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Circumcision
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Circumcision A Taddio, The Hospital for Sick Children, Toronto, ON, Canada and University of Toronto, ON, Canada ã 2008 Elsevier Inc. All rights reserved.
Glossary Circumcision – The surgical removal of the foreskin from the penis. Phimosis – Inability to retract the foreskin due to a narrow preputial ring. Preputial – Space between the foreskin and penis.
Introduction Circumcision is the most common surgical procedure performed in male infants in the newborn period. It originated over 5000 years ago and has become an important ritual in several cultures worldwide. Circumcision has been promoted for its health benefits including protection against urinary tract infection (UTI) in infancy, penile cancer, and HIV infection. However, it may cause numerous complications, including pain, bleeding, infection, phimosis, meatitis, and other adverse effects. Nonritual circumcisions are not routinely recommended by medical associations except in very select situations. For infants undergoing circumcision, established analgesic interventions should be used to minimize pain. These include injectable and topical local anesthesia, sucrose solutions, and acetaminophen.
History of Circumcision Male newborn infant circumcision is the most common planned surgical procedure, estimated to be practiced by 15% of the world’s male population. It is the subject, however, of continual controversy. It has been debated as a matter of hygiene, religious ritual, and infant mutilation. Although the origin of the procedure is unknown, one of the first records of circumcision dates back to Egyptian times, over 5000 years ago. The reason for circumcision may have involved a hygienic measure to combat either dry, dusty, and hot environments or disease. However, it may also have been performed for punitive reasons (attenuation of castration, as castration was often a mortal injury), as a pubertal or premarital rite, as an absolution against vaginal blood, or as a mark of slavery. For certain religious and cultural groups, circumcision is an important ritual. These groups include members of the Jewish religion as well as Muslims, black Africans, Australian
aborigines, and other groups around the world. There is a sociological component of circumcision as well. Circumcision provides a rite of passage for socialization and kinship. Written documentation of circumcision appears in the Bible, where the ritual was elevated to a religious act by the Jews. In the biblical Covenant of God with Abraham, the ‘father of the Hebrew nation’, circumcision is described as a sacrifice of the foreskin to be performed in male newborn infants on the eighth day of life. The act of circumcision, however, has been continuously debated. In the early Christian era, Christians debated the need to be circumcised in order to be ‘saved’ and circumcision was cast as a mutilation, which led to a revolt of Jews against Rome. The health benefits of circumcision became prominent in the nineteenth century. One of the theories promoted at that time was that circumcision prevented masturbation, which was the source of a variety of illnesses. Circumcision was believed to cure or prevent alcoholism, seizure disorders, asthma, gout, rheumatism, and many other conditions. In addition, circumcision was believed to act as a moderator of excessive sexual activity, making the practice consistent with mid-Victorian attitudes that sex was sinful. Circumcision became widespread in Englishspeaking countries around the turn of the century and was reinforced in the US in World War II due to hygienerelated urogenital disorders in noncircumcised soldiers. It began to be questioned by the medical community shortly thereafter, however, due to unproven benefits, and by the 1970s, national medical organizations declared that the procedure was not medically justified. The practice became virtually abandoned in the UK and uncommonly performed in other English-speaking countries except for in the US. In fact, the practice of routinely performing nonritual circumcisions in male newborn infants is unique to the US. In the US, the potential health benefits of circumcision were increasingly evaluated to justify prophylactic circumcision. In contrast, in Europe, studies of the natural course of foreskin development were undertaken that supported the conclusion that the procedure was unnecessary. There was also increasing opinion in Europe that experiences in the newborn period influenced emotional and psychological development in infants. Accordingly, gentle birth and gentle newborn experiences were promoted rather than violent birth and painful newborn circumcision. In 1985, in response to consumer demand for accurate information regarding circumcision, the National
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Organization of Circumcision Information Resource Centres (NOCIRC) was founded. It held its first international symposium in 1989 and declared that all human beings have a right to an intact body, including foreskin. Moreover, it stated that parents do not have the right to surgically remove the normal genitalia of their children and that physicians have the responsibility to refuse such procedures. It proclaimed that physicians practicing circumcision are violating the first maxim of medical practice, ‘‘First Do No Harm,’’ as well as the United Nations Declaration of Human Rights ‘‘No one shall be subjected to torture or to cruel, inhuman, or degrading treatment.’’ There is an ethical dilemma due to the fact that circumcision is not a medically necessary procedure but acceptable based on religio-cultural beliefs. From a human rights perspective, the right of parents to authorize the procedure on their child’s body for nontherapeutic reasons has been questioned. The best interests of the child are of paramount importance in such debates.
