Making the Circumcision Decision

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The parents of a newborn boy must decide whether or not to have their child circumcised. Circumcision is not considered medically necessary so it is ultimately a parent’s choice. Because circumcision is usually performed in the first few days of life, it is best to consider the benefits and risks ahead of time so that you are not overwhelmed with the decision after delivery.


What Is Circumcision?


Boys are born with a layer of skin that covers the end of the penis called the foreskin or prepuce. Circumcision is an optional surgical procedure where this foreskin is removed exposing the tip (glans) of the penis and the urethral opening. Circumcision is commonly performed in the newborn-period by an experienced physician such as a pediatrician, family practitioner, obstetrician or a pediatric urologist. In special circumstances, circumcision may be performed at a later age by a pediatric urologist under general anesthesia.


History of Circumcision


Circumcision is an ancient practice that predates recorded history, so the exact origin is not known. It has been practiced as a religious rite for thousands of years.


In the early 1900s some Western societies began to advocate for circumcision to prevent disease. Scientific evidence for disease prevention was lacking, but nonetheless, the procedure remained common. In the past, as many of 90 percent of males in the United States were circumcised. In recent years that number has dropped to an estimated 60 percent and there are significant geographic variations.


What Happens?


Circumcision is usually performed in the hospital on the second or third day of life, though it can be performed in the outpatient setting ideally within the first 10 days of life. The infant is placed on a circumcision board to limit movement and the procedure takes approximately 10-20 minutes. Measures to control pain may include a pacifier dipped in sugar water, a topical anesthetic and a local nerve block.


Two commonly used techniques for foreskin removal include the GOMCO clamp and the Plastibell device. If the GOMCO clamp is used, the foreskin is removed with a scalpel and the exposed penis tip is covered with Vaseline gauze.


With the Plastibell, the excess skin is tied off and subsequently falls off with the plastic bell, ideally within 6-12 days. Mild swelling and scant bleeding can be expected after circumcision but excessive swelling, bleeding or increased redness should be brought to the attention of your doctor.


As the circumcision heals, it is important to gently pull back on any remaining foreskin so that it doesn’t reattach to the glans.


Care of the Uncircumcised Penis


If you elect to not circumcise your son, care of the uncircumcised penis in the newborn period simply entails washing the area with soap and water. The foreskin will separate from the glans of the penis in the first several years of life and once this happens, the foreskin can be pulled back or retracted. It is important to never force foreskin retraction. Most boys can retract their foreskin by age 4 to 5 years.


Other Considerations


Check with your health insurance plan to see if the procedure is covered. Not all insurance plans cover circumcision, so parents may be responsible for the cost out of pocket. Ultimately parents have to weigh the benefits and risks to decide what is in their child’s best interest. Consultation with your baby’s doctor is advised prior to making the final decision about circumcision.


The Pros


Medical benefits of circumcision include a slightly decreased rate of urinary tract infections in the first year of life, and decreased transmission of sexually transmitted infections. Circumcised males also have a lower rate of penile cancer though penile cancer is extremely rare. The current stance of the American Academy of Pediatrics is that these medical benefits are not sufficient to recommend routine circumcision for all males.


Parents often elect circumcision for societal reasons. They may want their son to look like other males in the family, or are concerned that their child will look different than his peers.


The Cons


Circumcision is not considered medically necessary and parents may have fear of putting their newborn through an elective procedure. Though uncommon, there are risks associated with any surgical procedure including excessive bleeding, infection and adverse reaction to anesthesia. In some cases, there is a poor cosmetic result and revision of the circumcision may be necessary.


Some infants cannot undergo routine circumcision due to a suspected bleeding disorder, premature birth or birth anomalies of the penis. In such special circumstances, consultation with a specialist is advised.


Dr. Johathan Maynard is a pediatric resident at Levine Children’s Hospital and Dr. Erin Stubbs is a general pediatrician at Myers Park Pediatrics and Levine Children’s Hospital.