Circumcision is the one of the most commonly performed surgical procedure. It is associated with lots of misinfrmation & misconceptions. Following are the few of commonly asked questions regarding circumcision & their answers.

Q-What are reasons for doing circumcision?

Newborn circumcision consists of removal of the foreskin to near the coronal sulcus performed in early infancy (before age 2 months). The procedure prevents phimosis, paraphimosis, and balanoposthitis. Meatitis is more common in circumcised boys. There is no evidence that meatitis leads to stenosis of the urethral meatus.
It is particularly important that uncircumcised boys be taught careful penile cleansing. As the boy grows, cleansing of the distal portion of the penis is facilitated by gently, never forcibly, retracting the foreskin only to the point where resistance is met. Full retraction may not be achieved until age 3 years or older.
A small percentage of boys who are not circumcised as newborns will later require the procedure for treatment of phimosis, paraphimosis, or balanoposthitis. When performed after the newborn period, circumcision may be a more complicated procedure.

The follow up is a summary of factors relating to neonatal circumcision, which may be considered by parents before deciding on the procedure.

Religious

Traditional, cultural, and religious factors play a role in the decision made by parents, paediatrician, obstetrician, or family practitioner on behalf of a son. The final decision by parents is based on true informed consent. It is advantageous for discussion to take place well in advance of delivery, when the capacity for clear response is more likely.

Prevention of Phimosis

Phimosis is tightness of foreskin with inability to retract for hygiene. It is very common in newborn period. It resolves in few children as they grow, but persists in many. Circumcision should be done in infancy or at least before boy starts school.

Faciliation of Hygiene

Circumcision, properly performed, eliminates much of the need for careful penile hygiene. If circumcision is not performed, lifelong penile hygiene is required. Factors such as climate, the social and emotional reaction of prospective parents to penile cleansing, and the ability to understand and facilitate good hygiene, etc. should be taken into account when deciding whether circumcision should be performed.

Urinary Tract Infections

Studies conducted at US Army hospitals involving more than 200,000 men showed a greater than tenfold increase in urinary tract infections in uncircumcised compared with circumcised male infants; moreover, as the rate of circumcision declined throughout the years, the incidence of urinary tract infection increased. In another army hospital study, infants were examined in the first month of life and it was concluded that the high incidence of urinary tract infection in uncircumcised boys was accompanied by a similarly increased incidence of other significant infection, including bacteremia and meningitis26; Still another recent army hospital study lends support to a 1986 hypothesis that circumcision prevents preputial bacterial colonization and thus protects male infants against urinary tract infection..

Sexually Transmitted Diseases

There is higher risk of gonococcal and nonspecific urethritis in uncircumcised men,29,30 Published reports suggest that chancroid, syphilis, human papillomavirus, and herpes simplex virus type 2 infection are more frequent in uncircumcised men, .29,30,32-34

Cancer of the Penis

This condition occurs almost exclusively in uncircumcised men.12-14 In five major reported series since 1932, not one man had been circumcised neonatally.11, 15-19 The predicted lifetime risk of cancer of the penis developing in an uncircumcised man has been estimated at 1 in 600 men in the United States20
Factors other than circumcision are important in the etiology of penile cancer. The incidence of penile cancer is related to hygiene. In developing nations with low standards of hygiene, the incidence of cancer of the penis in uncircumcised men is 3 to 6 per 100,000 men per year22. The decision not to circumcise a male infant must be accompanied by a lifetime commitment to genital hygiene to minimize the risk of penile cancer developing. Poor hygiene, lack of circumcision, and certain sexually transmitted diseases all correlate with the incidence of penile carcinoma.

Cancer of the Prostate

There is presently no convincing scientific evidence to substantiate the assertion that circumcision reduces the eventual incidence of cancer of the prostate.

Cervical Carcinoma

There appears to be a strong correlation between squamous cell carcinoma of the cervix and sexually transmitted diseases. Human papillomavirus types 16 and 18 are the viruses most commonly associated with cancer of the cervix 35-38; Herpes simplex virus type 2 has also been linked with cervical cancer.36, 39 Although human papillomavirus types 16 and 18 are also associated with cancer of the penis,23,37 evidence linking uncircumcised men to cervical carcinoma is inconclusive. The strongest predisposing factors in cervical cancer are a history of intercourse at an early age and multiple sexual partners. The disease is virtually unknown in nuns and virgins.

Balanitis and Venereal Disease

Balanitis is infection of the glans.
Posthitis is infection of the foreskin. It occurs only in uncircumcised males.
Balanoposthitis is infection of both the glans and the foreskin. It is very painful. If this occurs, staged surgical corrections may be necessary - first a dorsal slit to allow inflammation to subside, and then a secondary circumcision. .
If Circumcision leaves foreskin remnants, which partially cover the glans, then any of these conditions may occur also in circumcised males.
Adequate studies to determine the relationship between circumcision and the incidence of venereal disease have not been performed.

Surgical Risk and Aftermaths

Circumcision is a surgical procedure that requires careful aseptic technique, systemized postoperative observation, and evaluation after discharge from the hospital.

Q-What Anaesthesia is required for circumcision?

