Neonatal Circumcision

Lianne Beck, MD
Assistant Professor
Emory Family Medicine
Adapted from
Josephine R Fowler, MD MSc

Objectives

Epidemiology of Circumcision
View Organizations statements on circumcision.
Review indications for circumcisions.
Review risks associated with circumcision.
Review evidence for anesthesia and/or analgesia
during procedure.
Review most common methods.

Foreskin Embryology
Development of prepuce between week 8 and 16
in utero
Prepuce mucosa and glans are contiguous
Exfoliation of underlying epithelium in a proximal
direction leads to resolution of the physiological
adhesions and formation of a preputial sac
Usually complete by 3 - 5 years but may continue
until puberty

Natural History
Work by Gairdner
1949 and Oster 1968
Less than 1% of boys
require a circumcision

Epidemiology
Circumcision rate varies by

Geographic region ( 1 in 6 worldwide)

Religious affiliation
Socioeconomic classification
Uncommon in Asia, S. America, Central America,
Europe
48% circumcised in Canada
>80% in US in 1980 and declining
Whites > blacks or hispanics
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AAFP, AAP, ACOG

The AAFP recommends physicians discuss the potential harms and
benefits of circumcision with all parents or legal guardians
considering this procedure for their newborn son.
AAP -Parents should determine what is in the best interest of the
child. They should be given unbiased information and be provided the
opportunity to discuss this decision.
ACOG- Existing literature is inadequate to evaluate appropriately
routine circumcision of the newborn infant.
All agree evidence is insufficient to support routine circumcision.
All agree anesthesia is warranted.
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Recent Studies Supporting Health Benefits

In three recent RCTs involving about 10,000 HIV-negative
men (age range, 1849) in Africa, circumcision decreased
male heterosexual acquisition of HIV disease by 53% to 60%
compared with uncircumcised men during an average followup of 1.5 to 2 years .
In two trials, circumcision decreased acquisition of HSV type
2 infections by 28% to 34% and penile HPV infections by
32% to 35%.
Some evidence suggests that female benefits of male
circumcision include a decrease in transmission of BV,
trichomoniasis and HIV.

Neonatal Circumcision
Most common surgical
procedure performed in
US.
1 million/year in the US.
Evidence conflicting on
risk and benefits.
Most decisions based on
nonmedical reasons
(religious, ethnic, cultural,
cosmetic).

Complication rate 0.1% to

35%.
Infection (0.2-0.4%)
Bleeding (usually minor)
Failure to remove enough
foreskin
Meatal stenosis
Necrotizing fasciitis
Urethral fistula
Partial penile amputation
Penile necrosis
Concealed penis
Death
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Indications
True indications rare!
Penile cancer (cannot predict which babies will develop
cancer)
Recurrent balanitis (esp. diabetics)
Phimosis (cannot be diagnosed in newborn period)

Optimal Timing and Contraindications

12-24 hours post
delivery.
Evaluate for
hyperbilirubinemia,
infection, bleeding
diathesis.
Make sure infant has
voided.

Contraindications:

Congenital penile abn

Prematurity
Bleeding disorder
Medical problem

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Infection and Circumcision

Among infants less than 3 months of age, male infants
account for 75% of UTIs.
An uncircumcised male has a 3 to 20 times risk of
developing a UTI compared to a circumcised male but
absolute risk increase only 1%. (NNT =90-195)
Studies relating association with STDs inconclusive.
Studies in Africa show an association between contracting
HIV and being uncircumcised.
Evidence supporting association between circumcision
status and risk of developing cervical cancer is inconclusive.
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Does Circumcision Prevent Penile

Cancer?
SCC penis is rare
Neonatal circumcision is protective whereas adult
circumcision is not.
Studies estimate that 600-900 circumcisions are
needed to prevent one lifetime case of penile
cancer
Probably related more so to poor hygiene
Confounders (smoking, phimosis, genital warts,
multiple partners)
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Sexual Functioning
Prepuce is filled with nerve endings similar to lips or fingers
(much more so than the glans)
Circumcision permanently inhibits sexual function ?
Glandular skin undergoes hyperkeritinization
An investigation of the exteroceptive and light tactile
discrimination of the glans of circumcised and uncircumcised
men found no difference on comparison.
No valid evidence to date, supports the notion that being
circumcised affects sexual sensation or satisfaction.