What is Circumcision? The male penis consists of a shaft, glans (cone-shaped end), urethral opening, foreskin or prepuce (redundant fold of penile skin which overlaps the glans penis), and the frenulum (fold of skin connecting the inner foreskin to the glans penis). The skin on the penile shaft and the outer part of the foreskin are similar; both are keratinized, stratified squamous epithelium, and barriers against infectious microorganisms. The inner part of the foreskin, however, is a mucosal membrane, and rich in blood supply and nerves, making it very sensitive to touch. At the time of birth, the foreskin is fused to the glans penis, and may not be retracted. If left unmanipulated, the foreskin separates from the glans penis over the first few years of life through physiologic processes including growth of the penis, accumulation of skin debris, and intermittent penile erections. Circumcision is a surgical procedure that involves removal of the foreskin. Removal of the foreskin during circumcision removes a natural protective barrier for the glans penis against irritation and infection from urine and feces. There is a compensatory effect, however, in that there is development of a thicker, tougher skin over the glans which may be more resistant to disease.
reasons. There are studies demonstrating both health benefits and complications of the procedure. Circumcision has benefits as a preventive health measure against conditions such as UTI, penile inflammatory conditions, penile cancer, and sexually transmitted diseases, including HIV. However, the benefits are counter-balanced by risks, including surgical complications and infant pain. Benefits of Circumcision There are several potential benefits of circumcision on future health (Table 1). Urinary tract infection Circumcision is associated with a significant reduction in the risk of UTI in boys. It has been postulated that the foreskin of uncircumcised males, which fosters a moist and warm environment, is conducive to the growth of infectious organisms. Circumcision may therefore prevent periurethral colonization of the foreskin by bacteria. Assuming that the incidence of UTI is 1% in the first year of life, there is a 10-fold reduction in risk to 0.1%. Most UTIs are uncomplicated, that is, they are diagnosed and treated with antibiotics, and do not lead to significant morbidity and mortality. A reduced incidence of UTI, therefore, does not lead to medical justification of routine circumcision of normal boys. Male infants with a history of recurrent UTI or underlying renal tract anomalies, however, may benefit from circumcision. In these infants, the risk of UTI ranges from 10% to 30%, respectively and circumcision may result in a substantial reduction to 1% to 4% respectively, in the occurrence of UTI. Penile cancer Circumcision may protect men against penile cancer. However, penile cancer is a rare disease; the incidence of it is extremely low (approximately 1 case per 100 000 males in the US). Furthermore, there is a strong relation between penile hygiene and penile cancer, such that good hygiene practices significantly reduce the risk of cancer. It has been estimated by Learman that more than 322 000 neonatal circumcisions would be required to prevent one
Table 1
The Debate over the Health Benefits of Circumcision There is currently widespread debate over whether newborn infants should be routinely circumcised for health
Potential benefits of circumcision
Prevention of Urinary tract infection Penile cancer Sexually transmitted disease, including HIV Penile inflammatory disorders
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case of penile cancer per year and estimates suggest that there are more deaths from circumcision than penile cancer each year. Sexually transmitted diseases, cervical cancer, and HIV infection
There is some evidence that circumcision reduces the risk of sexually transmitted diseases such as herpes, gonorrhea, Chlamydia, and syphilis. In a recent report by Fergusson, it was estimated that the overall rate of sexually transmitted diseases could be reduced from 10% to 5% if all males were circumcised. In addition, circumcision has been suggested to be protective against cancer of the cervix in women. Uncircumcised men have been reported to be three times more likely to be carriers of human papilloma virus, the infectious agent that is involved in development of cervical and penile cancer, compared to circumcised men (absolute risk, 20% vs. 6%, respectively). There are many factors that are believed to be important to overall infection transmission rates. For example, geographic location, access to healthcare, lifestyle, race, socioeconomic status, and sexual habits, all affect the pathogenesis of venereal diseases. The higher risk of sexually transmitted diseases in noncircumcised males is postulated to be due to the combined effects of overgrowth of pathologic organisms and susceptibility of the uncircumcised penis to minor trauma and ulcerative disease during intercourse. This, in turn, increases the risk of infection in males and their sexual partners. In addition, it is believed that the inner mucosal layer of the foreskin contains cells that are specific HIV-target cells and therefore facilitate HIV transmission. The role of circumcision in the epidemiology of disease appears to be particularly important for HIV infection, a condition that is associated with significant worldwide morbidity and mortality. Circumcision has been investigated as a prophylactic measure against HIV infection in regions of high disease prevalence and poor hygiene, such as subSaharan Africa. In a recent report by Auvert, there was a 60% reduction in the chance of becoming infected with HIV in sub-Saharan African men who were circumcised at the beginning of a 14-month observation period when compared to a group of men who were circumcised after the observation period (absolute risk, 1.8% vs. 4.4%, respectively). It is believed that, in the future, male circumcision will become a valuable tool for reducing men’s (as well as women’s) risk of acquiring HIV infection in communities where HIV is common. Penile inflammatory disorders
