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What is circumcision?
Circumcision is the removal of the excess foreskin of the penis. Benefits include lower risks of urinary tract or foreskin infection, sexually transmitted disease and penile cancer. The absolute numbers of these risks are low, for example, the risk of urinary tract infection is 1 out of 1,000 patients for circumcised boys, and 1 out of 100 for uncircumcised boys. There are risks of the procedure which are discussed below.
Should my baby boy have a circumcision?
The decision for circumcision during infancy is a personal one. The American Academy of Paediatrics Circumcision Policy Statement recognizes the health benefits of circumcision but does not deem the procedure to be a medical necessity for the well-being of the child (1). Many parents from America, Australia and Philippines were circumcised when they were newborn and it is culturally acceptable. The Jewish and Arabic religions also propose it to be performed within 7 days of life.
When is the best time for circumcision?
The best time for circumcision remains controversial, and is strongly influenced by religious and cultural beliefs. It is performed during infancy or as a boy or as an adult. In the newborn or infancy, the circumcision can be performed without general anaesthesia (GA), hence avoiding GA risks. Secondly, there is minimal memory of the procedure having been performed. However, there are risks of secondary phimosis, skin bridges, device dislodgment, bleeding, meatal stenosis and need for a repeat procedure. Meatal stenosis or secondary phimosis is due to ammonia dermatitis from the exposure of the glans to the urine sodden diaper.
In childhood, there is the need for GA when the child is unable to cooperate and stay still. With age comes memory and stress post surgery. Conversely, when the child is able to cooperate, the operation can be performed under local anaesthesia, without need for GA.
Now, my son has grown up and has possible infection of the foreskin. Should he have a circumcision?
Your son should be examined by a paediatrician or a paediatric surgeon. During an acute infection of the foreskin, treatment is oral antibiotics and painkillers. After the infection has settled, your doctor will re-examine your child and advice whether circumcision or topical steroid cream should be used to prevent recurrent infection. The benefits and risks of circumcision are as discussed, and the procedure is the definitive treatment to prevent a recurrence. Topical steroid cream is effective in some patients, which is dependent on patient and caregiver compliance and technique. In uncooperative patients, it is difficult to apply the steroid cream and gently retract the foreskin, hence decreasing the effectiveness of treatment. Prolonged steroid cream use has the risk of skin ulceration further tightening the foreskin.
How is circumcision performed?
In the newborn, circumcision is performed under local anaesthesia and a Plastibell device is used (Figure 1). The baby is awake and has a pacifier dipped into glucose water for comfort. The foreskin is cleaned under antiseptic conditions. Local anaesthesia is given and the foreskin gently retracted. An appropriate sized Plastibell is selected and placed over the tip of the penis. A string is tied around the Plastibell to constrict the blood supply to the excess foreskin. Circumcision is completed by trimming the excess skin off. I have started to move away from doing the Plastibell to the free hand circumcision, because I find there is less risk of a secondary phimosis occuring.
In a child, free hand circumcision is performed under general and local anaesthesia. The excess foreskin is trimmed and hemostasis achieved using diathermy (a heat device that seals the blood vessels). The skin is closed with absorbable sutures. Another instrument used to trim the foreskin is laser, which works on a similar principle of heat sealing of the skin and blood vessels. The outcome of diathermy and laser is the same. I do not recommend using laser to avoid passing the cost to my patients. Do bring along boxer shorts or loose underwear for your child to wear after circumcision.
Recovery post circumcision:
This is a clean surgery, oral or topical antibiotics is not required. The patient can have normal baths. Washing with tap water or sterile solution after each pee helps keep the wound clean. Minimal bleeding or swelling is expected. Granulation tissue appears as small yellowish areas on or around the head of the penis, because the raw skin is exposed and forms a more mature layer.
In babies, it is advisable to change the diapers 2 to 3 hourly to keep the wound clean. If the diaper tends to stick to the wound, a thin layer of Vaseline can be applied to the diaper to prevent this. After 3 to 14 days, the Plastibell drops off as the excess foreskin shrivels up. In a child, pain improves after the 1st day, painkillers is required during the first 2 to 3 days.
Risks include excess bleeding, infection or early Plastibell dislodgement. Infection presents as increasing redness, swelling, pain, or abnormal discharge from the penis. If any of these occur, treatment is available and your doctor should be consulted early
Are there alternatives to circumcision?
Yes, topical steroid 0.1% betamethasone cream has been tried with varying success reported from 50 to 90% in the literature (2). It is important to know where and how to use the cream to ensure the highest efficacy. This should only be given for a maximum of 4 weeks. Recurrent tightening of the foreskin around the urinary tract opening is concerning for worsening of the condition and scarring (balanitis xerotica obliterans).
policy statement. American Academy of Pediatrics. Task Force on Circumcision.
Pediatrics. 1999 Mar;103(3):686–93.
(2) Moreno G, Corbalán J, Peñaloza B, et al. Topical corticosteroids for treating phimosis in boys. Cochrane Database Syst Rev. 2014 Sep 2;(9):CD008973.
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