Circumcision may be the oldest known surgical procedure. For the past 100 years, it has consistently been the most frequently performed surgery in the world.1 The procedure is performed on almost all males in the Jewish and Muslim communities. The World Health Organization estimates that 30% of males worldwide are circumcised; the majority are Muslims.2 In the United States, the prevalence of newborn circumcision peaked at 80% in the 1960s but had declined to 65% (or 1.2 million procedures annually) by 1999.1 Circumcision is less common in other developed countries, where it is often viewed as unnecessary. Many types of physicians perform circumcisions, including obstetricians, pediatricians, family physicians, and surgeons.
In addition to the religious reasons for circumcision, foreskins have been removed as trophies of battle, for hygienic reasons, as a milder form of castration, for cultural identity, and as a rite of passage.1 In the late 1800s, circumcision was touted as a means of freeing up the glans from a constricting foreskin that led to irritation of "other organs." Masturbation, headaches, gout, and a laundry list of other problems were thought to be preventable through circumcision. These theories were debunked in the 1900s, when cultural or cosmetic rationales for circumcision again became the norm. In recent years, new evidence has been emerging on the medical benefits of the procedure. Circumcision has been associated with a decreased risk of urinary tract infections; balanitis; phimosis; penile cancer; and sexually transmitted infections, including HIV infection.1,3-5
PREOPERATIVE COUNSELING
Parents have often reached the decision to have their infant circumcised before I say anything. However, as with any procedure, it is prudent to discuss the associated risks and benefits beforehand; misinformation among parents abounds. I tell parents about the above-mentioned medical benefits of circumcision. You may also want to mention that several studies of sexual satisfaction among circumcised and uncircumcised men have been done; these show similar to slightly increased satisfaction among circumcised men and their partners.1
Associated risks. I also discuss the risks associated with circumcision, which consist chiefly of pain, infection, and bleeding. Much less likely—but still possible—are lidocaine toxicity; trauma to the glans or urethra; and a "degloving" injury, in which the skin of the shaft retracts proximally and needs to be stitched back into place (seen primarily with the Gomco method). Another rare complication, seen primarily with the Mogen and Plastibell techniques, is paraphimosis. Meatal stenosis is a common late complication thought to be caused by chronic diaper irritation of an unprotected meatus; however, it is rarely of clinical significance.
I again emphasize that newborn circumcision is an entirely elective procedure. In a 2005 Task Force statement, the American Academy of Pediatrics did not recommend newborn circumcision. I also discuss the risk of a poor cosmetic outcome or a result that may not look exactly like what the parents had expected. Finally, I make sure that both parents are in agreement about proceeding with the procedure.
I often invite one or both parents to watch their baby's circumcision in order to relieve any anxiety about what is being done to their child. About half of parents take me up on this offer. It is a good idea to keep a chair nearby in case someone gets light-headed.
Contraindications. Cited contraindications to circumcision include illness, premature birth, age younger than 12 hours or older than 6 weeks, known bleeding diathesis, ambiguous or unusual appearance of genitalia, urethral anomalies, and—in the case of the Gomco method—a short penile shaft (less than 1 cm).3,4 If a hypospadias is discovered on cutting open the foreskin, it is recommended that the physician suture the foreskin back up and abandon the procedure; the urologist is likely to need to use the foreskin to repair the defect.6
ANALGESIA AND ANESTHESIA
After 1 hour of nothing by mouth to minimize the risk of aspiration, I place the infant on a restraint board, preferably with a cuddly blanket wrapped around his upper torso. I give him a pacifier dipped in a solution of 25% sucrose, which helps soothe him during the procedure.
Topical anesthetics, such as lidocaine or EMLA (eutectic mixture of local anesthetics), have been shown to reduce the pain of circumcision if applied in advance. Injectable lidocaine without epinephrine is most often used. Some physicians dilute the lidocaine with 0.1 mL of 1% sodium bicarbonate(Drug information on sodium bicarbonate) to counteract the burning effect of this agent. The maximum dose of lidocaine for children is 3 to 5 mg/kg.4 Given that 1% lidocaine contains 10 mg/mL, the maximum dose for a 3-kg newborn would be about 1.5 mL. I superficially inject 0.4 mL of 1% lidocaine without epinephrine at both the 10 o'clock and 2 o'clock positions; I draw back first to avoid intravascular delivery (Figure 1). Failure to wait a full 5 minutes after injection before starting the procedure may be the biggest pitfall in pain management during circumcision.4,6
Preparing for insertion of the bell. Next, use a straight clamp to create a crush line on the dorsal aspect of the foreskin at the 12 o'clock position. Again, tent the skin up as you advance the lower blade of the clamp in order to avoid entry into the urethra. The crush line should stop about 1 cm distal to the coronal sulcus (Figure 6).3,6 You need only keep the clamp on for a few seconds to create the crush line. Next, cut down the middle of the crush line with scissors that have at least 1 blunt-tipped blade (Figure 7). You are creating an opening through which the bell will later be inserted; it need only be large enough to accommodate the bell. If the cut edge of the crush line bleeds, briefly crush that edge again with the clamp.
Inserting the bell. With the glans exposed, determine which size bell will best cover the glans completely (1.3 cm is the most commonly used size). Too small a bell will force you to pull more foreskin than underlying mucosa through the hole in the base plate, and too large a bell will tent the foreskin up away from the shaft, making it hard to see landmarks. I wipe the edge of the bell with the petroleum gauze (this helps it slip off the foreskin at the end of the procedure) and apply the bell to the glans. Make sure that the bell completely covers the glans and that the arms of the bell remain perpendicular to the axis of the patient.
