8 common questions about newborn circumcision
As the medical benefits of male circumcision become more widely known, it is important to dispel the myths and describe the evidence surrounding this traditional surgical practice
5. When is the best time to perform a circumcision?
The medical literature provides no firm answer to this question. The younger the baby, the easier it is to perform a circumcision as a simple procedure with local anesthesia. The older the baby, the larger the penis and the more aware the baby will be of his surroundings. Both these factors will make the procedure more difficult.
Most clinicians would be reluctant to perform a circumcision in the office or clinic after the baby is 6 to 8 weeks old. If a family desires their son to be circumcised after that time—or a medical condition precludes earlier circumcision—the procedure is best performed by a pediatric urologist in the operating room.
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6. What are the potential complications of circumcision?
The rate of circumcision complications is very low: 0.2%.13 That being said, the 3 most common types of complications are postoperative bleeding, infection, and damage to the penis.
Far and away the most common complication is postoperative bleeding , usually at the frenulum of the head of the penis (the 6 o’clock position). In most cases, the bleeding is light to moderate. It is controlled with direct pressure applied for several minutes, the use of processed gelatin (Gelfoam) or cellulose (Surgicel), sparing use of silver nitrate, or placement of a polyglycolic acid (Vicryl) 5-0 suture.
Infection, an unusual occurrence, is seen within 24 to 72 hours after circumcision. It is marked by swelling, redness, and a foul-smelling mucus discharge. This discharge must be differentiated from dried fibrin, which is commonly seen on the head of the penis in the days after circumcision but has no odor or association with erythema, fever, or infant fussiness. True infection should be treated, in collaboration with the child’s pediatrician, with a staphylococcal-sensitive penicillin (such as dicloxacillin).
More serious is damage to the penis, which ranges from accidental dilation of the meatus to partial amputation of the penile glans. Any such injury should immediately prompt a consultation with a pediatric urologist.
More of a nuisance than a complication is the sliding of the penile shaft’s skin up and over the glans. This is a relatively frequent occurrence after normal, successful circumcisions. Parents of an affected newborn should be instructed to gently slide the skin back until the head of the penis is completely exposed again. After several days, the skin will adhere to its proper position on the shaft.
- Just before the procedure, have a face-to-face discussion with the parents. Confirm that they want the circumcision done, explain exactly what it entails, and let them know they will receive complete aftercare instructions.
- Make sure one of the parents signs the consent form.
- Circumcise the right baby! Check the identification bracelet and confirm that the newborn’s hospital and chart numbers match.
- Prevent excessive hip movement by securing the baby's legs. The usual solution is a specially designed plastic restraint board with Velcro straps for the legs.
- Examine the infant’s penile anatomy prior to the procedure to make certain it is normal.
- For pain relief, administer enough analgesia, as either dorsal nerve block or penile ring block (the best methods). Before injection, draw the plunger of the syringe back to make certain that the needle is not in a blood vessel.
- During the procedure, make sure the entire membranous layer of foreskin covering the head of the penis is separated from the glans.
- Watch the penis for several minutes after the circumcision to make sure there is no bleeding.
7. What is a Jewish ritual circumcision?
For their newborn’s circumcision, Jewish parents may choose a bris ceremony, formally called a brit milah, in fulfillment of religious tradition. The ceremony involves a brief religious service, circumcision with the traditional Mogen clamp, a special blessing, and an official religious naming rite. The bris traditionally is performed by a mohel, a rabbi or other religious official trained in circumcision. Many parents have the bris done by a mohel who is a medical doctor. In the United States, the availability of both types of mohels varies.
8. Who should perform circumcisions—obstetricians or pediatricians?
The answer to this question depends on where you practice. In some communities or hospitals, the obstetrician performs newborn circumcision, while in other places the pediatrician does. In addition, depending on local circumstances or the specific population involved, circumcisions may be performed by a pediatric urologist, nurse practitioner, or even out of hospital by a trained religiously affiliated practitioner.
Obstetricians began doing circumcisions for 2 reasons. First, obstetricians are surgically trained whereas pediatricians are not. It was therefore thought to be more appropriate for obstetricians to do this minor surgical procedure. Second, circumcisions used to be done right in the delivery room shortly after delivery. It was thought that the crying induced by performing the circumcision helped clear the baby’s lungs and invigorated sluggish babies. Now, however, in-hospital circumcisions are usually done in the days following delivery, after the baby has had the opportunity to undergo his first physical examination to make sure that all is well and that the penile anatomy is normal.
Clinician experience, proper protocol contribute to a safe procedure
In the United States, a large percentage of male infants are circumcised. Although circumcision has known medical benefits, the procedure generally is performed for family, religious, or cultural reasons. Circumcision is a safe and straightforward procedure but has its risks and potential complications. As with most surgeries, the best outcomes are achieved by practitioners who are well trained, who perform the procedure under supervision until their experience is sufficient, and who follow correct protocol during the entire operation.
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