Iowa Neonatology Handbook: Procedures

Circumcision

Iowa Neonatology Fellows
Peer Review Status: Internally Peer Reviewed

The controversial indications for circumcision have been discussed in the literature at length and is dealt with in recent publications including Report of the Task Force on Circumcision, Pediatrics 1989;84:388-391 and The Status of Circumcision of Newborns, NEJM 1990;322:1308-1315. Enclosed is an excerpt from the consent form presently used at the UIHC:

I. "What are the potential advantages of newborn circumcision? The glans of the penis is easier to keep clean if the male is circumcised. Because of this ease of cleanliness, certain infections which can occur in uncircumcised boys or men with poor hygiene cannot occur in those who are circumcised. Circumcision will prevent several conditions that cause an accumulation of fluid and swelling around the foreskin and glans, as well as a problem known as phimosis, which is the inability to retract the foreskin. Newborn circumcision protects against the later development of cancer of the penis, although this is an extremely rare disease. In recent years some new evidence, which is preliminary, suggests that the incidence of urinary tract infection in male infants may be decreased when circumcision is performed during the newborn period.

II. What are the potential risks and disadvantages of circumcision? The immediate risks of circumcision are bleeding, inadvertent injury to the remainder of the penis, and infection. Although circumcision is considered to be a generally safe procedure, in rare cases these or other complications can lead to severe problems and even death. Inflammation of the external urethral opening (meatitis) is more common in circumcised boys. Newborn circumcision is usually performed without anesthesia. Although the procedure is relatively brief, the newborn experiences some pain and discomfort.

III. What about local anesthesia? Traditionally newborn circumcision has been done without anesthesia because of the misconception that the newborn does not experience pain. In recent years, there has been more interest in providing local anesthesia for this procedure, but by no means is this universally accepted. Local anesthesia is provided by injecting a medication into the nerves at the base of the penis. If performed properly, this procedure will reduce the infant's pain and behavioral changes. Complications due to local anesthesia are rare and consist mainly of bleeding and damage to the skin where the injection occurs. Local anesthesia adds an additional element of risk to the procedure and thus far has not been used in large numbers of babies.

IV. The pediatric resident serving on the newborn nursery rotation and the obstetric resident assigned to the postpartum ward will be given instruction in Gomco clamp circumcision and dorsal penile block. They will be supervised by an attending member of the circumcision squad and will be signed off after demonstrating sufficient skill. The Gomco clamp method is described in detail in the chapter entitled "Circumcision" 378-388 in Atlas of Procedures in Neonatology, 2nd edition. Fletcher and MacDonald (eds), 1993, JB Lippincott Co., Philadelphia.

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