A mother gives birth to a term male infant with a normal penis (no evidence of hypospadias or penile chordee). The testes are descended bilaterally and normal to palpation. The parents decline elective circumcision. 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 is taken to the emergency room. A dorsal slit is performed by the consulting urologist and the paraphimosis is reduced. He subsequently undergoes an elective circumcision and has had no further penile complaints.
Male circumcision is one of the most common operations performed in the United States, with an estimated 1.1 million newborn boys (55%) undergoing the procedure every year (1,2). The practice of male circumcision has strong religious and cultural roots throughout history and across the world. Ritual circumcision is near universal in the Jewish and Muslim faiths as well as for many Polynesians and African populations. This is in contrast to many other parts of the world, such as Scandinavia and Great Britain, where circumcision is rarely performed. Globally, it is estimated that about 37% of males are circumcised (1).
Elective neonatal circumcision remains a controversial issue. The rate of newborn circumcision in the United States has fluctuated over the past 40 years, with a downward trend (3). This is partly due to the changing guidance of the American Academy of Pediatrics. The 2012 Circumcision Policy Statement of the American Academy of Pediatrics states that the 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 (4). In 2018, the U.S. Centers for Disease Control and Prevention released affirmative guidelines in support of nontherapeutic neonatal circumcision, qualifying again that the decision ultimately lies with the neonate’s parents or guardians (5).
Male circumcision involves removing the prepuce, or foreskin, which covers the glans penis. In most newborn boys, the inner epithelial lining of the prepuce is adherent to the glans and is therefore non-retractile. The foreskin should not be pulled back forcefully as spontaneous separation will occur over time. Physiologic preputial retraction can occur at various ages, with a mean age of approximately 10.4 years (6). The progressive separation of the foreskin epithelium from the glans epithelium is caused by an enlarging accumulation of trapped desquamated cells, termed smegma (6). Uncircumcised boys and their parents should be advised that the appearance of smegma (thick white or yellow substance) is a normal finding and not a concern for infection.
Pediatricians, obstetricians, and family physicians perform the vast majority of newborn circumcisions in the United States. Circumcision is contraindicated in the presence of penile abnormalities, including hypospadias, epispadias, chordee, or micropenis (a stretched penile length 2.5 SD below the mean, or less than 1.9 cm in the neonate). Neonatal circumcision is also contraindicated in those with significant prematurity, illness, blood dyscrasia, or a family history of a bleeding disorder (7).
The three most commonly used methods involve the Gomco clamp, the Mogen clamp, and the Plastibell. In all, the penis is first examined and the preputial adhesions to the glans are lysed with a probe or clamp. Each procedure has unique advantages and disadvantages. The Mogen clamp requires the least training of the three methods and is associated with less bleeding and complications. However, it does not directly protect the glans. In contrast, the Gomco safely protects the glans but requires more skill to use. The Plastibell offers superior hemostatic control but involves leaving a foreign body at the site for several days. Despite these differences, the three techniques are equally effective. The choice of the device should therefore be guided by the physician’s experience and level of comfort (7).
Regardless of the chosen method, all newborn circumcisions should be performed under local anesthesia. Safe and effective anesthesia may be achieved with either a dorsal penile nerve block or a ring block with plain lidocaine (7).
To use the Gomco clamp or the Plastibell, a dorsal slit must first be created, incising the prepuce at the 12 o’clock position. This is done with a straight kelly clamp applied to the dorsal foreskin creating a hemostatic line of crushed skin that can be slit. The foreskin is then separated from the glans. The Gomco clamp involves placing a metal bell over the glans and pulling the redundant foreskin over the bell and through the clamp. The clamp is then screwed onto the bell and the foreskin is excised. With the Plastibell, following the dorsal slit, a plastic ring is then placed between the glans and the foreskin. While the foreskin is pulled forward over the ring, a silk suture is tied tightly onto a groove in the ring. The ring is left in place and disrupts the blood supply to the distal prepuce, which falls off in 7 to 10 days. The Mogen clamp is used in ritual Jewish circumcision and requires pulling the prepuce forward, causing the glans to retract slightly. The clasp is locked across the redundant foreskin and the foreskin is excised. Both the Mogen and Gomco clamps achieve hemostasis by clamping, crushing, and sealing the skin edges that remain after the foreskin is excised. Electrocautery should never be used with the metal clamps since the current can be transmitted to the entire penis and result in penile necrosis.
Male circumcision is a safe procedure, with a postoperative complication rate of 0.4%. The most common adverse events are bleeding (0.1%) and infection. Meatal stenosis is a late complication that can be prevented by educating parents to apply petroleum jelly with each diaper change until healing is complete. Other less common complications include phimosis, concealed penis, skin bridge formation, ring retention, meatitis, chordee, inclusion cyst, penile lymphedema, urethrocutaneous fistula, hypospadias and epispadias formation, penile amputation, and penile necrosis (8). While minor bleeding and infection can be managed by primary care physicians, a urologic consultation should be obtained for the management of more serious complications.
Newborn circumcision taught in residency training programs is highly variable in that it is sometimes taught in Pediatrics residency, Obstetrics residency, Family Medicine residency, or not at all. Traditionally, obstetricians performed the circumcisions in some parts of the country, while pediatricians performed the circumcisions in other parts of the country.
