About Newborn Circumcision

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

As with any surgical procedure, circumcision carries both benefits and risks.

Benefits

• Reduced Infection Risk: Lower risk of urinary tract infections (UTIs), particularly during infancy and old age.

• Disease Prevention: Decreased risk of sexually transmitted infections (STIs) in adulthood.

• Cancer Prevention: Near-elimination of the risk of penile cancer.

Medical Indications

While often elective, circumcision may be medically indicated for conditions such as:

• Phimosis: Inability to retract the foreskin at an age when it should naturally be retractable.

• Infections: Recurrent penile infections or urinary tract infections.

• Inflammation: Chronic inflammatory changes of the foreskin.

• Congenital Abnormalities: Urinary tract abnormalities that inherently increase the risk of UTIs.

Potential Risks and Complications

• Short-Term Risks: Bleeding, infection, injury to the urethra or glans, a retained Plastibell device, or a trapped penis.

• Long-Term Complications: Penile skin adhesions or scarring; an asymmetric cut; abnormally long or short remaining skin; abnormal narrowing of the urethral opening; or unrecognized abnormal penile angulation (bending).

Many complications are straightforward to treat. For example, a retained Plastibell can be safely removed in the office, and soft penile skin adhesions can often be resolved with medication and gentle separation. However, significant or highly symptomatic conditions—such as severe narrowing of the urethral opening (urethral meatal stenosis), extensive scar tissue, severe penile angulation, or a trapped penis—may require surgical correction under general anesthesia.

About Dr. Hwang

Dr. Hwang is a pediatric urologist specifically trained in surgeries of the male genitalia and the urinary tract for both boys and girls. He is highly experienced in performing neonatal circumcisions using a combination of topical numbing cream and local anesthesia injections while the baby is awake. He also performs circumcisions in conjunction with repairs of other penile abnormalities as an outpatient surgery under general anesthesia.

Our priority is always to keep your child comfortable, achieve excellent results, and prevent complications; however, we cannot guarantee specific cosmetic or functional outcomes.

Your Appointments: What to Expect

The First Appointment (Circumcision Consultation)

Please note: The circumcision is NOT performed during this first visit. During this consultation, Dr. Hwang will examine your child’s overall health and genital area to determine if they are a suitable candidate for a procedure under local anesthesia.

During this visit, Dr. Hwang will:

• Review the procedure, pre-operative preparation, and post-operative aftercare.

• Instruct you on how to apply numbing cream to the penis and administer the appropriate dose of Tylenol (acetaminophen) before arriving for the procedure.

• Prescribe antibiotics prior to the procedure if your child has certain minor cardiac conditions.

• Provide a written instruction sheet and schedule your child’s specific procedure date.

2. Eligibility Criteria for Office Circumcision

Newborn circumcision can be performed in our office or at an outpatient surgery facility using local anesthesia if the baby meets the following criteria:

• Healthy and weighs less than 15 pounds.

• Is under 4 to 6 months of age (depending on the baby’s medical condition and penile anatomy).

Note for NICU Parents: Premature infants who stay in the NICU for several weeks often miss the window to have a circumcision performed by a pediatrician. We can often still perform the procedure in our office, provided the boy meets the weight and age criteria listed above.

Insurance and Prior Authorizations

Many insurance plans require prior authorization for circumcisions, even when performed on newborns and infants using local anesthesia. Our office will do its best to secure this authorization before your scheduled procedure date.

Please be aware that the circumcision date may be delayed if authorization is not obtained in time. Common reasons for delays include:

• The baby has not yet been added to the parents’ insurance plan.

• The insurance company has not yet updated the baby’s information in their online portal.

• The insurance medical director requires a formal physician review of the request.

Medical Contraindications (When to Delay or Avoid Office Circumcision)

General Health Conditions

The following conditions will prevent a baby from undergoing a circumcision during the neonatal period:

• Failure to thrive (inadequate weight gain).

• Severe jaundice.

• Significant congenital or acquired conditions (e.g., severe heart, lung, neurological, gastrointestinal, or musculoskeletal conditions).

• A known bleeding disorder, or a family history of a bleeding disorder pending evaluation.

• A known reaction to local anesthetics (like lidocaine), or a family history of abnormal anesthesia reactions.

• An acute penile or genital infection.

• An acute respiratory illness.

Penile Abnormalities

The following anatomical conditions make a penis unsuitable for a standard newborn office circumcision:

• Significantly abnormal penile curvature or twisting (torsion).

• A buried, hidden, or concealed penis (where the penis hides inside the pubic fat pad) with poor protrusion of the glans (head of the penis).

• A webbed penis (where the scrotum wraps high onto the shaft, too close to the head of the penis).

• Micropenis (an abnormally thin and short penis).

• Disorders of sexual differentiation (abnormal sex chromosomes accompanied by genital abnormalities).

• An abnormally short foreskin.

• Hypospadias (where the urethral opening is located on the underside of the penis, often accompanied by curvature).

Next Steps for Penile Abnormalities

If your child has any of the penile conditions listed above, a standard clamp circumcision using local anesthesia should not be performed. Instead, the circumcision must be done concurrently with the surgical repair of the penile abnormality.

We typically wait until the boy is 4 to 9 months old to ensure he can safely tolerate general anesthesia. At this age, a sterile surgical environment (like a hospital or surgery center) and complete immobility are required for a successful surgery.

• Outcomes: Repairing these abnormalities will not affect the long-term function of the penis. Because nerves, blood vessels, and critical structures are carefully preserved, sensation, erections, orgasms, and ejaculation are expected to be normal.

• Recovery: At 4 to 9 months of age, pain levels, healing times, and aftercare requirements are highly comparable to a standard newborn circumcision.

