Circumcision
DEFINITION
Circumcision is one of the most common procedures performed in the community today. It is also an ancient procedure with significant cultural and religious importance.
The foreskin is a cylindrical fold of skin that covers the head of the penis. In the circumcision procedure, the foreskin is surgically removed and the skin on the shaft of the penis is secured behind the head of the penis.
Circumcision may be recommended for medical reasons such as;
Urinary tract infection (UTI) prevention in the setting of other bladder or kidney abnormalities
Recurrent balanitis (infections of the foreskin and glans penis)
Phimosis which is symptomatic and refractory to management with medicines alone
Balanitis Xerotica Obliterans (BXO) a severe inflammatory condition of the foreskin
Circumcision is also performed for religious, cultural and family reasons.
GOALS OF CARE
A circumcision should be performed in a child friendly environment, by a medical practitioner with adequate surgical skills and training to perform the operation safely, and also to treat the rare but serious complications that may arise. This is a consensus recommendation from the Royal Australasian College of Physicians (RACP).
OUTCOMES
Circumcision is a low risk procedure in well trained hands. For UTI prevention in boys with a normal bladder and kidney, 111 circumcisions need to be performed to prevent 1 UTI. For boys with severe reflux and recurrent UTIs, the number of circumcisions needed is between 4 and 7. The risk of UTI in a boy with a normal renal tract is so low, that the risk of other complications from circumcision outweighs the specific benefit of UTI prevention, so is not medically indicated if your son has normal kidneys and a normal bladder.
For Balanitis Xerotica Obliterans, circumcision is curative, and a small number of boys will need a follow up operation to address scarring on the eye of the penis (urethral meatus).
Other complications may arise from circumcision. Meatal stenosis (narrowing of the urethral meatus) is most common when the circumcision is performed in the newborn period, and if a ‘plastibell’ is used and/or if the frenulum is ligated. Meatal stenosis is the most common reason that patients require additional operations after a circumcision.
Prevalence and causes of meatal stenosis in circumcised boys
The risk of post operative bleeding is 1%. Most cases can be successfully treated with a compression dressing, but a small number of boys will need to go back under general anaesthetic to get control of the bleeding.
Less than 1% of patients will have an excess of shaft skin at completion of the procedure, and if this skin gets stuck in front of the head of the penis (called a pseudophimosis), then the patient will require a revision of the circumcision. Most boys with an excess of skin do not need reoperation, and will “grow in to it.”
The risk of injury to the head of the penis (glans) is very low, especially when performed by a well trained surgical practitioner, but if it occurs, injury to the glans has serious and life long impacts.
Circumcision is also one of the commonest procedures associated with errors relating to erroneous medical practices. The performance of circumcision by non-surgeons remains an area of controversy. (“An examination of erroneous medical practices in circumcision PSI June 2024”). For this reason, it is prudent to do as much research as possible about the skills, training and practices of the surgeon performing the procedure for your child.
Painful procedures on awake infants is another area of controversy, and recent literature has suggested that there is lasting impacts from performing painful interventions in terms of the risk of chronic pain, neurodevelopmental and motor difficulties in childhood and long term emotional difficulties in adulthood.
Effects of pain, sedation and analgesia on neonatal brain injury and brain development
Neonatal male circumcision is associated with altered adult socio-affective processing
OUR APPROACH
Dr Rob performs medically indicated circumcisions in a timely manner suited to the pathology. Pain management is optimised by a combination of general anaesthesia, so that the patient is unaware of the procedure being performed, and a penile nerve block using local anaesthetic, so that the penis is numb for up to 12 hours after the operation. This combination results in significantly less discomfort than those performed under sedation with topical and local anaesthetic.
The operation is performed using a scalpel, dissolving sutures and surgical magnification of the operating field, as this is the safest method, which can also provide the most tailored and best cosmetic and functional outcome.
For patients having circumcision for religious, cultural or family indications, Dr Rob performs them once the patient is at least 6 months old. This is the best balance of being old enough to have an easy, safe, straightforward anaesthetic and operation, and young enough that the patient does not recall the experience and the recovery is simplified by the patient still wearing nappies.
POST OPERATIVE RECOVERY AND CARE
The procedure is performed as a day case, so you will be able to take your child home a few hours after the surgery is complete.
The head of the penis may look red, or raw, and will be puffy for a few weeks. You will be asked to apply vaseline liberally to the penis at least three times per day, aiming to keep the penis well lubricated while it heals. If there is crusting, then daily baths in salty water is recommended, and well tolerated.
A post operative review will be conducted 1 week after the operation. The final cosmetic result may not be evident for many weeks after the surgery.