Local Anesthesia

Dorsal penile nerve block using no more than 1cc lidocaine (without epinephrine) in appropriate doses (3 to 4 mg/kg)
Ring Block 1%-2% Lidocaine around root of penis

General Anesthesia

I.V. anaesthesia-using injectable medicines
Inhalation anaesthesia-using anaesthetic gases.

Q-What are the techniques of performing circumcision?

Circumcision is a safe surgical procedure if performed carefully by a trained, experienced operator using strict aseptic technique. The procedure should be performed only on a healthy, stable infant.
Various techniques are available . Precise method used depends on condition of penis & Surgeon’s preference.
Clamp techniques (eg, Gomco or Mogen clamps)-Metallic clamps are used
Plastibell (disposable plastic devise) give equally good results
Free hand surgical excision of skin followed by stitching

Q-when circumcision should not be done?

Circumcision is contraindicated in an unstable or sick infant.

Genital anomalies-Infants with genital anomalies, including hypospadias, should not be circumcised because the foreskin may later be needed for surgical correction of the anomalies.

Bleeding disorders. Appropriate laboratory studies should be performed when there is a family history of bleeding disorders.

Unstable infant. Wait till he is stabilised. Infants who have demonstrated an uncomplicated transition to extrauterine life are considered stable. Signs of stability include normal feeding and elimination and maintenance of normal body temperature without an incubator or radiant warmer.

Neonatal illness -A period of observation may allow for recognition of abnormalities or illnesses (eg, hyperbilirubinemia, infection, or manifest bleeding disorder) .That should be treated before elective circucision

Premature infant. It is prudent to wait until a premature infant meets criteria for discharge before performing circumcision.

Immediate neonatal period --or until complete neonatal physical adoption has occurred (usually 12 to 24 hours). The avoidance of circumcision in the delivery room is particularly important because neonatal disease is not always apparent at birth.

Q-what are the complications of circumcision?

Ans - Circumcision is a surgical procedure involving anaesthesia.Like any other surgery complications may occur.
The exact incidence of postoperative complications is unknown,50 but large series indicate that the rate is low, approximately 0.2% to 0 6%.44,45,51,52
The most common complications are local infection and bleeding. Deaths attributable to newborn circumcision are rare; there were no deaths in 500,000 circumcisions in New York City52 or in 175,000 circumcisions in US Army hospitals.51
Complications due to local anesthesia are rare and consist mainly of hematomas and local skin necrosis.41,46-49,54.
Newborns circumcision is a rapid and generally safe procedure when performed by an experienced operator. It is an elective procedure to be performed only if an infant is stable and healthy. Infants respond to the procedure with transient behavioral and physiologic changes.

Q-What happens after circumcision

procedure

One of the advantages of Circumcision by our technique is that, you need not make frequent visits to hospital for follow up. If any minor problem arises you can yourself manage it at home as per advice given below. But if you feel there is a problem you are not able to cope with, then immediately bring the child to us for proper assessment and management.

Q.1. There is a swelling of change?

Ans. Usually some swelling wil be there due to anaesthesic injection and presence of device. It will decrease after wards. If swelling is increasing contact us

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Q 2. There is colour change?

Ans. Some redish or bluish spot may be appear at injection site. There is nathing to worry. It wil disappear with time. Skin over the ring wil turn black. It is norml course of event, don’t worry.

Q 3. There are blebs on penis?

Ans. Due toallergy to a
ntiseptic. Rash may develop. Contact us for advice or treatment.

Q 4. Child complain of pain?

Ans. Some children complain of mild pain while passing urine. Give the prescribed medicine regularly if pain persists, contact us.

Q 5. Child has difficulty in passing urine?

Ans. Child wil pass urine freely and painlessly. Some children hold urine due to fear. Give him plenty of fulids to drink. Wash with warm water or make the child sit in a tub of warm water. He wil pass urine. In case difficulty persists,contact us.

Q 6. There is pus formation?

Ans. Dried up ointment and scab may appear like pus. Wash it well and apply ointment. In case there is some discharge contact us.

Q 7. Child has fever?

Ans. There wil not be any fever after circumcision. If temperature is >100f, then there is some othere problem. Contact us for assessment @ treatment.

Q 8. There is bleeding?

Ans. Blood may ooz from injection site,press the part with cotton.it wil stop. Some bleeding may occur at the time of seperation of ring. Wash it with clean cotton,bleeding wil stop. If bleeding persists,bring the child to hospital.

Q 9 Ans. Ring has not seperated?

Ans. The plastiblell ring wil separates and falls off on its own after healing of wounds. Attempt to remove it prematurely wil cause pain and bleeding. So leave it alone and don’t try to pull it. In case it has not separated by 15 days,then bring the child for ring removal

Q 10 Is adult cicumcision different from child circumcision?

Yes. In adults plastibell cannot be applied. Circumcision is done by Excision and suture. The redundant skin is cut away. Absorble stitches will be applied.which will dissolve later on. There will be dressing for 3 days

Q 11 How much rest is required after adult circumcision?

adults need no hospitalisation.Circumcision is done on out patient basis, under local anaesthesia. Person can walk home immediately after the procedure.Even at home there is no need for bed rest.You can walk about.& do mild indoor activities.

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