Circumcision

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Circumcision is the removal of the foreskin.  The most common reasons  for newborn circumcision include personal preference, improvement in hygiene, prevention of infection, cultural customs, or religious beliefs.

There are benefits as well as risks for this procedure, just like any surgical procedure.  

The main benefits of circumcision are reduced risk of urinary tract infections, especially during infancy and old age, and sexually transmitted diseases in adulthood, as well as near elimination of risk of penile cancer.  The most common medical indications for circumcision are: inability to retract the foreskin (phimosis) at an age when it should be retractable, penile infections, urinary tract infections, chronic inflammatory changes of the foreskin, or the presence of a congenital urinary tract abnormality that increases the risk of urinary tract infections. 

The main short-term risks of circumcision include bleeding, infection, injury to the urethra or glans, retained Plastibell, trapped penis, etc. Longer term complications include:  penile skin adhesion or scarring; asymmetric cut or abnormally long or short penile skin; abnormal narrowing of the urethral opening; unrecognized abnormal penile angulation; etc.

Some of the complications are easily treated. For example, retained Plastibell is easily removed in office, and soft penile skin adhesions can be treated with medication and gentle separation. Other conditions, if significantly symptomatic, may need surgical correction under general anesthesia in a hospital setting. These may include abnormal narrowing of the urethral opening (urethral meatal stenosis), extensive scar tissue formation, significant penile angulation, or trapped penis.

Dr. Hwang is very experienced in performing neonatal circumcision – using topical and local anesthesia with the baby awake, as well as circumcision done in conjunction with repair of other penile abnormalities under general anesthesia as outpatient surgery. As a pediatric urologist, he is specifically trained in surgeries of the male genitalia.  We take great care to make the child comfortable, achieve good results, and prevent complications.  However, we cannot guarantee cosmetic or functional outcome.

First appointment (Circumcision Consultation)
During the first visit, the circumcision is NOT performed.  Dr. Hwang needs to examine the child’s overall health condition and the genital area, to determine if the child is a suitable candidate for a circumcision to be done under local anesthesia. He will review the procedure, preparation prior to procedure and after-care with the parents. He will also prescribe a numbing cream to be applied onto the penis prior to arrival to make the child more comfortable. He may also prescribe an antibiotics if the child has certain minor cardiac conditions.  We will give you a written instruction sheet as well as a specific date to return to have the procedure done.
Newborn circumcision can be performed in our office or at an outpatient surgery facility using local anesthesia in a healthy boy who weighs less than 12 pounds and is less than 8-10 weeks old. Sometimes, a premature boy who has stayed in the NICU for more than a few days may miss the opportunity to have the circumcision done at the pediatrician’s office.  We may still be able to do the circumcision provided the boy meets the above criteria.  
Some of the general health conditions that would prevent the baby from having the circumcision done during the neonatal period are:
  • Failure to thrive (not gaining weight appropriately)
  • Severe jaundice
  • Other significant congenital deformities or acquired conditions, such severe heart, lung, neurological, gastrointestinal, or musculoskeletal conditions
  • Known bleeding disorder, or family history of bleeding disorder that is pending evaluation
  • Known reaction to anesthetic agents or family history of abnormal reaction to anesthesia
  • Acute penile / genital infection
  • Acute respiratory illness, etc.
There are several conditions of the penis that make it unsuitable for newborn circumcision:
  • Significantly abnormal penile curvature and/or twisting (penis bent or twisted)
  • Buried/hidden/concealed penis (penis hides inside fat pad) with poor protrusion of the glans (head of penis).
  • Webbed penis (scrotum wraps around the penis, reaches too closes to the head of penis)
  • Micropenis (penis abnormally thin and short)
  • Disorders of sexual differentiation (abnormal sex chromosomes with genital abnormality)
  • Abnormally short foreskin
  • Hypospadias (urethral opening opens too low, often with abnormal penile curvature)
  • Many rare but severe abnormal conditions of the penis.
With these conditions, circumcision should not be performed with clamps under local anesthesia, but need to be performed at the same time that the more serious penile condition is repaired.  We would wait till the boy is old enough to tolerate general anesthesia well, typically after 4-9 months of age, depending on the child’s general health condition and the penile condition to be repaired. At this age, the pain level, healing time, and after care are about the same as regular newborn circumcision.  Repairing such abnormalities would not affect the functioning of the penis, as the nerves, blood vessels, and other important structures are preserved. Therefore, sensation, erection, orgasm, and ejaculation after penile surgery are expected to be the same as a penis after a regular circumcision. These types of surgeries require a sterile surgical field to prevent infections, and the patient needs to be completely still. Therefore, we need to wait till the child is mature enough to undergo general anesthesia very safely to proceed with these types of surgery.
Boys, especially when they reach adolescence, have a strong sense of body image. This is why we strive to counsel the parents carefully and choose the best surgical approach to achieve an acceptable outcome. We wish to minimize the chance that the boy will need another surgery in the future. Several times a year, we see some older boys who were circumcised as newborns who come in for consultation to have the abnormality of the penis corrected. These conditions may include abnormal penile angulation, abnormal scar formation, abnormal urethral opening, etc.
It is important to keep in mind that circumcision is considered irreversible. For this reason, to proceed with the procedure in young boys, we require that both birth parents agree to the procedure. Older boys must give ascent, in addition to the consent of birth parents.
We do not perform circumcision on boys in foster care, unless there is a strong compelling medical reason to do so. It may require a court consent and the case worker to be present on the day of surgery.