There are some medical complications that may arise in the development of the foreskin in uncircumcised boys
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that eventually leads to them being circumcised at an older age. These include phimosis (intractable foreskin), paraphimosis (retraction and constriction of the foreskin), balanitis (inflammation of the glans penis), posthitis (inflammation of the foreskin), and balanoposthitis (inflammation of the glans penis and foreskin). Being circumcised at a later age is associated with increased costs due to a more complicated surgical procedure that may involve general anesthesia as well as profoundly negative psychological effects in the child from fear of mutilation and pain. Circumcision has been advocated by some as a preventive measure against a future need for circumcision in boys by preventing these conditions from arising. The percentage of uncircumcised male children who require circumcision later due to such complications is not well documented; in the US, it is estimated to be in the order of 5–10%. It is important to make a distinction between ‘physiological’ and ‘pathological’ phimosis. Pathologic phimosis is due to recurrent infection of the foreskin causing scarring and narrowing of the preputial (between foreskin and penis) ring. Physiologic phimosis is an asymptomatic nonretractible foreskin. The underlying reason for many cases of postinfancy circumcision has been suggested to be from forceful retraction of the foreskin of infants by parents who are trying to ‘clean’ the penis, leading to complications. The proper care of the foreskin in uncircumcised male infants involves avoiding any manipulation. During infancy, when the foreskin and glans are attached to one another, external washing with water are sufficient. When the foreskin and glans have separated, then retraction of the foreskin and washing with water can be done. Phimosis is a diagnosis that is often made prematurely, but does not usually require treatment. It has been suggested that the diagnosis of phimosis should not be made before the age of 18 years in uncircumcised males, and that some men are never able to retract their foreskins. In these men, the preputial space cleans itself by secretions of the prostate, seminal secretions’, and mucin secretions. The sloughed epithelial cells (smegma), which lubricate and protect the glans, are broken down by these secretions as well. If treatment is needed, then nonsurgical techniques such as gentle stretching and topical steroids (such as 1% hydrocortisone or 0.05% betamethasone 2–4 times daily for 4–12 weeks) are tried first before circumcision is performed. Complications of Circumcision Circumcision is a surgical procedure and like all surgical procedures, is associated with a risk of complications (Table 2). The overall complication rate is estimated to be between 2% and 10%.
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Table 2
Potential risks of circumcision
Acute
Subacute
Pain Bleeding Infection Amputation
Phimosis Skin bridges Inclusion cyst Meatitis Urethrocutaneous fistula Penile sensation Inadequate foreskin removal
Pain
Circumcision causes intense pain in newborn infants, which is evident by striking changes in physiologic and behavioral parameters. The physiological manifestations of pain include activation of the sympathetic autonomic nervous system and the ‘flight or fight’ response. Behavioral responses to pain including facial grimacing expressions and intense crying. In the immediate postoperative period, continued pain from the wound causes frequent crying and fewer infant interactions with mothers. Circumcision pain may cause long-term changes in pain responsiveness as well, due to ‘imprinting’ of pain in their memory. In two separate studies, the pain response during routine immunization 4 to 6 months after circumcision was more intense among circumcised male infants compared with uncircumcised male infants. Administration of anesthesia for circumcision partially attenuated the hypersensitivity to future pain. Until recently, most circumcisions were performed without the benefits of analgesia. Analgesics were not administered routinely because of the beliefs that newborn infants could not feel pain or that it was unimportant to manage, and because of concerns regarding the adverse effects of drugs. It is now recognized that the pain from circumcision is clinically important and should be prevented. Effective pain-relieving medications have also been evaluated and demonstrated to be safe. In its 1999 policy statement on circumcision, the American Academy of Pediatrics (AAP) recommended that if circumcision is to be performed on an infant, adequate analgesia should be provided. Bleeding
Bleeding occurs in approximately 1% of circumcision cases. Most episodes are minor and only require administration of pressure on the wound for treatment. Rarely, bleeding can be sufficiently severe so as to require medical intervention (such as silver nitrate, dilute lidocaine with epinephrine, fibrin, sutures, blood transfusion). Circumcision is contraindicated in infants with clotting abnormalities or a family history of bleeding disorders due to the risk of hemorrhage.
