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The Circumcision Mystique

The Circumcision Mystique: To Cut or Not to Cut, Is That the Question?

Circumcision remains the most commonly performed procedure in the United States. It has also been the subject of intense controversy in terms of opinions for and against routine newborn circumcision.

In 1975 the American Academy of Pediatrics (AAP) amended their 1971 policy by stating “there is no absolute medical indication for routine circumcision in the newborn.” This position was repeated in 1983 by both the AAP and the American College of Obstetrics and Gynecology. As a result of this posturing, many insurance companies have refused to pay for this procedure. Approximately 70% of all newborns in the U.S. still undergo routine newborn circumcision, costing upwards of $200 million dollars per year. By the mid to late 1980’s Wiswell and colleagues demonstrated that uncircumcised male newborns had a greater than ten-fold increased risk for urinary tract infection (UTI) compared to the circumcised male. This information caused the AAP task force on circumcision to re-examine its earlier stance.

In 1999 the American Academy of Pediatrics in a policy statement recognized the potential benefits of newborn circumcision, however, these benefits were not considered great enough to recommend routine neonatal circumcision. Because they recognized that the “procedure is not essential to the child’s current well-being parents should determine what is in the best interest of the child.”

What is the natural history of foreskin?

At birth, the prepuce and glans penis are essentially fused together and can be retracted in less than 10% of newborns. The separation of the prepuce from the glans is a process that begins at birth and may take up to adolescence to complete. By age 6 years, approximately 90% of children can retract the foreskin at least to the proximal glans. Phimosis is NOT a pathological problem in young children unless associated with balanitis or, rarely, urinary retention. Because of the physiologic separation of prepuce and glans over time, it is not recommended to actively retract the foreskin in the infant or child as this may lead to pain, bleeding, and, not uncommonly, a true phimosis secondary to preputial scarring at the distal margins. Simply external rinsing or washing of the prepuce is sufficient until puberty, at which time the adolescent learns to retract the foreskin and cleanse himself daily. The aforementioned recommendations are printed in the AAP brochure on Care of the Uncircumcised Newborn.

Advantages of the Newborn Circumcision

Presently newborn circumcision has been compared to immunization from the viewpoint that side effects and complications are usually immediate and minor but whose benefits increase over one’s lifetime. Benefits include pro-tections against UTI in infancy, prevention from balanoposthitis (common around age 3-5 years) and prevention of true phimosis or paraphimosis. Genital hygiene is a non issue in circumcised males. Reducing predisposition to HIV, other sexually transmitted diseases and linkage to cervical carcinoma is still unproven and controversial at this writing. There is no question that circumcision is prophylactic against penile cancer later in life. There have been over 50,000 cases of documented penile cancer in the United States since 1930, of which only 9 occurred in circumcised men. Whether this is attributable to poor hygiene or the mere presence of foreskin is still debatable. Finally, newborn circumcision avoids possible later circumcision under anesthesia which carries its own risks.

Arguments against Newborn Circumcision

There are certain congenital conditions in which newborn circumcision is clearly contraindicated. This includes any penile anomaly including hypospadias and chordee without hypospadias. In the majority of these children, an incomplete foreskin is the rule with a dorsal hooded appearance and no ventral prepuce, making the diagnosis easy. However, in about 5% of cases, the male infant will have a complete prepuce, thus hiding the hypospadias anomaly lurking beneath. Hence, any doctor contemplating circumcision must fully retract the foreskin and visualize the meatus to avoid inappropriate circumcision in these babies. Fortunately, due to the particular type of hypospadias these infants have, successful urethral reconstruction can still be performed after circumcision although, as stated, it is much more preferable to leave the prepuce of these babies intact. Additionally, newborn circumcision should not be performed in the presence of a significant penoscrotal web. A free hand circumcision under anesthesia after 6 months of age with lysis of the penoscrotal web will result in a more cosmetically and functional appealing phallus. Circumcision should also be deferred in boys with large hernias/hydroceles, large infrapubic fat pads or in the presence of a diminutive phallus as the penis may retract beneath the abdominal wall creating both an unsightly “umbilical” appearance and potentially lead to a secondary cicatrix phimosis. Sick, premature infants or neonates should also have circumcision deferred. Finally, avoiding newborn circumcision obviates potential complications.

Circumcision Complications

The actual incidence of newborn circumcision is unknown although reported series range from 0.2% to 5%. Unfortunately, much of this morbidity is secondary to the fact that this operation is often delegated to inexperienced or poorly supervised house officers. In most communities, the obstetrician performs the procedure, the pediatrician cares for the wound and the urologist cares for the complications. Most of the complications that we see are avoidable with appropriate knowledge and training, with the ideal training program being multidisciplinary and it should include pediatric urology. Fortunately, most circumcision complications are relatively minor, however, disastrous results have been well recorded.

