Circumcision

What exactly happens during a circumcision?

Circumcision of the Baby Boy
If you are expecting a baby boy, you have an important decision to make before you take your son home: whether to circumcise him. For some families, the decision making process is simple because of cultural or religious beliefs. But for others, the right option isn't as clear-cut. Before you make a circumcision decision, it's important to talk to your child's pediatrician. Knowing the basics of circumsion will also help to make sure that you make a well-informed decision.

What Is Circumcision?
Boys are born with a foreskin that covers the head (also called the glans) of the penis. During a circumcision, the foreskin is surgically taken off, exposing the end of the penis. Approximately 56% of all newborn boys - about 1.1 million babies - are circumcised in the United States each year. The procedure is much more widespread in the United States, Canada, and the Middle East than in Asia, South America, Central America, and most of Europe, where it's uncommon. Parents who choose circumcision often do so based on religious beliefs, concerns about hygiene, or cultural or social reasons, such as the wish to have their son look like other men in the family.

If you choose to circumcise your baby, it's best to perform the operation within the first 2 to 3 weeks after birth. It can become more complicated as a child gets older. But the procedure is usually performed during the first 10 days (often within the first 48 hours), either in the hospital or, for some religious ritual circumcisions, at home. If you decide to have your son circumcised at the hospital, your pediatrician, family doctor, or obstetrician will perform the procedure before you bring your baby home. The doctor should prepare you by telling you about the procedure he or she will use and the possible risks.

In some instances, doctors may decide to delay the procedure or forgo it altogether. Premature babies or those who have special medical concerns may not be circumcised until they're ready to leave the hospital. And babies born with physical abnormalities of the penis that need to be corrected surgically often aren't circumcised at all because the foreskin may eventually be used as part of a reconstructive operation.

The Pros and Cons
Circumcised infants are less likely to contract a urinary tract infection (UTI) in the first year of life. Circumcised men may also be at lower risk for penile cancer, although the disease is rare in both circumcised and uncircumcised males. Studies show that circumcised men have a reduced risk of STD's.

It is easier to keep a circumcised penis clean. Uncircumcised boys can learn how to clean beneath the foreskin once the foreskin becomes retractable (usually some time before age 5). However, some uncircumcised boys can end up with infected foreskins as the result of poor hygiene. Thouroughly teaching young boys how to properly care for themselves is very important in preventing infection.

Some studies show that people claim circumcision either lessens or heightens the sensitivity of the tip of the penis, decreasing or increasing sexual pleasure later in life. Neither of these subjective findings has been proven to be true.

Even though being circumcised does appear to have some medical benefits, it also carries potential risks. It is a surgical procedure, and all surgeries carry risks. These risks are small, but you should be aware of both the possible advantages and the problems that can be associated with the procedure before you make your decision. Complications of newborn circumcision are uncommon, occurring in between 0.2% to 3% of cases. Of these, the most frequent are minor bleeding and local infection, both of which can be easily treated by your child's doctor.

One of the hardest parts of the decision to circumcise is knowing that the procedure can be painful. In the past, it wasn't common practice to provide pain relief for babies being circumcised, but because studies have shown that it benefits the infant to receive anesthesia, most doctors will now provide it. Also, the American Academy of Pediatrics (AAP) recommends the use of pain relief measures for circumcision. Even up until recently, though, anesthesia hasn't been universally used, so it's important to ask your doctor ahead of time what, if any, pain relief will be utilized with your son. Two primary forms of local anesthetic are used to make the operation less painful for your baby:

• a topical cream (a cream put on the penis) that requires at least 20 to 40 minutes to take its full effect
• an injectable anesthetic that requires less time to take effect and may provide a slightly longer period of anesthesia

Besides anesthesia, giving a pacifier dipped in sugar water can help reduce your baby's level of stress (and yours). Used together, these methods can decrease your baby's discomfort by more than 50%.