Neonatal Circumcision Procedure 

The procedure typically takes between 15-30 minutes and is done either in the office or at Affinity Surgery Center, it is usually performed using a Plastibell, one of the commonly used devices for newborn circumcision. Dr. Hwang also performs circumcision using the Gomco clamp at Affinity Surgery Center.

With the Plastibell, there is a ring that will stay on the penis and fall off on its own within 2 – 12 days, similar to how the umbilical cord clamp works. The baby will be secured on a board. The genital area is then cleansed with Betadine. Local anesthesia, lidocaine, will be injected at the base of penis all around. The foreskin is separated from the head of penis and cleansed with Betadine. The frenulum may be released. Bleeding areas are controlled. The Plastibell is inserted inside the foreskin and secured to the skin with a string, adjusted as needed to correct mild penile torsion or other minor conditions such as partial foreskin deficiency. The bar on the Plastibell is then removed and the procedure is complete. Dr. Hwang will be using the numbing cream throughout the procedure to keep the penis numb and reduce pain, so be sure to bring it on the procedure date.

The baby sometimes can have erections that pull the Plastibell too low and cause it to get stuck on the head of penis, to the point that it may not fall off on its own. If the Plastibell does not fall off by 10 days after circumcision, please text a photo via Updox (https://forms.myupdox.com/form/100463) for Dr. Hwang to review. 

In the office, we allow parents to be present during the procedure, but it is not required. At Affinity, both parents can come but only one is allowed in the procedure room due to facility regulation. As soon as the procedure is completed, the parents are able to hold and feed the baby. The parents are given written instructions for post procedure management and are also given verbal instructions by the physician and the staff. Most post-procedure pain can be managed with small doses of acetaminophen and continued application of the numbing cream for a few days. The key is to minimize the discomfort during the procedure, as it will make the baby more comfortable at home as well.

Newborn Circumcision Care Instructions (tap to download)

Care and Avoidance of Potential Complications of Circumcision 

The most common immediate complication of newborn circumcision is bleeding; infection is less common.   The most common intermediate term complication is penile skin adhesion.  Most of the time, bleeding is limited and can be controlled with gentle manual compression of the bleeding site for 5-10 minutes.  If bleeding does not stop, please call our office immediately.  No oral or topical antibiotics is needed as the infection risk is low.  The key is to keep the area clean through regular bathing with warm water and non-irritating baby shampoo (the “no tear” kind).   

Typically, we will see the child again in two weeks to make sure the circumcision has healed properly. You may also text Dr. Hwang (through the office number 702-728-5686) and attach photos with the text any time if there is something you are concerned about and want Dr. Hwang to review.

What we look for mainly are signs of infection and penile skin adhesion.  If a penile adhesion develops, it can usually be treated fairly easily at an early stage with application of a steroid cream for a few weeks followed by gentle manipulation of the skin to separate the adhesion, with numbing of the skin and oral Tylenlol prior to procedure.

Notes on using Plastibell for circumcision:

After performing many newborn circumcisions using the Gomco and the Plastibell, Dr. Hwang prefers the Plastibell for the following reasons:

  • Less risk of bleeding and hospital visits
  • Allows circumcision to be done on bigger boys, usually up to 12 pounds. Bigger boys have higher risk of bleeding with Gomco and suturing was often required
  • Mild penile twisting can be corrected with rotation of the Plastibell, avoiding the need for some babies to undergo general anesthesia for the correction of the penile torsion
  • Mild hidden penis can be done under local anesthesia, as the Plastibell prevents the penis from retracting immediately into the fat pad, which can cause bleeding or penile trapping