Circumcision Health Article

Diagnosis/Preparation

Despite a long-standing belief that infants do not experience serious pain from circumcision, physicians now believe that some form of local anesthesia is necessary. Over 80% of pediatric residents, 80% of family practice residents, and 60% of obstetric/gynecological residents are routinely given instruction on pain control for circumcisions. Local anesthesia is often injected at the base of the penis (dorsal penile nerve block) or under the skin around the penis (subcutaneous ring block). Both anesthetics block key nerves and provide significantly lowered perceived pain. EMLA cream (lidocaine 2.5% and prilocaine 2.5%) can also be used.

Aftercare

After circumcision, the wound should be washed daily. An antibiotic ointment or petroleum jelly may be applied to the site. If there is an incision, a wound dressing will be present and should be changed each time the diaper is changed. Sometimes a plastic ring is used instead of a bandage. The ring will usually fall off in five to eight days. The penis will heal in seven to 10 days.

Infants who undergo circumcision may be fussy for some hours afterward, so parents should be prepared for crying, feeding problems, and sleep problems. Generally, these go away within a day. In older boys, the penis may be painful, but this will go away gradually. A topical anesthetic ointment or spray may be used to relieve this temporary discomfort. There may also be a bruise on the penis, which typically disappears with no particular attention.

Risks

Complications following newborn circumcision appear in between two and six of every 1,000 procedures. Most complications are minor. Bleeding occurs in half of the complications and is usually easy to control. Infections are rare and occur at the circumcision site, the opening to the bladder, or at the tip of the penis as a result of contact with urine or feces. Infections are indicated by fever and signs of inflammation, and are treatable with antibiotics.

There may be injuries to the penis itself, and these may be difficult to repair. In 2000, there were reports that the surgical clamps used in circumcision were at fault in over 100 injuries reported between July 1996 and January 2000. In nearly all cases, the clamps were assumed to be in working order but had been repaired with replacement parts that were not of the manufacturer's specifications. Physicians were urged to inspect the clamps before use and ensure that their dimensions fit their infant patients.

Normal results

When an infant or an adult is circumcised, the surgical wound should heal quickly, with normal urinary function resuming immediately. An infant or older child should have no complications and should be able to pass through adolescence and eventual sexual activity normally. After a period of recovery, an adult male should be able to resume sexual intercourse normally.

Morbidity and mortality rates

Complications as a result of circumcision are usually minor if the physician is experienced and makes sure the Mogen or Gomco clamps that are used are in good working order. Severe penile injuries are rare, but they are serious, and include penile amputation (partial or total), laceration, hemorrhage, and damage to the urinary tract. Other serious complications such as meningitis, penile necrosis, necrotizing faciitis, and sepsis can occur. Some of these, like meningitis and sepsis, can even cause death.

Hidden complications also occur. Subcutaneous masses have been detected under the skin of the penis. These masses usually have no symptoms, but, left untreated, could lead more serious outcomes. Physicians should examine the penis at every well-baby checkup during the first year. If a mass is detected, it can easily be removed under a local anesthesia and sent to a pathology lab.

Alternatives

The only alternative to this surgery is to make an informed decision not to have an infant circumcised. Some Jewish parents are even electing not to hold a Bris Milah, a religious circumcision, for their sons, and choosing instead to hold a Brit Shalom, a naming ceremony, similar to that given for their infant daughters.

BOOKS

Gollaher, David L. Circumcision: A History of the World's Most Controversial Surgery. New York: Basic Books, 2000.

PERIODICALS

"Circumcision." Harvard Men's Health Watch 6, no. 3 (October 2001).

Imperio, Winnie Anne. "Circumcision Appears Safe, But Not Hugely Beneficial." OB GYN News 35, no. 7 (1 April 2000): 9.

"Link to Uncircumcised Males Found." Women's Health Weekly (May 9, 2002): 10.

Schmitt, B. D. "The Circumcision Descision: Pros and Cons." Clinical Reference Systems (2000): 1579.

OTHER

American Academy of Pediatrics. New AAP Circumcision Policy Released (Press Release). March 1, 1999. <http://www.aap.org/advocacy/archives/marcircum.htm>.

Janie F. Franz