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Physician Views About Pain

Pain of injecting medication may be
greater than procedural pain.
Newborns do not feel or remember pain.
Potential side effects of analgesic agent too
harmful for neonate.

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Studies Reviewing Perception of Pain in the

Neonate During Circumcision
Infants exhibit
physiological changes
associated with pain.

HR
BP
cortisol levels
O2 saturation
changes in interaction
and feeding

Current standard of care in most

sites - no anesthesia.
Greater increase in HR and
crying (no anesthesia vs.
DPNB) Williamson and
Williamson, 1983

Decreased motor performance

and responsiveness after
procedure Dixon et al., 1984
Circumcised infants have
stronger pain response to
vaccines later compared to noncircumcised infants Taddio et al,
March 1997
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Methods of Pain Reduction During Neonatal

Circumcision
Technique:
Mogen < Gomco (shorter
procedure)

Pacifier +/-sucrose
reduced crying with water
moistened pacifier
better with sucrose
less elevation of HR but not
sufficient analgesia for
neonatal circumcision

Tylenol
did not significantly alter
intraoperative pain
parameters

EMLA (2.5% lidocaine and

2.5% prilocaine applied 60 to
90 min before procedure)
concern about local
irritation, uneven
absorption, systemic
toxicity
apply under adhesive
dressing for > 45 minutes
potential risk of
methemoglobinemia
Limited anesthesia during
tissue lysis of adhesions
and tightening of clamp

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Studies Reviewing Perception of Pain in the

Neonate During Circumcision (Cont.)
Dorsal Penile Nerve
Block
requires 3-5 min wait
multiple studies document
significant reduction in pain
and improved postoperative
behaviors
45% to 76% less crying
rare, mild complications
(local bruising, hematoma)

Subcutaneous and penile

ring block
SQ ring of 0.8cc- 1.0cc plain
0.5% lidocaine above corona
subcutaneously and
circumferentially
equally effective at all stages
of procedure
diminished pain response
no reported complications
may be most effective
anesthetic
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Looking at the Data

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Comparing Agents

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Comparisons
Padded restraints better
than rigid plastic
Sucrose + EMLA more
effective than no
intervention
DPNB better pain
reduction than EMLA
SQ local block simpler to
perform and provides
good pain reduction

Ring block more effective

than DPNB which is more
effective than EMLA,
which is better than
placebo in reducing
elevation in HR, and high
pitched cry.

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Basic Steps in Circumcision

Parental counseling and consent

Ritual?
Parent presence?
Conflicts?
Examine the glans
Prepare clean/sterile environment
Prevent Pain
Take down adhesions
Place device
Remove foreskin
Prevent Bleeding
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Choosing the Right Surface

Pad board with blankets or
other thick soft materials.
Restraint boards in semireclining position have
been shown to decrease
distress.

22

Swaddling
Swaddle the upper body
and legs to provide
warmth or use a radiant
warmer.
Consider soft music
before, during, and after
the procedure.
Provide human swaddling
and comfort after the
procedure.

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Preparation
Use betadine to clean
area where anesthesia
will be applied if using
a block, penile shaft,
and glans.

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Anesthesia

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Anatomy of the Penis

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Dorsal Penile Block

27 gauge needle or TB syringe is
used to inject 0.4 cc of 1%
lidocaine at 10- and 2 oclock
positions at the base of the penis.
Needle directed posteromedially 3
to 5mm until Bucks fascia is
entered at base of penis.
Allow 3 to 5 min before
proceeding.
Anesthesia lasts 1-2 hours
Bruising is the most common
complication.
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Subcutaneous and Ring Block

0.8 to 1.0 cc of 0.5-1.0%
lidocaine without
epinephrine.
Inject SQ along shaft at
2,10 and ventral surface
(very superficially).
Alternatively inject a
small ring immediately
adjacent to the corona.

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Apply Sterile Drape

Draping keeps area clean
and provides a clean
environment to place
instruments during
procedure.

