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 elect not to have their child circumcised. When he is 12 years old, he develops recurring balanoposthitis, and worsening phimosis. He subsequently develops paraphimosis after retracting his foreskin in the shower. Unable to reduce it at home, he was taken to the emergency room, where a dorsal slit was done, by the consulting urologist, and the paraphimosis reduced. He subsequently underwent an elective circumcision and has had no further penile complaints.
Circumcision is the most common operation performed on males in the United States. It is estimated that 1.1 million (56%) of newborn males in the United States undergo circumcision (1). In Scandinavia and Great Britain, it is rarely performed in newborns. Ritual circumcision is near universal in the Jewish and Muslim faiths.
The prepuce, or foreskin, covers the glans penis. Initially, the inner epitheleal lining of the prepuce is adherent to the glans, and is therefore non-retractile. At birth, the prepuce (foreskin) is retractable in only 4% of boys. By 3 years, 90% of the boys’ foreskin can be completely retracted (2). At age 17, 99% of the boys can retract their foreskin (2). 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 (2). This smegma is not to be confused with infection. The prepuce should not be forcibly retracted as spontaneous separation will occur physiologically.
The 2012 Circumcision Policy Statement of the American Academy of Pediatrics states: "Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it. Specific benefits identified included prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV." (3)
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.
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 penis (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 recommended as a dorsal penile nerve block or a ring block in the performance of newborn circumcision (4).
The post operative complication rate of circumcision is between 0.2 and 0.6%. These complications including bleeding, infection, phimosis, concealed penis, skin bridge formation, ring retention, meatitis, urethral stenosis, chordee, inclusion cyst, penile lymphedema, urethrocutaneous fistula, hypospadias and epispadias formation, penile amputation, and penile necrosis (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 the management of complications.
Phimosis is the inability to retract the foreskin over the glans penis due to narrowing or constriction. Congenital neonatal foreskin adhesions usually lyse during the first several years of life, and forceful retraction of the foreskin during infancy may result in scarring of the distal foreskin and worsening of the phimosis and development of posthitis (inflammation/infection of the foreskin). Poor genital hygiene may also result in chronic infection and fibrosis, resulting in phimosis, and possibly posthitis and/or balanitis (inflammation/infection of the glans penis). Minor phimosis can be managed with improved genital hygiene and topical corticosteroid ointment. Mild balanoposthitis can be managed with broad spectrum oral antibiotics and topical antibiotic ointment. Severe balanoposthesis may require emergent dorsal slit circumcision (5). Elective circumcision is curative.
Paraphimosis is a condition in which the retracted foreskin becomes trapped proximal to the glans penis due to the constricting band of the foreskin’s preputial apeture, which may occur after forced or traumatic retraction of foreskin, placement of urethral catheters, or genital piercing placements. This results in penile edema, erythema, and pain of the prepuce distal to the constricting band. In a circumcised male presenting with paraphimosis, a hair/thread foreign body tourniquet must be ruled out, (and removed if present) (6). Emergent reduction of the foreskin is indicated as it may progress to penile glans ischemia, gangrene, or autoamputation.
Therapy for paraphimosis involves patient reassurance, preputial edema reduction, and restoring the prepuce to its original position and condition. Ice packs, penile compressive elastic wraps, and direct circumferential manual compression help to reduce the edema. Application of a local topical anesthetic, for a few minutes to an hour, before the manipulation helps to reduce the pain of the reduction. Gentle manual reduction is performed by placing both thumbs on the glans penis and wrapping the fingers behind the prepuce. Gentle steady pressure is applied to the prepuce, with counter pressure to the glans penis as the prepuce is pulled down. The constricting band of tissue should come down to completely cover the glans with the prepuce. If the prepuce comes down, but the constricting band remains behind, the paraphimosis has not been reduced properly or sufficiently (6). Emergent dorsal slit or circumcision is indicated if the paraphimosis is unable to be reduced.
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?
6. What is paraphimosis? Is it an emergency?
1. Zhang, X, Shinde, S, Kilmarx, PH, et al, Trends in In-Hospital Newborn male Circumcision ---United States, 1999—2010. Center for Disease Control Morbidity and Mortality Weekly Report, Sep 2, 2011/60(34); 1167-1168.
2. McGregor, T. Pathologic and physiologic phimosis. Can Fam Physician. Mar 2007;53(3)445-448
3. Task Force on Circumcision (American Academy of Pediatrics). Circumcision Policy Statement. Pediatrics 2012: 130;585-586.
4. Weiss, J, Kohn, I. Urological Emergencies. In: Hanno, PM, Malkowicz SB, Wein, AJ (eds). Penn Clinical Manual of Urology. 2007, Philadelphia: Saunders Elsevier, pp. 275-276.
5. Coplen, ED, Phimosis and Paraphimosis. In: Gomella, Leonard G (ed). The 5-minute Urology Consult, 2nd Edition. 2010, Philadelphia: Lippicott, Williams, and Wilkins. Pp. 260-261.
6. Donohoe, Jeffrey M. (2012, Jan 23). Paraphimosis. Medscape. Retrieved 4/1/2013 from http://emedicine.medscape.com/article/442883.
Answers to questions
1. Penile cancer, balanitis, posthitis, 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 reason associated with each answer. Yes, because it protects against penile cancer, etc. No, because of the risks of complications of infection, bleeding, concealed penis, penile adhesions, meatitis, fistula formation, penile amputation and penile necrosis.
6. Paraphimosis is a condition in which a constricting band of the tip of the retracted foreskin gets trapped proximal to the coronal sulcus of the glans penis, with resultant edema, erythema, and pain. Yes it is an emergent condition.