Newborn male circumcision is a topic that remains controversial in pediatrics, and overall the AAP has maintained a neutral stance on it. The most recent AAP report, issued in 2012, stated that overall, male circumcision has adequate benefits compared to risks to “justify access to the procedure for families who choose it.” In Washington State, families who choose circumcision must pay for the procedure out of pocket. At the UW Northgate Clinic, one of the available local sites, it costs about $300.
Materials for this week:
- Case discussion
- Male Circumcision AAP Technical Report 2012
- Circumcision Policy Statement AAP 2012 – co-authored by Dr. Doug Diekema
- Neonatal circumcision videos and photos (includes common procedures and complications), Stanford Newborn Nursery
Key take-home points:
- What are the main benefits and risks of circumcision? Benefits include decreased risk of UTI before age 2, and decreased risk of heterosexual transmission of STIs including HIV, HPV, HSV-2, and bacterial vaginosis in female partners. It may reduce the risk of penile cancer, which is rare overall. Complication rate is about 0.2% and mostly minor, including bleeding (0.1%), infection (0.06%) and penile injury (0.04%). There are also known later complications, such as adhesions, phimosis, inclusion cysts, and poor cosmetic outcome. Contraindications include known bleeding disorders, penis malformations including chordee, hypospadias, epispadias, and buried penis.
- What are the 3 most common circumcision procedures? There are many types of approaches/devices, but the Gomco, Plastibell and Mogen (or Mogan) are the most commonly used (see videos above for all 3). Gomco and Mogen use scalpel dissection to cut the tissue and have a higher risk of bleeding. Plastibell technique uses a tying off of tissue with the Plastibell ring (minus handle), residual foreskin, and suture remaining on the glans and falling off in 5-7 days. All procedures should have appropriate analgesia, ideally with a dorsal penile or subcutaneous ring block, less helpful is topical lidocaine/prilocaine. Adjunctive oral sucrose can be used but should not be the sole analgesia.
- What key anticipatory guidance should we provide regarding circumcision care? After circumcision, the glans can appear red and raw appearance from lysing foreskin adhesions, which can be somewhat worrisome to parents. Swelling peaks 24-48 hours after the procedure and there may be fibrinous exudate as the glans heals. Parents should clean with warm water and mild soap if fecal material gets on the penis. Fortunately, infection is rare; observe for increasing redness, swelling, pain or purulent discharge. For circumcisions done with sharp dissection (Gomco or Mogen), parents should apply petroleum jelly on a gauze pad over the penis tip with each diaper change for 1-2 weeks until the skin is epithelialized. Plastibell circumcisions do not require vaseline but observe for slippage of the bell or difficulty urinating.
- When is referral indicated for management of circumcision problems? What about for later circumcision? Most often referral to urology after circumcision is for addressing redundant foreskin, meatal stenosis, and adhesions or skin bridges. Later medical circumcision might be considered for recurrent UTI, phimosis or paraphimosis, or high risk of UTI (high grade vesicoureteral reflux, bladder neck obstruction hydronephrosis, posterior urethral valves).
- What advice do we give about care for the uncircumcised penis? The only care needed is washing the external surface with soap and water and not retracting the foreskin, which can cause pain, bleeding and lead to paraphimosis, when it becomes stuck in the retracted position. Only 4% of uncircumcised infants have completely retractible foreskin initially. Most babies have physiologic phimosis (inability to retract the foreskin), which usually resolves by age 3 in about 90% of boys, and by teenage years in almost all boys.