Consent, Body Image, and Revision Surgeries

Boys develop a strong sense of body image as they grow, particularly as they approach adolescence. To avoid the need for corrective surgeries later in life, we counsel parents carefully and select the best surgical approach from the start. Throughout the year, we frequently see older boys who were circumcised elsewhere as newborns who now require specialized consultations to correct penile angulation, abnormal scar tissue, or urethral misalignments.

• Irreversibility: Circumcision is an irreversible procedure. To proceed in young boys, we require the consent of both birth parents. Older boys must also provide their own assent alongside parental consent.

• Foster Care Policy: We do not perform elective circumcisions on boys in foster care unless there is a compelling, documented medical necessity. In these cases, court consent and prior authorization from Nevada Medicaid are required, and the caseworker must be present on the day of surgery.

The Neonatal Circumcision Procedure

The procedure typically takes 10 to 20 minutes and is performed either in our office or at the Affinity Surgery Center using a Plastibell device.

How the Plastibell Works

The Plastibell is a plastic ring that remains on the penis and falls off on its own within 2 to 15 days, very similarly to an umbilical cord clamp.

Step-by-Step of the Procedure

1. The baby is secured safely on a padded restraint board.

2. The genital area is cleansed with an antiseptic solution (Betadine).

3. Local anesthesia (lidocaine) is injected at the base of the penis.

4. The foreskin is gently separated from the head of the penis and cleansed again.

5. The frenulum is released if necessary, and any minor bleeding is controlled.

6. The Plastibell ring is inserted inside the foreskin and secured to the skin with a sterile string. Dr. Hwang will adjust the device to correct minor conditions like mild penile twisting or partial foreskin deficiencies.

7. Excess foreskin is safely removed.

Important Note on Pain Management: Dr. Hwang applies numbing cream multiple times throughout the procedure to keep the area comfortable. Please remember to bring your prescription numbing cream with you to the procedure appointment, in addition to applying it at home before you leave.

Plastibell Monitoring

Occasionally, a baby may have normal erections that pull the Plastibell ring too low, causing it to become stuck on the head of the penis. If the Plastibell ring does not fall off on its own by 12 days after the circumcision, please take a clear photo and text it to us securely via Updox (https://forms.myupdox.com/form/100463) for Dr. Hwang to review.

Parental Presence

Parents are welcome to stay in the room during the procedure, though it is not mandatory. When the circumcision is performed in our office, both parents can be present. When it’s performed at the Affinity Surgery Center, both parents may come to the facility, but only one parent is permitted in the procedure room due to strict facility regulations.

Immediately After: As soon as the procedure is finished, you may hold and feed your baby. Most post-procedure discomfort can be managed easily with small doses of acetaminophen (Tylenol) and continued applications of numbing cream for a few days.

Post-Procedure Home Care Instructions

Managing Immediate Bleeding

The most common immediate complication is minor bleeding; infection is rare. Dr. Hwang may apply an elastic bandage if there is more than usual bleeding.

• If you notice bleeding at home, apply gentle, continuous manual pressure to the site using a clean gauze pad for 5 to 10 minutes.

• If the bleeding does not stop after continuous pressure, call our office immediately.

• Please avoid taking your baby straight to the Emergency Room if possible. Emergency room staff may not be familiar with specific infant circumcision care and will end up contacting Dr. Hwang anyway. Calling us directly ensures the fastest specialized care.

Hygiene and Infection Prevention

Routine oral or topical antibiotics are generally not necessary after a circumcision because the risk of infection is low. Keep the area clean by bathing your baby regularly with warm water and a gentle, non-irritating baby shampoo (a “tear-free” formula).

The Three-Week Follow-Up

We will schedule a follow-up appointment three weeks after the procedure to ensure the penis is healing correctly.

• Adhesion Prevention: At this visit, Dr. Hwang will evaluate the site for penile skin adhesions (where the healing skin tries to reattach to the head of the penis). Left unchecked, adhesions can turn into dense scar tissue that requires a future procedure. He will teach you the correct technique to regularly and gently retract the skin during diaper changes to prevent this.

• Steroid Cream Treatment: If an adhesion does develop early on, it is treatable fairly easily. Dr. Hwang will prescribe a topical steroid cream to use for a few weeks, followed by gentle manual separation in the office after pre-visit Tylenol and numbing cream application.

• Photo Consultations: If you have any concerns about healing, swelling, or redness before your appointment, you can text a photo to Dr. Hwang anytime via the secure Updox link (https://forms.myupdox.com/form/100463).

Why Dr. Hwang Prefers the Plastibell Method

After performing many newborn circumcisions using both the Gomco clamp and the Plastibell device, Dr. Hwang prefers the Plastibell method for several medical reasons:

• Lower Bleeding Risk: The Plastibell carries a lower risk of post-operative bleeding, reducing emergency or unexpected hospital visits.

• Accommodates Larger Babies: The Plastibell allows us to safely circumcise larger or older infants (up to 15 pounds or 4 to 6 months old). The Gomco clamp carries a much higher risk of bleeding in larger babies and often requires surgical sutures. Suturing causes more pain and is difficult to perform perfectly while a baby is awake and moving. Because of this limitation, doctors who use the Gomco method generally limit the procedure to babies under 10 pounds or under 1 month of age.

• Corrects Minor Torsion: The Plastibell allows Dr. Hwang to correct mild penile twisting (torsion) during the procedure. This improves the final cosmetic and functional outcome, preventing the child from needing a formal surgery under general anesthesia later.

• Protects Hidden Penises: The Plastibell can be safely used on babies with mild hidden or concealed penises. The rigid ring prevents the penis from retracting immediately back into the pubic fat pad during early healing. When a penis retracts too early, it can cause severe bleeding or a “trapped penis” (where skin scars completely over the tip of the penis), which requires corrective surgery under general anesthesia.