Circumcision

A circumcision is a surgical procedure that removes the foreskin (the loose tissue) covering the glans (rounded tip) of the penis.

• Circumcision may be performed for religious or cultural reasons, or for health reasons.
• Newborn circumcision is thought to diminish the risk for cancer of the penis and lower the risk for cancer of the cervix in sexual partners.
• It is also believed to decrease the risk of urinary tract infections in infants and lower the risk of certain sexually transmitted diseases, especially HIV.

Circumcision is generally a safe surgical procedure if the following conditions are met:

• The circumcision is performed carefully, using a strict aseptic (sterile) technique.
• The circumcision is performed by a trained, experienced practitioner.
• The circumcision is performed only on a healthy, stable infant.
• There is no medical reason not to have the circumcision performed (see below).

The circumcision may be performed using surgical clamp techniques or with a special disposable plastic device called a Plastibell. The results are equally good.

• Pediatricians and occasionally the mother's ob-gyn will perform the circumcision of a normal newborn infant. A pediatric urologist will circumcise an older infant/child or may perform circumcision as part of a reconstructive genital surgery procedure.
• In the Jewish tradition, a mohel may be selected to circumcise a healthy newborn. A mohel receives special training in performing a circumcision, as well as the religious rituals that accompany the procedure.

Following completion of the circumcision, the practitioner may apply gauze impregnated with petroleum jelly. You should follow any instructions regarding the care of the infant given to you by the practitioner, and these might include the following:

• Generally it is recommended that the area be cleaned several times a day with warm water.
• At each diaper change, you can apply a small amount of unscented petroleum jelly, or your doctor might recommend application of an antibiotic ointment as well. Petroleum jelly should not be used on a Plastibell unless directed to by your physician.
• It may take up to seven to 10 days for the area to heal.
• After the region has healed, no further care is required except for normal hygiene.
• At the first well-baby visit following hospital discharge, the penis should be carefully examined by the doctor and the parents given more information concerning further care.

Newborns who have a circumcision without analgesia (medication for pain relief) respond in ways that strongly suggest that they do feel pain and experience stress.

• They show changes in heart rate, blood pressure, and oxygen saturation, as well as changes in cortisol levels and behavioral changes.
• The behavioral changes include crying at the time as well as changes in sleep patterns and mother-child interactions that are temporary and disappear within 24 hours of the procedure.

Analgesia has been found to be safe and effective in reducing the pain associated with circumcision and should be provided if the procedure is performed.

• Analgesic methods include EMLA cream (a topical mixture of local anesthetics),
• the dorsal penile nerve block, and
• the subcutaneous ring block.

Several studies also demonstrate pain reduction if the infant sucks on a pacifier dipped in a low concentration of sucrose (table sugar) solution. Often several anesthetic techniques (for example, dorsal nerve block and oral sucrose solution) are provided at the same time.

Unstable or sick infant: Circumcision is contraindicated if the baby is unstable or sick. Circumcision is elective surgery and, as with other medically elective procedures, it should be delayed until the baby is well. Signs of stability include normal feeding, waste elimination, and maintenance of normal body temperature without an incubator or radiant warmer.

A period of observation after the infant's birth may allow for recognition of abnormalities or illnesses (for example, serious jaundice, infection, or manifest bleeding disorder) that should be addressed before this elective surgery.

Prematurity: It is usually best to wait until a premature infant meets the criteria for discharge from the hospital before performing circumcision.

Genital anomalies: Infants born with genital anomalies (including one called hypospadias) should not be circumcised. The foreskin may be needed for the surgical correction of the anomalies.

Bleeding problems: Whenever there is a family history of bleeding disorders, appropriate laboratory studies should be performed to make certain the baby himself has not inherited the bleeding disorder. All newborns should receive an injection of vitamin K immediately after birth to stimulate the child's blood coagulation system. Orally administered vitamin K has not been shown to have the same effectiveness as the injected form.

Large-scale studies indicate that the rate of complications is low, ranging from one in 200 to one in 500. The most common complications are local infection and bleeding. Complications due to local anesthesia consist mainly of hematomas (bruises) and local skin necrosis (damage and loss).

Deaths attributable to newborn circumcision are rare. No deaths occurred, for example, in an analysis of 500,000 circumcisions in New York City or 175,000 circumcisions in U.S. Army hospitals.

The American Academy of Pediatrics states: "Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it."