Anesthesia Complications

In the past, and still very common today, is the practice of circumcision without any anesthesia. Studies have clearly shown significant changes in physiologic parameters of nocioception and pain perception at the time of circumcision including increased cardiac and respiratory rates, elevated cortisol levels, decreased oxygen saturation and infant withdrawal. As a result of thee studies confirming the significant pain of circumcision, many practitioners are now employing dorsal penile nerve blocks by injecting 0.2 – 0.4 ml of 0.5% Lidocaine or 0.25% Bupivacaine (without epinephrine). Aspiration prior to injecting the anesthetic is paramount to avoid intravascular injection and/or corporal injury. If performed properly, significant pain relief is elicited and minimal complications such as transient hematomas occur. The advent of EMLA cream (Eutectic mixture of local anesthetics) has furthered the cause of local anesthesia by simple direct application of this cream one hour prior to the procedure, covering the penis with bio-occlusive dressing to allow the agent to sit and be absorbed. No untoward effects have been seen in our hands thus far and pain relief is excellent.

Intraoperative Complications

(1) Bleeding is the most common intraoperative complication but usually is a minor problem. This can usually be successfully managed by applying pressure for a short period and/or the use of silver nitrate, Surgicel (oxidized cellulose) or 1:200,000 epinephrine solution. Care must be exercised with silver nitrate as it is easy to inure adjacent tissue, especially the underlying urethra. Occasionally some absorbable sutures may be needed to stop the oozing. (2) Removal of too little or too much skin may occur. IF too much shaft skin is removed and insufficient inner preputial skin is removed, fibrosis of the healing preputial ring may result in a concealed penis and possibly a cicatrix phimosis. Wound separation may occur if foreshortening of the penile shaft occurs by excision of too much skin. Fortunately healing by secondary intent usually will allow for an acceptable cosmetic/functional phallus. If however the entire penile shaft is removed, skin grafting may be necessary. Finally, removal of more skin ventrally than dorsally can create chordee secondary to skin tethering. (3) Disfigurement of the phallus has occurred by the inappropriate use of electrocautery on a Gomco clamp which essentially caused necrosis of the entire penis. Gender reassignment was necessary in one case. Amputation of part of all of the glans has occurred with the use of various clamps. Hypospadias/epispadias has occurred at the time of dorsal or ventral slit prior to the actual circumcision. Urethrocutaneous fistulas have resulted from either a clamp or Plastibell type circumcision and also from inappropriate suture placement.

Post-Operative Problems

(1) Recurrent penile adhesions or skin bridges between the penile shaft and glans occur commonly. Painful erections may result and even chordee. Treatment involves surgical division. (2) Infection has been seen in less than 1% of circumcision, most being of minor consequence. However, documented isolated cases of fatal sepsis status post circumcision have been noted. (3) Meatitis is a common post circumcision problem which may develop into full fledged meatal stenosis heralded by a thin, often misdirected, urinary stream. Meatotomy is necessary in the latter case. (4) Penile inclusion cysts secondary to inversion at the skin during healing of the circumcision wound. Simple excision corrects this condition. (5) Penile lymphedema is a fortunately rare, but frightening, complication which can be seen after an infection, wound separation or circumcision revision.

Conclusions?

As the reader can see, circumcision is not a cut and dried issue. Do we circumcise the many to protect the few who will develop problems secondary to intact foreskin? If we know who “the few” are, the answer would be simple. If circumcision is to be done, we believe that barring contraindications, the procedure should be performed in the newborn period after thorough informed consent.

Updated July 2002


CIRCUMCISION POST-OPERATIVE DISCHARGE INSTRUCTIONS

Diet:
May resume regular diet as tolerated.

Activity:
Quiet activity today, then resume normal activity tomorrow as tolerated. No straddle toys for 2 days.

Bathing:
May resume tub baths on day 3 post-op.

Incision Care:
May remove dressing on 3rd day post-op after tub bath (if dressing hasn’t already fallen off on its own). Apply Neosporin ointment to penis 2-3 times a day for 1 week. Sutures, if present, are dissolvable.

Medications:

  • Tylenol (Acetaminophen) ____mg (15 mg/kg/dose) every 4 hours as needed for pain.
  • Antibiotic Ointment 2-3 times a day for 1 week as mentioned above.
  • Other: ____________________________________________

Follow-Up Appointment:
Please call our office for a follow-up appointment in 2 weeks.

Please notify our office or on call MD for any signs & symptoms of infection, such as fever >101, redness or swelling. Also notify for difficulty urinating, excessive bleeding or pain not relieved by Tylenol (Acetaminophen).


The information above, although based on a thorough knowledge and careful review of current medical literature, is the opinion of the doctors at Urology for Children, LLC, and is presented to inform you about surgical conditions. It is not meant to contradict any information you may receive from your personal physician and should not be used to make decisions about surgical treatment. If you have any questions about the information above or your child’s care, please contact our doctors at any time by calling 856.751.7880.