach terrorism preparedness, I am on the local police foundation...Heck, I have even done vasectomies on a bunch of their fellow Airport police. We even know each other by our first names!

I guess this did not help. My thought was that probably the word had gone out from the FBI -- "Watch out for an older, Caucasian male urologist in an old plain pickup with a tag one month expired, trying to pick up his son. Warning, this guy with a mildly receding hairline could be dangerous."

Finally, they left me. Embarrassed. Alone. Told to drive and drive slowly, and to get my tag renewed immediately. Did he mean now at 10 PM? But before he left, he handed me a special gift. A note thanking me for all the hundreds of hours I donate to help the local police? A little message telling me how much they appreciate all I do for his fellow airport officers?

No, it was a ticket. But not just any ticket. It was the mother of all tickets. I was now being charged with not having a valid renewal tag, driving with an expired tag, and most importantly, not having the tag in my possession. Wow, he must have been in a bad mood. Fight with his wife, too much starch in his shorts, not get the promotion, not enough fiber?

Whatever it was, he nailed me and nailed me good. Over $1000 in fines. Hey, at least I was safe. My highly trained, armed airport police doing what they do best, keeping our country safe from terrorists and evil-doers....and those potentially dangerous middle-aged men with expired license plate tags. Good job, Officer. Tucson is safer tonight thanks to you.

I know Bin Laden and his clan are just a little more worried; that we are just one step closer.

Run and hide, Osama, if you can.

Tags: ticket,cartags,airport,stress,webmd,

Prostate Cancer - A Preventable Loss

It's New Years Eve day and I find myself out in the middle of nowhere, visiting the home of a patient I have known for more than 12 years. Dave has become a friend over the past decade. We have shared family stories and observations about the world. Today is different. Dave is now bedridden, paralyzed and dying of his prostate cancer.

For so many years, I knew he was a time bomb, waiting to explode. But Dave had other ideas. He believed that if he took exotic herbs and weird oils, he could avoid recommended treatments for his rising PSA. Then when he started having problems from his recurrent prostate cancer, he finally allowed us to start hormone injections- though only for a short time before he turned back to his "magic" herbal therapies from the jungles of someplace far away. Now he is at the end of his life. A few years ago, with his insurance changes, I switched from doctor to friend. With my encouragement, Dave has allowed his new team of doctors at the university to treat him aggressively. But with time, that too has failed.

As I entered his living room converted to bedroom, Dave lay there thin, pale and green. Really green. "So why are you green?" I asked. "Oh," he replied, "that's the green light that is taking the pain away. That with these new anti-oxidant herbs I bought from Texas. Not only does it take the pain away, it makes the cancer shrink. I'm on a study, so it only cost me $695 dollars every two months." I didn't have the heart to tell Dave that real studies don't charge patients. If anything, it is the other way around. I was sure it was another scam. "So what are you doing with that computer in your lap?" I asked. "Oh, I am trying to figure out how to make my house payments so I don't get foreclosed," Dave responds. "Hey, by the way, the radiation doctor, who is so great, has been trying to get me to have radiation for these spots that hurt so much from the cancer. I am worried about side effects. What do you think? Excuse me while I dab some anti-oxidant cream on these spots on my head."

So classic. Treatments that are proven to prolong life and at least reduce his pain and improve his quality-of-life are questioned, challenged and delayed. Dave and I sit and discuss the pros and cons, short and long-term scenarios of each. He still is reluctant, even when there is nothing to lose. When it comes to "natural" herbs, oils and special cancer-killing diets, there is no questioning, no challenging. Whatever it takes, whatever the cost. This has become a recurring theme for so many patients I have known in the last 19 years. Patients will gladly part with huge sums of money to pay for unproven "alternative" treatments that are "guaranteed" by the inventor to work. I knew of one man who even mortgaged his home to pay for immune system boosting urine injections because he was so certain that this treatment would rid him of cancer, avoiding the need for surgery or radiation. The patient was devastated when a follow-up biopsy showed the cancer was still there, only larger.

Sadly, I have yet to see one of these alternative therapies that are successful. Yet they exist. And desperate people, afraid of the disease and apparently the treatments, will continue to make these hucksters wealthy. Playing on the ultimate vulnerability, these quacks take patient's money, rob the gullible of any opportunity for the proven treatments to work, and often steal their lives. While these crooks are out on their new yachts, the patients are at home wondering why it didn't work.

Meanwhile the cancer grows, and Dave lies in his bed, bathed in green light, still waiting for the magic to happen. "You have a happy new year too, Dave."

Related Topics: Alternative vs. Conventional Medicine, Are Herbal Supplements Safe?

Tags: alternativemedicine, healthcare, PSA, prostatecancer, webmd