Caring for a Circumcised Penis
It is important to keep your son's penis clean, whether he is circumcised or not . The penis should be washed with soap and warm water every time you give your baby a bath. And you don't need to use cotton swabs, astringents, or any special bath products. Soap or baby wash will work just fine.

In newly circumcised babies, there are no special washing precautions. Being gentle is important because your baby may have some mild discomfort after the circumcision. If your son has a bandage on his incision, you might need to apply a new one whenever you change his diaper for a day or 2 after the procedure (put petroleum jelly on the bandage so it won't stick to his skin). Doctors often also recommend putting a dab of petroleum jelly on the baby's penis or on the front of the diaper to alleviate any potential discomfort caused by friction against the diaper.

The way that you take care of your baby's circumcision site may also vary depending on the type of circumcision procedure your child's doctor performs. It is important that you understand what type of aftercare will be needed. Make sure that you feel comfortable caring for the babies healing penis. It usually takes between 7 to 10 days for the circumcision to heal. Until it does, the tip may seem raw or yellowish in color. Although this is normal, certain other symptoms are not. Call your child's doctor right away if you notice any of the following:

• persistent bleeding
• redness around the tip of the penis that gets worse after 3 days fever
• signs of infection, such as the presence of pus-filled blisters not urinating normally within 6 to 8 hours after the circumcision

Caring for an Uncircumcised Penis
Just the same as a penis that has been circumcised, an uncircumcised penis should also be kept clean. No cotton swabs, astringents, or any special bath products are needed - simple soap or baby wash and warm water every time you bathe your baby will work.

You should never forcibly pull back the foreskin to clean beneath it. Carefully and gently tense it against the tip of the penis and wash off any smegma (the whitish "beads" of dead skin cells mixed with the body's natural oil). Over time, the foreskin will retract on its own so that it can be pulled away from the glans toward the abdomen. This happens at different times for different children, but most boys can retract their foreskins by the time they're 5 years old. As your son grows up, teach him to wash beneath the foreskin by gently pulling it back from the glans, rinsing the glans and the inside of the foreskin with soap and warm water, then pulling the foreskin back over the head of the penis.

Procedure
The baby is first placed in a special restraint called a circumstraint. It has Velcro straps to hold the baby's arms and legs down so that he cannot move.

The area is prepared with Betadine, which is an antiseptic. A surgical drape is placed over the baby. Some doctors will use local anaesthesia, but this is by no means common. Anaesthetic injections will cause the penis to swell, causing pain and making the surgery more difficult. Both injections and topical anaesthetic creams can be dangerous. General anaesthesia is never used on young babies because of the risk of breathing problems.

The foreskin opening in a newborn is normally very small, to prevent the entry of foreign matter, like fecal matter. The first stage of circumcision is to grasp the foreskin with forceps, and widen the opening. The foreskin is normally attached to the glans by a membrane called the synechia. The glans and inner lining of the foreskin are still developing in the young child. During circumcision, the synechia must be torn apart. Naturally, this is painful. The foreskin is clamped. A slit is made in the dorsal side of the foreskin. The slit is separated and the foreskin is laid back, exposing the raw and bleeding glans. A PlastiBell of appropriate size is slipped over the glans, and the foreskin is laid over it. A ligature is tied in the ridge of the bell, as tightly as possible around the foreskin. Oozing will occur if the ligature is loose. After one or two minutes to allow for crush, the foreskin is sliced off at the distal edge of the ligature using a knife or scissors. The surgeon trims as much tissue as possible to reduce the amount of necrotic tissue and the possibility of infection. The handle of the bell is snapped off at this time. The rim of tissue will become necrotic (dead) and separate with the bell in 5 to 10 days. Occasionally, edema (swelling) will trap the plastic ring on the shaft of the penis. In this case it's usually necessary to cut off the ring, using a guide and ring cutter, although application of ice will sometimes reduce edema enough to remove the ring.



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