Neonatal Circumcision

Circumcision has been used in religious rites for centuries and was used in ancient Egypt as a method for hygiene. Modern data in the United States is conflicting as to the benefits versus risks. By age 5 years, 90% of boys have a spontaneously retractable foreskin. The incidence of phimosis decreases with age and may be treated with a steroid cream. The medical approach to phimosis is initially successful in about 80% of cases and a year later 60% had no phimosis (Ku and Huen, 2007). Many parents still elect to have their male infants circumcised.

The American Urological Association revised their policy to say that circumcision should be presented for health benefits (Tobian et al., 2010). The American Academy of Pediatrics, American Medical Association, and American College of Obstetrics and Gynecology all consider the procedure elective with minimal benefits (Lannon et al., 1999). The WHO-United Nations program on HIV/AIDS concluded that male circumcision is efficacious in reducing sexual transmission of HIV from women to men. In Africa, circumcision decreased HIV acquisition by 53% to 60%. Herpesvirus type 2 is decreased by 28% to 34% and HPV prevalence by 32% to 35% in circumcised men. Among female partners of circumcised men in these African studies, the incidence of bacterial vaginosis was reduced by 40% and Trichomonas vaginalis by 48%; genital ulcers decreased as well (Tobian et al., 2010).

The incidence of urinary tract infection (UTI) is reduced with circumcision in some populations. If a population has a baseline UTI incidence of 3% or higher and circumcision complication rate less than 2%, circumcision is helpful in reducing UTIs. In normal infants the risk of UTI is 1% or less, in those with prior UTI 10%, and in those with vesicoureteral reflux 30% (Singh-Grewal, 2005). The main risk is bleeding, followed by infection. Actual rates of hemorrhage in medically indicated or ritual hospital-based circumcision range from 0.2% to 3% (Bocquet et al., 2010).

Although numbers may be declining in some U.S. areas, circumcision remains one of the most common procedures performed. A neonatal circumcision is normally performed at 12 to 48 hours old once the infant has stabilized after birth, but may be performed up to 4 to 6 weeks of age. Before the procedure, each patient should be examined thoroughly for signs of congenital anomalies of the penis, urethra, or urinary tract. If hypospadias is present, circumcision is stopped or not performed, to allow the tissue to be used in a corrective surgical procedure to repair the urethra and glans.

Many locations recommend no oral intake for 1 hour before the procedure to prevent aspiration. Oral sucrose can be used to reduce pain during the procedure (Gatti, 2003). A dorsal penile block or penile ring block is more effective then EMLA cream or sucrose. EMLA cream provides anesthesia but has a risk of methemoglobinemia (Brady-Fryer et al., 2010).

Inspect first to make sure there is no hypospadias or hidden penis. If the penis is normal and parental consent has been obtained, the infant is placed on a circumcision restraint board and the skin prepared. A dorsal block is achieved by injecting 0.4 to 0.5 mL of 1% lidocaine without epinephrine at the base of the penile shaft at both the 10 and 2 o'clock positions and 5 mm distal to the skin reflection onto the pubic area. Inject 1 to 3 mm deep under Buck's fascia after aspirating to ensure you are not in a blood vessel. A ring block can also be done, slightly higher on the penile shaft circumferentially in the subcutaneous tissues, taking care to avoid injury to the urethra or vasculature (Fig. 28-20).

Once anesthesia is complete, grasp the foreskin distally at 3 and 9 o'clock with two hemostats. All techniques require freeing of adhesions with blunt dissection, usually done with a straight Kelly clamp inserted between the foreskin and glans in a superior direction to avoid the urethra. Open the clamp and sweep laterally. Avoid the highly vascular frenulum. Free the adhesions to the coronal sulcus of the glans. Use a straight hemostat to clamp the free dorsal foreskin, again making sure the tip is held up and away from entering the urethra. Clamp three-fourths the length of the foreskin dorsally. Insert iris scissors and carefully cut the foreskin along the crushed line. Peel the foreskin back to reveal the glans. Avoid degloving the shaft and damage to the frenulum.

Gomco Clamp

The Gomco is the most common circumcision clamp. Test the clamp's fit with the base before use. Estimate the correct size so that the bell covers at least seven-eighths of the glans (1.1, 1.3, and 1.5 sizes available). The glans is then covered with the Gomco bell and the foreskin pulled over it, sometimes with the aid of a clamp or safety pin. The bell and foreskin are then pulled through the hole in the base plate and the foreskin is arranged to ensure even tissue removal. The clamp is than placed on the base plate and the bell stem hooked over the clamp bar. Once positioning is confirmed, the clamp is tightened for 5 to 10 minutes and the remaining foreskin removed with a #10 scalpel. If hemostasis is confirmed, the clamp is removed and the glans is covered regularly with petroleum jelly at each diaper change. Healing should take 4 to 10 days. Complications include bleeding, infection, and trauma to the penis. Bleeding can be controlled with silver nitrate or a simple suture if not resolved with pressure. (See Tuggy Video: Neonatal Circumcision.)

Plastibell

The Plastibell device is a plastic ring on the end of a central removable post. The ring is placed between the glans and foreskin. A tight ligature of moistened suture is placed around the foreskin and tightened into a sulcus on the ring. Foreskin distal to the ring is excised and the handle of the device broken off. The plastic ring stays in place, with the ligature tied tightly around the protective ring, for 5 to 10 days and falls off spontaneously. The appearance of the small amount of necrotic skin may worry parents, and it may be

Deep dorsal vein, artery, and nerve

Deep dorsal vein, artery, and nerve

Circumcision Uti

Figure 28-20 Dorsal penile block. The dorsal penile nerve is anesthetized using no more than 1.0 mL total of 1% lidocaine without epinephrine. The anesthetic is administered at the dorsum of the penis approximately 0.5 cm distal to the penile root at the 12 and 2 o'clock positions.

(From Pfenninger JL, Fowler G [eds]: Procedures for Primary Care Physicians, 2nd ed. St Louis, Mosby, 2003; and Chavez MC, Maker VK. Office surgery. In Rakel RE. Textbook of Family Medicine, 7th ed. Saunders-Elsevier, Philadelphia, 2007.)

Figure 28-20 Dorsal penile block. The dorsal penile nerve is anesthetized using no more than 1.0 mL total of 1% lidocaine without epinephrine. The anesthetic is administered at the dorsum of the penis approximately 0.5 cm distal to the penile root at the 12 and 2 o'clock positions.

(From Pfenninger JL, Fowler G [eds]: Procedures for Primary Care Physicians, 2nd ed. St Louis, Mosby, 2003; and Chavez MC, Maker VK. Office surgery. In Rakel RE. Textbook of Family Medicine, 7th ed. Saunders-Elsevier, Philadelphia, 2007.)

complicated with incomplete or irregular skin edges if the ligature is not tied tightly enough.

Mogan Clamp

The Mogan clamp is used in traditional Jewish circumcisions and may cause less pain by being faster. The foreskin is grasped with the nondominant hand and the glans pushed downward. The foreskin is slid into the clamp from anterior to posterior, taking care not to trap the glans. The clamp opens only 3 mm to prevent major glans entrapment. Once in place and the glans is confirmed below the plate, the clamp is closed and the distal foreskin removed. The clamp is left in place for a few minutes, then removed, and the foreskin retracted over the glans.

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