Surgeries and Procedures: Circumcision

Circumcision is a common procedure in which the skin covering the tip of the penis is surgically removed. It's usually performed on a newborn boy before he leaves the hospital, and often within the first 2 days of life. In the Jewish faith, it is performed in a special ceremony when a baby is 8 days old.

Boys are born with a hood of skin, called the foreskin, covering the head (glans) of the penis. In circumcision, the foreskin is removed to expose the head of the penis. It's a quick procedure that causes very little bleeding and stitches aren't needed. Older boys can be circumcised, but the procedure is a bit more involved. After the circumcision, a protective bandage may be placed over the wound, which generally heals on its own within a week to 10 days.

In the United States, many newborn males are circumcised. Circumcision is not medically required, but studies show that it lowers certain health risks. In fact, according to the American Academy of Pediatrics (AAP), the benefits of the procedure outweigh the risks.

Most parents make the decision about circumcision based on cultural, religious, or personal reasons (such as whether other male family members have been circumcised).

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Preparing for the Circumcision

Once you decide your baby will be circumcised, discuss it with the doctor who'll perform the procedure. Many circumcisions on newborns are done by obstetricians, but pediatricians, family practitioners, urologists, neonatologists, and pediatric surgeons also can do them.

Most healthy babies can be circumcised within 1 to 2 days after birth. However, circumcision is delayed for babies with certain medical conditions. Your child's examining pediatrician or neonatologist will decide if your newborn should wait to be circumcised.

If it is OK for your child to have a circumcision, the doctor will review any risks, potential benefits, and instructions on caring for your baby after the procedure. The doctor will also ask about any family history of bleeding disorders (like hemophilia or von Willebrand's disease). Ask the doctor to explain anything you don't understand.

When you feel comfortable with the information and your questions have been fully answered, you will be asked to sign an informed consent form, which states that you understand the procedure and its risks and give your permission for your child to have the circumcision.

Circumcisions are often performed in the hospital's nursery treatment room. Some parents choose to be in the treatment room during the circumcision, while others prefer to wait for the baby to be returned to the nursery. If you'd like to be in the room, let your doctor know.

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What Happens During the Procedure?

A baby is typically awake for circumcision. He is usually positioned in a molded plastic seat that helps hold him safely in place. The penis and surrounding skin are cleansed with antiseptic before the procedure begins.

Pain-Control Measures

Several safe and effective pain-control methods can lessen a baby's pain during circumcision. Ask your doctor about the type of pain control your baby will have ahead of time.

A local anesthetic is used to numb the area of the penis where the incision will be made. This may include a numbing cream and/or medicine that is injected in the penis using a tiny needle. Because of the numbing cream, your baby will feel very little as the needle goes through the skin.

To further reduce stress and discomfort, the nurse may give your baby a "sucrose pacifier" (a pacifier dipped in sugar water), which has been shown to reduce newborn distress. Sometimes acetaminophen is given to help with pain. Babies may also feel better when swaddled.

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Circumcision Methods

In newborns, circumcision can be performed in several ways. The most common techniques protect the head of the penis with special devices while the foreskin is removed. Your doctor will determine which method is appropriate.

In newborns, the three most common circumcision techniques are:

1. The Gomco Clamp

A special instrument called a probe is used to separate the foreskin from the head of the penis (they are usually joined by a thin membrane). Next a bell-shaped device is fitted over the head of the penis and under the foreskin (an incision may be made in the foreskin to allow this). The foreskin is then pulled up and over the bell and a clamp is tightened around it to reduce blood flow to the area. A scalpel is used to cut and remove the foreskin.

2. The Mogen Clamp

Again, the foreskin is separated from the head of the penis with a probe. The foreskin is then pulled out in front of the head and inserted through a metal clamp with a slot in it. The clamp is held in place while the foreskin is cut with a scalpel and remains for a few minutes after this to make sure that bleeding has been controlled.

3. The Plastibell Technique

This method is similar to the Gomco clamp technique. After separation with a probe, the plastic bell is placed under the foreskin and over the head of the penis. A piece of suture is tied directly around the foreskin, which cuts off the blood supply to the foreskin. A scalpel may then be used to cut off the extra foreskin, but the plastic ring is left on. About 6 to 12 days later it falls off on its own.

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After the Procedure

After a circumcision, doctors will apply petroleum ointment over the wound and wrap the baby's penis in gauze to keep the wound from sticking to his diaper (unless the doctors have used the Plastibell method, which requires no dressing). Your baby will usually be brought to you shortly after the procedure.

There is very little bleeding after circumcision, no matter which technique is used. Though you may see a little bit of blood oozing from the edge of the incision or on the diaper when you first take the dressing off, this will generally stop on its own.

Your baby's penis may be sore for a few days after the procedure, so be gentle when bathing him. Never use astringent and special bath products. Most doctors recommend keeping the area clean with warm water. If poop gets on the penis, soapy water can be used to gently wipe it away.

If there is a dressing on the incision, apply a new one (with petroleum jelly) whenever you change a diaper for the first day or two. Even after the dressing is no longer needed, you should put a dab of petroleum jelly on the penis or on the front of the diaper for 3 to 5 days. This can help avoid discomfort from rubbing and sticking to the diaper.

It usually takes between 7 to 10 days for a circumcised penis to heal from the procedure. Until it does, the tip might be raw or yellowish. Call your doctor right away if you notice any of the following:

• bleeding that continues or blood on the diaper (more than quarter-sized)
• redness or swelling around the tip of the penis that gets worse
• fever
• signs of infection, such as the presence of pus-filled blisters
• not urinating within 12 hours after the circumcision

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Benefits

In the first year of life, a circumcised infant is less likely to get a urinary tract infection. It may be easier to keep a circumcised penis clean and uninfected, though boys who don't have circumcisions can be taught to properly clean beneath the foreskin once it becomes retractable (usually by puberty).

Later in life, studies show that circumcised men may also be at lower risk for developing cancer of the penis (although the disease is rare). Circumcision may lower the risk of contracting HIV and other sexually transmitted diseases (STDs) from an infected female partner.

Risks and Complications

A circumcision is considered a safe procedure with minimal, if any, risks. Most of the time, there are no complications.

In rare instances, complications can include:

• Infection: Infection is rare because doctors use sterile techniques to perform the procedure. Most circumcision-related infections are mild and easily treatable with antibiotics. Signs of infection include worsening redness, pus, pain, and swelling around the incision, or fever. If you notice any of these signs, call the doctor.
• Bleeding at the site: This is more likely when the child has a bleeding disorder, which is why it's important to let the doctor know about any family history of bleeding or clotting problems. Very rarely, a small blood vessel may be nicked during the procedure. In most cases, this bleeding will stop on its own, but occasionally stitches are required.
• Risks associated with anesthesia: Local anesthesia is very safe, but it can sometimes cause bruising, bleeding, or skin irritation. Rarely, it can cause irregular heart rhythms, breathing problems, an allergic reaction, and, very seldom, death. These complications are not common, and usually involve patients who have other medical problems.
• Incomplete removal of the foreskin: Sometimes too much skin is left behind. This becomes less apparent as the child ages. Occasionally, if the excess skin is uneven, a corrective procedure may be required at a later date.
• Damage to the penis: In rare cases, the head of the penis can be injured during a circumcision. However, precautions doctors take almost always prevent this from happening.

When your child is having any kind of procedure or surgery, it's understandable to be a little uneasy. But it helps to know that circumcisions are common procedures and complications are rare. A child who has a circumcision typically heals without any difficulty or health problems. If you have any questions about circumcision, talk with your doctor.