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The Gomco clamp

Introduced in 1935
Concerns
Choosing the right size bell
Average infant requires 1.3 size
(1.1,1.3,1.45,1.6)
Bell should completely cover
glans without overly distending
the foreskin
Always check bell and plate to
make sure they match
Technique gives better cosmetics
Do not perform if <1 cm penile
shaft

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Circumcision Step 1
Lysis of adhesions
Probably causes the most discomfort, if not
adequately anesthetized
Usually done with clamps at 3 and 9 oclock
and hemostat gently placed between skin and
fascia in an open and closing motion
Special care taken to avoid bleeding at the level
of the frenulum
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Gomco Step 1
Dorsal crush and slit

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Gomco Step 2
Insertion of bell over
glans
Insert safety through
both foreskin and
mucosa

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Gomco Step 3
Grasp edge of dorsal
slit and insert the arm
of the bell through the
hole of the plate.
Use a hemostat to pull
foreskin through base

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Gomco Step 4
Pull the foreskin
upwards and adjust the
bell and base plate.
Make sure bell stays under
the foreskin and over glans
Apex must be visible above
plate

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Gomco Step 5
Assemble yoke of
clamp to arm of the
bell.
Apply nut to connect
top plate with base
plate.

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Gomco Step 6
Excise foreskin near
base of plate on top
surface.

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Disassembling the Gomco Plate

Remove the nut from
the plate
(note sufficient
tightening produces a
suction after the
procedure)
Take a 2x2 and gently
release suction

38

Gomco Final Step

Push remaining
foreskin to just above
the corona.
Do not retract back too
far (leads to bleeding
if pulled back too far)

39

Mogen Clamp
Designed in 1954
Most commonly used by
mohels for ceremonial
circumcision
Has the advantages of being
rapidly performed and not
leaving a foreign body at the
circumcision site.
The disadvantage is that the
device does not directly protect
the glans during the procedure.

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Mogen Step 1
Separate the glans from the
preputial lining.
Lift the prepuce upward and
outward (this causes the glans
to retract towards the scrotum).
The open jaws of the Mogen
clamp are placed around the
prepuce (grooved side facing
the glans) as it is lifted
upwards.

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Mogen Step 2
Close clamp for 1 1
minutes.
Excise the prepuce distal to the
clamp.
Open the clamp slowly and
remove.

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Mogen Final Steps

Downward pressure is applied
to the preputial skin around the
corona until mucosal seal is
broken and glans is liberated.
Use a blunt probe to release any
additional adhesions.
As infant ages dog ears become
less prominent.

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Plastibell Technique
Introduced in the mid 1950s
Has the advantage of continuing
hemostasis after the procedure
is over, as the suture remains in
place for a few days.
Disadvantage is that there is a
foreign body at the site, which
could become dislodged or
infected.

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Online Videos
http://newborns.stanford.edu/Plastibell.html
http://newborns.stanford.edu/Gomco.html
http://newborns.stanford.edu/MogenIntro.ht
ml
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What if Bleeding Occurs?

Use a small gauze to apply pressure to the
area that is bleeding.
May use adrenaline on gauze.
Sometimes may require a small interrupted
suture with 6-0 absorbable suture.

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Indications for Discharge

Baby is not bleeding.
Most nurseries require that the baby has
voided.

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Summary of Evidence of Benefit

Neonatal circumcision prevents UTIs in the first year of
life with an absolute risk reduction of about 1%
Prevents the development of penile cancer with an absolute
risk reduction of less than 0.2%.
The evidence suggests that circumcision reduces the rate of
acquiring an STD, but careful sexual practices and hygiene
may be as effective.
Circumcision appears to decrease the transmission of HIV
in underdeveloped areas where the virus is highly
prevalent.
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Summary
No clear cut reason for routine neonatal circumcision.
One of the oldest medical surgeries.
Circumcision is a surgical procedure associated with pain,
stress, risks and benefits.
Provide adequate information to parents so they can make
the best decision possible for their baby.
Anesthesia can ease majority of discomfort.
Nonpharmacological means of comfort are equally
important.
Any technique can be done effectively in skilled hands.
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References
www.aafp.org/online/en/home/clinical/clini
calrecs/circumcision.html

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