Circumcision

and Care of the Infant Penis

by

Richard M. Parker, M.D.

Circumcision is the removal of the foreskin (prepuce)... which is the covering over the head (glans) of the penis. There are many facts, opinions and controversies about circumcisions and proper care of the penis in newborns. In this discussion I will describe the benefits and problems of circumcision, as well as the absolute contraindications and alternatives to the procedure.

What are the benefits of circumcision?...The prepuce in normal newborn males completely covers the head (glans) of the penis and is attached to the glans . It is normal not to be able to retract the foreskin at birth, although by age five, the foreskin has at least partly separated from the glans and can be retracted in 80-90% of boys. Complete separation may not occur until later.

Some children with an intact foreskin develop narrowing of the prepuce (phimosis) such that the foreskin cannot be retracted. They may also develop infections of the glans and foreskin (balanoposthitis). In addition to these "local" problems, uncircumcised infant boys develop urinary infections 10-20 times more often than those who are circumcised. Bacteria living on the inner surface of the foreskin pass into the urinary tract, where infection, especially if it involves the kidneys, can be life threatening. Good evidence exists that uncircumcised adults are also more susceptible to urinary tract infections.

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Certain venereal diseases, including gonorrhea, syphilis, chancroid and herpes are probably more frequent in uncircumcised men, although not all studies confirm this. Investigations from Africa show that HIV may be more easily transmitted to the non-circumcised. Cancer of the penis occurs almost exclusively in non-circumcised males.

A common "social" reason for circumcision is to have a child "look like Daddy." There are also religious and cultural reasons for many circumcisions. The majority of men in the United States have been circumcised, but this is not the case in Europe.

Ten percent or more of non-circumcised older children or adult males will eventually need a circumcision because of phimosis, penile infections or hygiene concerns, and they usually regret not having been circumcised earlier.

About the surgical procedure...Neonatal circumcision is the most common surgical procedure in childhood. As with any operation, there is some pain which causes increased crying, an elevated heart rate, as well as measurable hormonal changes. Most pediatric urologists believe that the use of local penile anesthesia prior to surgery decreases pain and should be used. It can be given by injection at the base of the penis, into the tissue to be cut, or topically with an anesthetic cream. An infant undergoing circumcision can be comforted by sucking on a nipple with sugar solution, and this also helps with pain. Thereafter, an instrument is placed around the head of the penis, and the foreskin is cut and removed; antibiotic ointment or a Vaseline gauze is used to cover the incision. The procedure usually takes about 10 minutes when done by an experienced person.

What are the complications of circumcision?...Complications vary from 0.2% to 5.0% in different reports, but are closer to 0.2% with experienced operators. They include pain, bleeding, infection, penile adhesions (skin attachments) from the glans to residual foreskin, penile chordee (bending), cysts at the incision site, fistulae (communication) from the urtethra to skin, meatitis, (infection at urethral opening) with subsequent narrowing of the meatus, and even amputation of the glans. Two commonly-used instruments, the Gomco clamp and the Plastibell, have a protective bell for the glans. The safest approach includes complete freeing of the glans and foreskin.

The most common technical problem of circumcison is insufficient removal of the foreskin, which can lead to phimosis (narrowing) of the residual foreskin opening and the cosmetic problem of looking uncircumcised. Removal of too much skin produces a shortened penis, or one which looks hidden in the lower abdominal fat (buried penis).

Complications from penile injection of local anesthesia include bleeding at the site of the needle puncture, or injection into the vascular spaces of the penis, with the possibility of severe life-threatening cardiac effects.

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What are the contraindications to circumcision?...Reasons not to consider circumcision at birth include a sick, unstable child, a family history of a bleeding disorder, any penile anomaly such as hypospadias (incomplete development of the penile urethra usually associated with an incomplete foreskin), penile chordee (bending), or torsion (twisting). Reasons to hesitate to circumcise include a large hernia or hydrocele with scrotal swelling, a small penis, and a webbed or concealed penis in which the penis is pulled into the lower abdominal fat and is hidden.

Special attention needs to be given to a less obvious form of hypspadias where a complete foreskin totally covers the glans, but an overly-large urethral opening (megameatus) exists. A practitioner who begins a circumcision thinking the penis is normal and finds an anomaly, should stop the procedure, and if possible, suture the foreskin back together.

Despite the formidable list of complications, the experienced person can prevent most complications, handle surprises properly and make circumcision a low-risk procedure.

When can a circumcision be done?...The decision to circumcise is usually made before birth or within 24-48 hours afterward. While you need to check with your insurer about outpatient coverage, the medical decision to circumcise can be made at any time during the first month of life. After the first month or two, circumcision becomes riskier and more expensive, often requiring general anesthesia and a brief hospitalization. Try to avoid this situation.

What is the best way to care for the uncircumcised penis?...If you decide to leave your son's forekin in place, learn and practice appropriate penile and foreskin care. A 1986 brochure from the Academy of Pediatrics describes care of the uncircumcised newborn penis as being "quite easy" and indicates that "leave it alone is good advice". Without trying to retract the foreskin, gently cleanse the outside of the penis. Forcible retraction is unneccesary since the foreskin spontaneously separates from the glans with age. You will start to see whitish "smegma"( old, dead skin from the prepuce) appear beneath the foreskin and on the glans penis. This helps to naturally separate the foreskin and glans over the years and is normal. After the foreskin separates (usually by the age 3-5 years), boys can learn to wash the glans by retracting the foreskin.

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Summary...The benefits of circumcision (Table 1) accumulate over a lifetime and help to prevent numerous diseases, while the risks (Table 2) are immediate and generally short-term. My own views are that the long-term medical benefits are greater than the risks.

Nevertheless, neonatal circumcison has generated much controvery, and some even believe that this procedure may affect subsequent sexual function in men. I believe that neonatal circumcision is a procedure to be performed at your discretion after much thought and informed consent. The decision is yours and needs to be based on the best current knowledge of the probable benefits and complications, as well as nonmedical, social, and religious considerations. I hope that I have made your work easier.


Table 1...Advantages of Neonatal Circumcision

  1. Prevent local penile problems of infection of the glans (balanitis) and inability to retract the foreskin due to narrowing (phimosis) of the prepuce.
  2. Decreased incidence of urinary tract infections in infants and adults.
  3. Decreases the chance of acquiring veneral disease and possibly HIV.
  4. Prevents development of cancer of the penis (rare).
  5. Prevents need for secondary circumcision as an older child or adult (10%).
  6. Social reasons.

Table 2...Risks of Neonatal Circumcision

  1. Pain, bleeding and infection from the operation.
  2. Technical surgical problems, with removal of too little or too much skin and development of penile adhesions.
  3. Meatal stenosis.
  4. Complications due to local anesthesia.
  5. Inexperienced operator.

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PUA Title

Richard M. Parker, M.D., F.A.A.P., F.A.C.S.
Parker@PedsUroLogic.com