Circumcision

Circumcision is not medically necessary. It is purely a decision made by parents in regards to their infant sons. There are many reasons one may choose to seek circumcision for their infant son, including personal preference, religious obligations/circumstances or matters regarding cultural sensitivity. The Canadian Pediatric Society’s position statement on male infant circumcision is as follows, “The CPS does not recommend the routine circumcision of every newborn male” (1).

The Procedure

There are various ways to do a circumcision, none of them seemingly more superior than the other. The method I use is called a Plastibell method. I slip a small plastic ring between the head of the penis and the foreskin. I put a string around the ring and tie it tightly. The range of time required for it to fall off is between 4 and 21 days. Rarely the ring remains on after 21 days as the penis can get too big for the ring, making it a little difficult to remove. If the ring remains on after 21 days I would like you to see your family physician or myself so the string holding the ring can be snipped. You don’t have to do anything about the ring – it will simply fall off on its own, leaving a circumcision line. A circumcision usually takes about 20 minutes to complete.

I will use freezing but will need your permission to use it. There has been good research to show that freezing does help with pain response later in life. The freezing is given by means of a needle and I will use some cream to numb the skin first. I also like to give Tylenol about one hour before the procedure as well. I also use sweetened water for the baby to suck for comfort.

Benefits

There are some benefits associated with circumcision. Circumcision has been demonstrated to reduce the risk of certain medical conditions later on in life as follows:

• Phimosis: Between 0.8-1.6% (8-16 in 1,000) of uncircumcised males will require circumcision prior to puberty due to phimosis, which is a condition wherein the foreskin can not be retracted over the head of the penis due to scarring or inflammation. Statistically, in order to prevent one case of phimosis, 67 circumcisions would have to be performed.
• Decrease in early UTI: The risk of febrile UTI (UTI with fever) in uncircumcised male infants is 10 times higher (20.1% vs 2.4%) than their circumcised counterparts. The overall rate of UTI in males drops precipitously after the first few months of life. One would need to perform between 111 and 125 circumcisions in order to prevent a single case of febrile UTI. For high risk infants, that number drops to needing to perform 4-6 circumcisions to prevent one febrile UTI. It is important to interpret these numbers with caution, as an unknown portion may be related to contamination of the urine with bacteria from the skin instead of the bladder.
• HIV: In HIV-endemic countries, there is a profound reduction (50-60%) in new HIV cases in circumcised men. In North America, these numbers are fuzzier given the significantly lower prevalence of HIV in the general population, as well as IV drug use being a large contributing factor behind HIV transmission in Canada (13.7%). Dependent upon the population, in between 55-1231 (with a weighted average of 298) circumcisions need to be performed in order to prevent one case of HIV.
• HSV: Roughly 16 circumcisions have to be performed in order to prevent one case of herpes.
• HPV: Five circumcisions need to be performed in order to prevent one case of HPV.
• Penile cancer: Penile cancer is rare in developed countries (1 in 100,000) with phimosis being a strong risk factor for the same. Between 900 and 322,000 circumcisions need to be carried out in order prevent a single case of penile cancer.
• Cervical cancer (in female partners of circumcised men): 90 to 140 circumcisions need to be performed in order to prevent a single case of cervical cancer.

Risks

• Pain: Despite pre-procedure analgesia, infants may still experience pain during the procedure, but it’s generally well tolerated, as is the recovery.
• Bleeding: Can be minor (up to 1.5% risk when combined with mild, local infection). This is compared to 6% when circumcision is done later in life. Case studies have been published about catastrophic bleeding, however, these are exceedingly rare, and I have never seen one in several years of practice.
• Infection: Local, minor infection can occur 1 in 67 times. This number also gets higher in adulthood. Risk is decreased with local application of antibiotic ointment (to be done with every diaper change until the ring falls off after 24 hours).
• Late meatal stenosis: Narrowing of the urethral opening. Can occur between 2-10% of the time, and may require surgical dilation. This risk drops to <1% with petroleum jelly application during diaper changes for the first six months of life.
• Cosmetic: Sometimes, the ligature used to cut off blood supply to the foreskin remnant does not fully do the job. Occasionally, while the majority of the ring has fallen off, a small ‘skin tag’ of foreskin may remain viable and attached to the penis and ring. Or, a skin bridge may connect this skin tag to a portion of the body (typically the penile shaft). If the ring is retained after 21 days, please book a follow up for assessment. If further intervention is required, I will either refer to Pediatric Urology or manage in office as needed.
• Ring slippage: This is the most common ‘complication’. Sometimes, the ring slips down around the penile shaft instead of being pushed off the penis. If this happens, bring your son in and we will cut the ring. It is a quick procedure and it is best to do this as soon as it is noticed as opposed to letting the ring sit around the penile shaft risking ischemic injury.

Contraindications

There are some medical conditions that prevent us from carrying out circumcision. We will carefully examine your baby boy to ensure that it is safe for him to get a circumcision, and if not, will go over further implications and future management.

Things to Consider

Circumcisions are done at the Saskatoon Community Clinic, 455 2^nd Avenue North. Please call 306-652-0300 to book an appointment. As the surgery is deemed unnecessary, it is not covered by Saskatchewan Health so payment is required prior to the procedure.

Discharge Instructions:

What should I expect after circumcision?

• Antibiotic ointment should be used with each diaper change to keep the wound from sticking to the diaper/prevent infection.
• A yellowish discharge or coating may form where the circumcision was done. This is part of the healing process, but this should not last longer than a week.
• The Plastibell (ring) will fall off in 4 to 21 days.
• It takes 7-10 days for the penis to fully heal after circumcision once the ring has fallen off.

Are there any problems that can happen after circumcision?
Problems after circumcision are rare.

If any of the following concerns arise, contact Dr. Khan at the Saskatoon Community Clinic, 306-652-0300:

• Your baby does not urinate normally within 24 hours after the circumcision.
• There is persistent bleeding.
• There is redness around the tip of the penis that gets worse after three to five days.
• You notice any other signs of infection such as swelling or foul-smelling discharge.
• The Plastibell has not fallen off within 21 days.

Bathing your baby after circumcision:

• Squeeze water on the penis during diaper changes to keep clean.
• No bathing on the day of the procedure.
• Bathing can commence as per usual the first day after the procedure.

For a more detailed discussion, please read the Canadian Pediatric Society’s Position Statement on Newborn Male Circumcision at https://cps.ca/en/documents/position/circumcision.

Dr. M. Farhan Khan, Saskatoon Community Clinic
Adapted from Lakeside Medical Clinic
Data obtained from Canadian Pediatric Society – Position Statement on Newborn Male Circumcision

Printable version:
Circumcision Information Sheet