Case Based Pediatrics For Medical Students and Residents
Department of Pediatrics, University of Hawaii John A. Burns School of Medicine
Chapter XIII.8. Circumcision
Robert G. Carlile, MD
May 2002

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A mother gives birth to a term male infant with a normal penis (no evidence of hypospadias or penile chordee). Testes are descended bilaterally and normal to palpation. The parents are do not want their child to be circumcised. This is not a problem until he is 12 years old, in 7th grade. Since the majority of his male friends are circumcised, he desires circumcision. This is performed by a urologist, under anesthesia, in the operating room. He recovers without any complications. However, the parents are distraught when they learn their medical insurance will not pay the $3,000 bill for this "cosmetic" procedure.


Circumcision is the most common operation performed on males in the United States. It is estimated that 1.2 million newborn males are circumcised in the United States at an annual cost of between $150 and $270 million (1). Sixty percent of boys in the United States undergo circumcision. In Scandinavia and Great Britain, it is rarely performed in newborns (2). Ritual circumcision has been part of Jewish and Muslim faiths.

The prepuce develops in the 10th week of fetal development as a small epithelial tag at the penile tip. At 12 weeks this tag becomes a pronounced fold and grows inward and vertically, surrounding the glans at birth. This fold's inner epithelial layer is fused with the glans' epithelium. The urethra must close before the prepuce (the foreskin covering the glans) completely develops (3). With incomplete urethral closure (hypospadias), the ventral development of the prepuce is incomplete and one will find a thinned or absent ventral foreskin in hypospadias. At birth, the preputial aperture (opening or meatus of the foreskin) is adequate for voiding.

At birth, the prepuce (foreskin) is retractable in only 4% of boys. By 3 years, 90% of the boys' foreskin can be completely retracted (4). At age 17, 99% of the boys can retract their foreskin (3). This progressive separation of the foreskin epithelium from the glans epithelium is caused, in part, by an enlarging accumulation of trapped desquamated cells called smegma (3). This smegma is not to be confused with infection. The prepuce should not be forcibly retracted as spontaneous separation will occur physiologically.

The decision on whether to circumcise a newborn male is controversial. The Task Force on Circumcision of the American Academy of Pediatrics stated that newborn circumcision is not recommended and that the procedure is not essential to the child's current well-being (1). However, there is compelling evidence that newborn circumcision protects against penile cancer, local infection, phimosis, urinary tract infection, and human immunodeficiency virus (HIV) infection (5).

Pediatricians, obstetricians, and family practitioners perform the vast majority of newborn circumcisions in the United States. Circumcision is contraindicated if any penile anomaly is found such as; hypospadias, epispadias, chordee, or micropenis (stretched penile length <2.5 cm). Also, neonatal circumcision is contraindicated with significant prematurity, illness, blood dyscrasia, or family history of a bleeding disorder.

The three methods most commonly used involve the Gomco clamp, the Bronstein (Mogen) clamp, or the Plastibell. In all, the penis is first examined and the preputial adhesions to the glans are lysed with a probe or clamp (2).

The Gomco clamp uses a metal bell placed over the glans with the redundant foreskin pulled over the bell and through the clamp. The clamp is screwed down tightly onto the bell and the foreskin excised. The Bronstein clamp is used in ritual Jewish circumcision and involves pulling the prepuce (foreskin) forward causing the glans to retract slightly. The clasp is locked across the redundant foreskin, and the foreskin is excised. Both the Bronstein and Gomco clamps achieve hemostasis by clamping, crushing, and sealing the skin edges that are left after the foreskin is excised. Electrocautery should never be used with these clamps, as the current could be transmitted to the entire penis, via the metal clamp, and result in penile necrosis.

The Plastibell is a plastic ring that is placed over the glans (inside the foreskin) to the coronal sulcus, and the foreskin is pulled over it, usually after a dorsal slit is made. A large silk suture is tied over tightly onto a groove in the ring. The foreskin is excised, and the ring is left in place (after the handle is broken off). This ring minimizes blood loss, and it falls off in 3 to 7 days.

Local anesthesia with lidocaine (plain) is generally recommended as a dorsal penile nerve block or a ring block in the performance of newborn circumcision (2,6).

The post operative complication rate of circumcision is between 0.2 and 0.6%. These complications include bleeding, infection, phimosis, concealed penis, skin bridge formation, ring retention, meatitis, urethral stenosis, chordee, inclusion cysts, penile lymphedema, urethrocutaneous fistula, hypospadias and epispadias formation, penile amputation, and penile necrosis (3,4). The two most common are bleeding and infection.

Minor bleeding and infection can be managed by primary care physicians, but a low threshold for obtaining a urologic consultation should be maintained for complication management.


Questions

1. What does neonatal circumcision protect against?

2. What are the 3 most common methods used to perform neonatal circumcision?

3. What are the 2 most common complications of neonatal circumcision?

4. What are the contraindications to performing a newborn circumcision?

5. Will you perform newborn circumcision? Why or why not?


References

1. Task Force on Circumcision (American Academy of Pediatrics). Circumcision Policy Statement. Pediatrics 1999:103(3);686-693.

2. Ross J, Elder JS. Much Said, Little Settled about Circumcision. Contemp Urol 1991;3(11):32-46.

3. Batholomew TH, McIver B. Other Disorders of the Penis and Scrotum. In: Gonzales ET, Bauer SB (eds). Pediatric Urology Practice. 1999, Baltimore: Lippincott, Williams, and Wilkins, pp. 533-539.

4. Niku SD, Stock JA, Kaplan GW. Neonatal Circumcision. Urol Clin North Am 1995;22(1):57-65.

5. Schoen EJ, Wisnell TE, Moses S. New Policy on Circumcision-Cause for Concern. Pediatrics 2000;105(3):620-623.

6. Lander J, et. al. Comparison of Ring Block, Dorsal Penile Block and Topical Anesthesia for Neonatal Circumcision: A Randomized Controlled Trial. JAMA 1997;278(24):2157-2162.


Answers to questions

1. Penile cancer, balanitis, phimosis, urinary tract infection, reduced risk of HIV.

2. Gomco clamp, the Bronstein (Mogen) clamp, and the Plastibell.

3. Bleeding and infection.

4. Hypospadias, chordee, epispadias, penile torsion, micropenis, significant prematurity, blood dyscrasia, or family history a bleeding disorder.

5. Yes or no; see reasons associated with each answer. Yes, because it protects against penile cancer, etc., (see #1). No, because of the risks of complications of infection, bleeding, concealed penis, penile adhesions, meatitis, fistula formation, penile amputation and penile necrosis.


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