Circumcision​​

Table of Contents

Should my baby boy have a circumcision?

The decision for circumcision during infancy is a personal, cultural and religious 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.

What is circumcision?

Circumcision is the removal of the excess foreskin of the penis. Benefits include better hygiene, lowered risks of urinary tract 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.

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, device dislodgment, bleeding, infection and need for a repeat 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 using diathermy (a heat device that seals the blood vessels) and 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.

Plastibell
Figure 1. A plastibell device

Recovery post circumcision

Minimal bleeding is expected when the Plastibell is in place. This is a clean surgery and oral or topical antibiotics is not required. The patient can have normal baths. Painkillers may be required for the first 2 to 3 days. In babies, it is adviseable to change the diapers 3 to 4 hourly to keep the wound clean. After 5 to 8 days, the Plastibell drops off by itself because the excess foreskin shrivels up.

Minimal bleeding is expected when the Plastibell is in place. This is a clean surgery and oral or topical antibiotics is not required. The patient can have normal baths. Painkillers may be required for the first 2 to 3 days. In babies, it is adviseable to change the diapers 3 to 4 hourly to keep the wound clean. After 5 to 8 days, the Plastibell drops off by itself because the excess foreskin shrivels up.

In a child, minimal bleeding is expected and stops by itself. Slight swelling is normal as the the wound heals. Minimal yellow discharge may form on the head of the penis, because the raw skin is exposed and forming a more mature layer. The patient should have normal showers and painkillers is needed for the first 2 to 3 days.

The result is a penis showing the head up to the groove. Risks include excess bleeding, infection and early device dislodgement (if a Plastibell is used). Infection presents as redness, swelling, pain, warmth and abnormal discharge from the penis. If any of these complications occur, treatment is available and your doctor should be consulted early.

circumcision
Sketch depicting pre- and post-circumcision

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Dr Wong Zeng Hao
Dr Wong Zeng Hao

Paediatric Surgery & Urology International