Mary Ellen T. Dolat, MD
Harry P. Koo, MD, FAAP, FACS
BASICS
DESCRIPTION
• Circumcision is the surgical removal of the foreskin (prepuce) from the penis.
• One of the oldest surgical procedures
• One of the most commonly performed surgical procedures in practice today
• There is some controversy concerning the need for circumcision and potential effects on sexual satisfaction in adulthood. This is weighed against the potential health benefits.
EPIDEMIOLOGY
• Few data are available to help estimate accurately the number of newborns circumcised worldwide.
– Country of origin, ethnicity, religious affiliation, and birth in a rural vs. an urban hospital clearly influences a child’s likelihood of being circumcised.
– In addition, lack of (or the type of) health insurance may influence a child’s likelihood of being circumcised.
• Most common reasons reported by US parents for choosing circumcision
– Health/medical benefits including hygiene (40–60%)
– Social concerns (23–37%)
– Religious requirements (11–19%)
Incidence
• Circumcision rate in newborns has declined from 83% in the 1960s to 77% in 2010.
– These incidence rates do not include out-of-hospital circumcisions
Prevalence
• 79% of men surveyed reported being circumcised (range: 42% for Mexican American; 88% for non-Hispanic Caucasian) (1)
– Prevalence rates are limited by the accuracy of the self-report
RISK FACTORS
• Urinary tract infection
– An increased risk for UTI in uncircumcised males younger than 1 yr; risk being the greatest toward the 1st 6 mo
– Given that the risk of UTI in infant males is ∼1%, the number needed to circumcise to prevent UTI is ∼100
– The benefits of male circumcision are, therefore, likely to be greater in boys at higher risk for UTI, such as infants with underlying anatomic defects
• Need for future circumcision
– Future medical complications for boys (and men) who are uncircumcised as newborns include balanitis, severe phimosis, and paraphimosis.
– For parents, there exists ∼2–5% risk that their sons will need a circumcision for a medical indication if they choose not to circumcise their sons as newborns (2)
• Penile cancer (see “Circumcision, Adult Considerations”)
– The relationship among hygiene, phimosis, and penile cancer is uncertain
– In a Danish study of penile cancer, there was a statistical decline in the rates of penile cancer over a 50-yr period despite a national circumcision rate of 1.6%. These data correlated with better penile hygiene resulting from improvements in sanitary conditions.
– Based on the low incidence of penile cancer in Israel (high prevalence of circumcision) and in Scandinavian countries (low prevalence of circumcision), 2 ways of preventing penile cancer:
Remove the foreskin
Practice good penile hygiene
• Sexually transmitted disease (refer to the Chapter, “Circumcision, Adult Considerations”)
Genetics
N/A
PATHOPHYSIOLOGY
• Prepuce serves as a specialized, junctional mucocutaneous tissue marking the boundary between mucosa and skin; it is similar to the eyelids, anus, and lips.
• Most neonates have a physiologic phimosis
• During childhood, the growth of the penile body, accumulation of epithelial debris, and intermittent penile erections eventually separate the prepuce from the glans, permitting retraction
• During the 1st 6 mo of life, there are more uropathogenic organisms around the urethral meatus of an uncircumcised male infant than around those of circumcised male infants; this colonization decreases in both groups after the 1st 6 mo (3)
• Boys with vesicoureteral reflux who are uncircumcised have a higher risk of UTI
ASSOCIATED CONDITIONS
• Phimosis
• Paraphimosis
GENERAL PREVENTION
Gentle periodic retraction during the newborn period will help prevent phimosis for the inability to retract foreskin later in life
DIAGNOSIS
HISTORY
• Prior history of posthitis or balanitis
• Prior history of meatitis
• Report of “ballooning” of the distal foreskin during voiding
• Prior history of circumcision
– Incomplete removal of foreskin
– Iatrogenic phimosis
• Some parents report “infected whitish pus,” which in most instances is due to normal secretion of smegma
PHYSICAL EXAM
• In newborns, perform a complete male genital exam
– In rare instances, a well-formed phallic structure in a baby with nonpalpable testes may be due to congenital adrenal hyperplasia
• Look for penile developmental variations that may be a contraindication of a newborn circumcision (see “Differential Diagnosis”)
• Some instances with newborns with incomplete foreskin development (ie, does not have natural phimosis), may still be amenable to a newborn clamp circumcision
– Recommend obtaining a pediatric urology consultation to determine whether the baby would be a candidate for newborn circumcision
DIAGNOSTIC TESTS & INTERPRETATION
Lab
Not necessary unless there is suspicion for intersex anomaly
Imaging
Not necessary unless there is suspicion for intersex anomaly
Diagnostic Procedures/Surgery
Not necessary unless there is suspicion for intersex anomaly
Pathologic Findings
N/A
DIFFERENTIAL DIAGNOSIS
• The penis should be carefully examined before the procedure to identify the following conditions that may preclude a circumcision
– Webbed penis
– Microphallus
– Chordee
– Epispadias
– Hypospadias
– Megameatus intact prepuce (MIP) variant of hypospadias
The foreskin is normally developed; the abnormal urethra is noted after the foreskin has been pulled back (or after the neonatal circumcision has already been performed)
TREATMENT
ALERT
In cases of Disorders of Sexual Development (DSD) with sex assignment concerns or significant anomaly such as hypospadius the infant should not undergo neonatal circumcision.
