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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. 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?
It may be performed during infancy or as a boy or as an adult. In the newborn or infancy, the benefit of circumcision is it can be performed without general anaesthesia (GA), hence avoiding GA risks. Secondly, there is little to no memory of the procedure having been performed. However, when performed in inexperienced hands, there are complications of injury to the tip of the penis, penile necrosis, device dislodgment, bleeding, infection and need for a repeat procedure. There is also the risk of ammonia dermatitis from the exposure of the glans to the urine sodden diaper. This can result in meatal stenosis or secondary phimosis requiring a second procedure.
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 on this page, 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 may be 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 of 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.
In a child, the procedure 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.
Recovery post circumcision
This is a clean surgery, oral or topical antibiotics is not required. The patient can have normal baths. Washing with normal saline or tap water after each pee helps with wound healing. Minimal bleeding or swelling is expected and should improve. Granulation tissue appearing as small yellowish areas may form 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 3 to 4 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 may be 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. 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 may be concerning for worsening of the condition and scarring (balanitis xerotica obliterans).
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