Circumcision may become necessary in older children presenting with acute penile and preputial pathology. Phimosis refers to the inability to retract the foreskin over the glans penis and can be categorized as physiologic or pathologic. As previously mentioned, a non-retractile foreskin is normal in young children whose foreskin adhesions have yet to lyse; additionally, the opening to the foreskin is too small (tight) to be fully retracted over the glans. This is called physiologic phimosis. With time, the adhesions lyse and the opening to the foreskin enlarges which permits the foreskin to be fully retracted over the glans at an age that is highly variable (6,9).
If the foreskin is forcibly retracted during childhood, scarring occurs, resulting in pathologic constriction. Poor genital hygiene is another risk factor for pathologic phimosis, as chronic infection and inflammation of the foreskin (posthitis) and glans (balanitis) over time can result in fibrosis. Minor physiologic or pathologic phimosis can be managed with improved genital hygiene and topical corticosteroid ointment, which has proven to be effective in two-thirds of cases. Mild balanoposthitis can be managed with broad-spectrum oral antibiotics and topical antibiotic ointment. Severe balanoposthitis may require emergent dorsal slit circumcision (9). Elective circumcision is curative.
Paraphimosis is a urological emergency that can be very difficult to identify. It occurs when the retracted foreskin becomes trapped proximal to the glans penis due to the constricting band of the preputial aperture. Paraphimosis may occur after forced or traumatic retraction of the foreskin, placement of urethral catheters, or genital piercings. The constricting band may lead to obstruction of venous outflow, resulting in penile edema, erythema, and pain of the prepuce distal to the band. A hair or thread-like tourniquet can resemble a paraphimosis. These hair or threat tourniquets must be identified and removed if present. One key in recognizing a paraphimosis is that if the patient is uncircumcised, the foreskin should be very visible and if it isn’t (i.e., the glans is very visible without any foreskin covering), the foreskin likely is constricting the base of the glans as a tight band. Emergent reduction of the foreskin is indicated since paraphimosis may progress to penile glans ischemia, gangrene, or autoamputation (9).
The management of paraphimosis involves reducing preputial edema and restoring the prepuce to its original position and condition. Ice packs, topical application of granulated sugar, hyaluronidase injections, penile compressive elastic wraps, and direct circumferential manual compression all help to reduce the edema. Applying a local topical anesthetic before manipulation also helps to reduce the pain of the reduction. Manual reduction is performed by positioning both thumbs on the glans and securing the remaining fingers behind the prepuce. Steady pressure is applied to the prepuce as it is pulled down, with counter pressure applied to the glans penis. 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 (10). 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. What are some complications of circumcision?
6. What is phimosis?
7. What is paraphimosis? Is it an emergency?
1. Morris BJ, Wamai RG, Henebeng EB, et al. Estimation of country-specific and global prevalence of male circumcision. Popul Health Metr. 2016;14:4. doi:10.1186/s12963-016-0073-5
2. Jacobson DL, Balmert LC, Holl JL, et al. Nationwide Circumcision Trends: 2003 to 2016. J Urol. 2021;205(1):257-263. doi:10.1097/ju.0000000000001316
3. Owings M, Uddin S, Williams S. Trends in Circumcision for Male Newborns in U.S. Hospitals: 1979–2010. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/data/hestat/circumcision_2013/circumcision_2013.htm. Published November 6, 2015. Accessed April 8, 2022.
4. American Academy of Pediatrics, Task Force on Circumcision. Circumcision Policy Statement. Pediatrics 2012:130;585-586. https://doi.org/10.1542/peds.2012-1989
5. Male Circumcision. Centers for Disease Control and Prevention. https://www.cdc.gov/hiv/risk/male-circumcision.html. Published November 8, 2019. Accessed April 8, 2022.
6. Prabhakaran S, Ljuhar D, Coleman R, Nataraja RM. Circumcision in the paediatric patient: A review of indications, technique and complications. J Paediatr Child Health. 2018;54(12):1299-1307. doi:10.1111/jpc.14206
7. Omole F, Smith W, Carter-Wicker K. Newborn Circumcision Techniques. Am FamPhys. https://www.aafp.org/afp/2020/0601/p680.html#afp20200601p680-b12. Published June 1, 2020. Accessed April 8, 2022.
8. Palmer LS, Palmer JS. Management of Abnormalities of the External Genitalia in Boys. In: Partin AW, Dmochowski RR, Kavoussi LR, Peters CA (eds). Campbell-Walsh-Wein Urology, 12th ed. 2021. Elsevier, Philadelphia, PA. pp. 871-904.
9. Offenbacher J, Barbera A. Penile Emergencies. Emerg Med Clin North Am. 2019;37(4):583-592. doi:10.1016/j.emc.2019.07.001
10. Pohlman GD, Phillips JM, Wilcox DT. Simple method of paraphimosis reduction revisited: Point of technique and review of the literature. J Pediatr Urol. 2012;9(1):104-107. doi:10.1016/j.jpurol.2012.06.012
Answers to questions
1. Penile cancer, balanitis, posthitis, phimosis, UTI, and a reduced risk of STDs (e.g., HIV).
2. Gomco clamp, the Mogen clamp, and the Plastibell.
3. Bleeding and infection.
4. Hypospadias, chordee, epispadias, penile torsion, micropenis, significant prematurity, blood dyscrasia, or family history of a bleeding disorder.
5. Complications of circumcision include infection, bleeding, concealed penis, penile adhesions, meatitis, fistula formation, penile amputation, and penile necrosis.
6. Phimosis is the inability to retract the foreskin. Physiologic phimosis is normal in infants and young children.
7. 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. It is a urologic emergency.