In the United States, circumcision is the fourth most common surgical procedure—behind cataract removal, cesarean delivery, and joint replacement.1 This operation, which dates to ancient times, is chosen for medical, personal, or religious reasons. It is performed on 77% of males born in the United States and on 42% of those born elsewhere who are living in this country.2 Whether it is performed depends not only on the parents’ race, ethnic background, and religion but also on region: US circumcision rates range from 74% in the Midwest to 30% in the West, and in between are the Northeast (67%) and the South (61%).3
Circumcision is not without controversy. Some claim that it is unnecessary cosmetic surgery, that it is genital mutilation, that the patient cannot choose it or object to it, or that it decreases sexual satisfaction.
In this article, I review 8 common questions about circumcision and provide data-based answers to them.
1. Should a newborn be circumcised?
For many years, the medical benefits of circumcision were scientifically ambiguous. With no clear answers, some thought that parents should base their decision for or against circumcision not on any potential medical benefit but rather on their family or religious tradition, or on a social standard, that is, what the majority of families in their community do.
Over the past 20 years, a growing body of evidence has demonstrated real medical benefits of circumcision. In 2012, the American Academy of Pediatrics (AAP), which previously had been neutral on the subject, issued a task force report concluding that the health benefits of circumcision outweigh its risks and justify access to the procedure.3,4 However, the report stopped short of recommending circumcision.
Opponents have expressed several concerns about circumcision. First, they say, it is painful and unnecessary, and performing it when life has just begun takes the decision away from the adult-to-be, who may want to be uncircumcised as an adult but will have no recourse. Second, they say circumcision will diminish the adult’s sexual pleasure. However, there is no proof this occurs, and it is unclear how the claim could be adequately verified.5
Health benefits of circumcision3
- Prevention of phimosis and balanoposthitis (inflammation of glans and foreskin), penile retraction disorders, and penile cancer
- Fewer infant urinary tract infections
- Decreased spread of human papillomavirus–related disease, including cervical cancer and its precursors, to sexual partners
- Lower risk of acquiring, harboring, and spreading human immunodeficiency virus infection, herpes virus infection, and other sexually transmitted diseases
- Easier genital hygiene
- No need for circumcision later in life, when the procedure is more involved
2. What is the best analgesia for circumcision?
Although in decades past circumcision was often performed without any analgesia, in the United States analgesia is now standard of care. The AAP Task Force on Circumcision formalized this standard in a 2012 policy statement.4 For newborn circumcision, analgesia can be given in the form of analgesic cream, penile ring block, or dorsal nerve block.
Analgesic EMLA cream (a mixture of local anesthetics such as lidocaine 2.5%/prilocaine 2.5%) is easy to use but is minimally effective in relieving circumcision pain,6 although some investigators have reported it is efficacious compared with placebo.7 When used, the analgesic cream is applied 30 to 60 minutes before circumcision.
Both penile ring block and dorsal nerve block with 1% lidocaine are easy to administer and are very effective.8,9 They are best used with buffered lidocaine, which partially relieves the burning that occurs with injection. With both methods, the smaller the needle used (preferably 30 gauge), the better.
These 2 block methods have different injection sites. For the ring block, small amounts of lidocaine (1 to 1.5 mL) are given in a series of injections around the entire circumference of the base of the penis. The dorsal block targets the 2 dorsal nerves located at 10 o’clock and 2 o’clock at the base of the penis. Epinephrine, given its vasoconstrictive properties and the potential for necrosis, should never be used with local analgesia for penile infiltration.
Analgesia can be supplemented with comfort measures, such as a pacifier, sugar water, gentle rubbing on the forehead, and soothing speech.10
Circumcision impedes viral disease. Will opposition fade?
3. What conditions are required for safe circumcision?
As circumcision is not medically required and need not occur in the days immediately after birth, it should be performed only when conditions are optimal:
- A pediatrician or other practitioner must first examine the newborn.
- The newborn must be full-term, healthy, and stable.
- The best time to circumcise a baby born prematurely is right before discharge from the intensive care nursery.
- The penis must be of normal size and without anatomical defect—no micropenis, hypospadias, or penoscrotal webbing.
- The lower abdominal fat pad must not be so large that it will cause the shaft’s skin to cover the exposed penile head.
- If there is a family history of a bleeding disorder, the newborn must be evaluated for the disorder before the circumcision.
- The newborn must have received his vitamin K shot.
4. What is the best circumcision method?
Circumcision can be performed with the Gomco circumcision clamp, the Mogen circumcision clamp, or the PlastiBell circumcision device. Each device works well, provides excellent results, and has its pluses and minuses. Practitioners should use the device with which they are most familiar and comfortable, which likely will be the device they used in training.
In the United States, the Gomco clamp is perhaps the most commonly used device. It provides good cosmetic results, and its metal “bell” protects the entire head of the penis. Of the 3 methods, however, it is the most difficult—the partially cut foreskin must be threaded between the bell and the clamp frame before the clamp is tightened. In many cases, too, there is bleeding at the penile frenulum.
The Mogen clamp, another commonly used device, also is used in traditional Jewish circumcisions. Of the 3 methods, it is the quickest, produces the best hemostasis, and is associated with the least discomfort.10 To those unfamiliar with the method, there may seem to be a potential for amputation of the head of the penis, but actually there virtually is no risk, as an indentation on the penile side of the clamp protects the penile head.
The PlastiBell device is very easy to use but must stay on until the foreskin becomes necrotic and the bell and foreskin fall off on their own—a process that takes 7 to 10 days. Many parents dislike this method because its final result is not immediate and they have to contend with a medical implement during their newborn’s first week home.
Electrocautery is not recommended. Some clinicians, especially urologists, use electrocautery as the cutting mechanism for circumcision. A review of the literature, however, reveals that electrocautery has not been studied head-to-head against traditional techniques, and that various significant complications—transected penile head, severe burns, meatal stenosis—have been reported.11,12 It is certainly not a mainstream procedure for neonatal circumcision.
Evaluate penile anatomy for abnormalities
Before performing any circumcision, the head of the penis should be examined to rule out hypospadias or other penile abnormalities. This is because the foreskin is utilized in certain penile repair procedures. The pediatrician should perform an initial examination of the penis at the formal newborn physical within 24 hours of delivery. The clinician performing the circumcision should re-examine the penis just before the procedure is begun—by pushing back the foreskin as much as possible—as well as during the procedure, once the foreskin is lifted off the penile head but before the foreskin is excised.