GENERAL MEASURES
• The AAP states that: The health benefits of newborn male circumcision outweigh the risks but the scientific evidence is not strong enough for the AAP to recommend routine circumcision of all newborns. The AAP advises parents to learn the facts about circumcision and weigh the risks and benefits.
• Most routine circumcision is performed between 2 and 10 days of life.
• Contraindications to newborn circumcision include:
– Congenital penile anomalies (see “Differential Diagnosis”)
– Significantly premature infants
– Blood dyscrasias
– Babies with a family history of bleeding disorders
– Disorders of Sexual Development (DSD)
• Relative contraindications to newborn circumcision:
– Incomplete foreskin development
– Prominent suprapubic fat pad (retrusive penis)
MEDICATION
First Line
• Analgesia is safe and effective in reducing the procedural pain associated with newborn circumcision
– Dorsal penile nerve block
1% lidocaine without epinephrine
– Subcutaneous ring block
1% lidocaine without epinephrine
– Topical cream may cause a higher incidence of skin irritation in low–birth-weight infants
Lidocaine–prilocaine (2.5% lidocaine and 2.5% prilocaine) applied for 30–40 min
ALERT
Epinephrine should not be used for pediatric circumcsion.
Second Line
• Nonpharmacologic techniques (eg, sucrose pacifier) alone are insufficient to prevent pain and are not recommended as the sole method of analgesia
– Sucrose on a pacifier has been demonstrated to be more effective than water alone for decreasing crying during circumcision (2)
SURGERY/OTHER PROCEDURES
• Common methods for the newborn circumcision
– Gomco clamp
– Plastibell
– Mogen clamp
• After the newborn and infant periods, circumcision is performed under general anesthesia
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
N/A
Complementary & Alternative Therapies
Traditional religious providers perform the procedures in community settings
ONGOING CARE
PROGNOSIS
Some groups believe that circumcision may reduce or increase the sensitivity of the tip of the penis, potentially impacting sexual pleasure later in life. The data are conflicting and mostly these subjective findings are not conclusive.
COMPLICATIONS
• Large US hospital-based studies estimate the risk of a significant acute circumcision complication to be between 0.19–0.22%.
• From neonatal circumcisions using clamp techniques
– Gomco clamp
Mainly related to technical factors
Insufficient or inadequate skin removal requiring additional revision procedure
Since the met al bell completely covers the glans, glans injury is extremely rare
– Plastibell
Incomplete circumcision
Retained Plastibell ring
– Mogen clamp
Potential for injury to glans, including partial amputation
• Immediate complications
– Significant bleeding (0.08–0.18%)
Postcircumcision bleeding may be the 1st manifestation on an underlying bleeding disorder
– Significant infection (0.06%)
– Significant penile injury (0.04%)
• Late complications
– Phimosis (iatrogenic)
– Adhesions
– Skin bridges
– Excess foreskin
– Insufficient penile skin
– Penile inclusion cysts
– Meatal stenosis
– Penile torsion
– Urethrocutaneous fistula
FOLLOW-UP
Patient Monitoring
• A small amount of petroleum jelly may help with discomfort due to diaper friction the 1st few days postop.
• Bandaging is optional after the 1st 1–2 days.
• Healing usually take place within 10 days.
• Clean site with warm water and avoid baby diaper wipes.
Patient Resources
American Academy of Pediatrics. Patient Education ONLINE. www.patiented.aap.org
REFERENCES
1. Nelson CP, Dunn R, Wan J, et al. The increasing incidence of newborn circumcision: Data from the nationwide inpatient sample. J Urol. 2005;173:978–981.
2. Lerman SE, Liao JC. Neonatal circumcision. Pediatr Clin North Am. 2001;48:1539–1557.
3. American Academy of Pediatrics Task Force on Circumcision. Circumcision policy statement. Pediatrics. 2012;130(3):585–586.
ADDITIONAL READING
• Cold CJ, Taylor JR. The prepuce. BJU Int. 1999;83 suppl 1:34–44.
• Perera CL, Bridgewater FH, Thavaneswaran P, et al. Safety and efficacy of nontherapeutic male circumcision: A systematic review. Ann Fam Med. 2010;8:64–72.
• Weiss HA, Larke N, Halperin D, et al. Complications of circumcision in male neonates, infants and children: A systematic review. BMC Urol. 2010;10:2.
See Also (Topic, Algorithm, Media)
• Circumcision, Adult Considerations
• Circumcision, Pediatric Considerations Images 
• Disorders of Sexual Development (DSD)
• Hypospadias
CODES
ICD9
V50.2 Routine or ritual circumcision
ICD10
Z41.2 Encounter for routine and ritual male circumcision
CLINICAL/SURGICAL PEARLS
• Make sure to carefully inspect the penis for any congenital defects such as hypospadias or chordee before proceeding with neonatal circumcision. It is best to delay circumcision until the primary defect can be repaired as the foreskin may be used in reconstructive procedure.
• The choice of neonatal circumcision is a matter of the physician’s personal preference. For circumcisions using a Gomco clamp, or Plastibell, select the correct size of the bell; this would ensure adequate foreskin removal.
• Always consider the cultural and religious beliefs of the family when counseling about newborn circumcision.