Infection Infection occurs slightly less frequently than bleeding. Usually, infection is limited to the wound and can be treated with topical antibiotics. Rarely, however, it spreads and can become life threatening. Phimosis Phimosis is a relatively common complication of inadequate circumcision. It results from the insufficient removal of foreskin and resulting contraction of scar tissue during healing. It may lead to obstruction of urinary flow and infection as well. When present, this complication leads to a repeat circumcision in approximately 10% of cases. Skin bridges Skin bridges are connections between the penile shaft and glans penis. They are thought to form when the glans sustains a minor injury during circumcision and fuses with the circumcision wound. Skin bridges can cause curvature of the penis and pain during erections. They are treated by surgical division under local anesthesia. Inclusion cysts Inclusion cysts are due to excess skin that folds inward or by smegma in the circumcision wound. They can become large and infected, and may require surgical excision. Urethrocutaneous fistula A fistula (abnormal opening) may be caused by injury to the urethra, usually by entrapment of the urethra in the clamp during circumcision or necrosis during aggressive treatment for circumcision bleeding. The complication requires surgical intervention in the first year of life. Meatitis The foreskin protects infants from irritation due to incontinence. Meatitis, an inflammatory condition of the urethral opening (meatus), is a common complication of circumcision, occurring in between one-tenth to onethird of infants. It is caused by injury to the penis from ammonia in wet diapers. Meatal stenosis (narrowing of the urinary opening), ulcers, and infections may also occur. These complications virtually never occur in noncircumcised penises. Penile injury Traumatic penile amputation is a complication of circumcision. The risk of this complication is not well
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documented but believed to be rare. It is immediately treated with microreplantation with variable success. The risk of amputation appears to be greater for the Mogen clamp compared to other instruments. Inadequate foreskin removal
The amount of foreskin removed may be either insufficient, excessive, or the pattern of removal may be asymmetrical, leading to poor cosmetic results. In addition, penile curvature from scarring skin may occur. Penile sensation
The clinical significance of removal of the foreskin on genital sensations has been a topic of much debate. Studies do not demonstrate a clear pattern of effects of circumcision on either penile sensation or sexual satisfaction. It has been suggested, however, that these studies are flawed because the differences are not in sensation of the glans, but rather, in alterations in sensation due to removal of the foreskin. The foreskin is rich in nerves and provides a gliding mechanism for the penis during intercourse. Moreover, the foreskin contains smegma, the exudates of dead skin cells and oils that may prevent the loss of vaginal secretions. The presence of the foreskin may therefore enhance sexual satisfaction in noncircumcised males. In support of this hypothesis are testimonials from men who were circumcised as adults claiming that sensitivity was lost after the foreskin was removed and that sexual satisfaction was harder to achieve. A number of circumcised men have subsequently undergone foreskin restoration, a practice that dates back to the first century, in order to regain their lost foreskin.
The Circumcision Decision Deciding whether or not to circumcise an infant is a decision that is currently made by the parents. In Western society, the overall rate of complications from circumcision is similar, if not higher, than the rate of benefits, and circumcision has not been accepted as a universal public health measure by national organizations such as the AAP and the Canadian Paediatric Society (CPS). Despite these position statements, however, there is no clear effort to try to eliminate routine circumcision by the medical community. There are other important determinants of circumcision practices, such as infant-specific benefit– risk assessments, cultural, religious, and economic considerations. Parents’ decisions about whether or not to circumcise their male infants are usually based on religious, cultural, or personal beliefs rather than on the health
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benefits and risks of circumcision, and, as such, circumcision will continue to be practiced unless attitudes and traditions are altered. The most prevailing reasons for nonritual circumcision are that the boy’s penis must be identical to the father’s penis or that the appearance of an uncircumcised penis is unappealing. It must be recognized that these attitudes are culturally based, and the reverse may be said for circumcised penises by the majority of the world’s population who does not circumcise.
The Circumcision Procedure It is currently estimated that 60% of male infants in the US are circumcised. For these infants, every possible measure should be undertaken to ensure that the procedure is successful and that the infant’s pain is minimized. Careful inspection of infant anatomy is important before performing circumcision as the procedure is contraindicated in the presence of certain anatomic abnormalities, including; hypospadias and epispadias (birth defects of the penis and urethra in which the urethra opening does not appear at the head of the penis but on the ventral or dorsal aspect of the shaft), displacement of urethral meatus, and an abnormally short penile shaft. This is because foreskin tissue may be needed for their future repair. In addition, circumcision is contraindicated in infants with bleeding disorders or a family history of bleeding disorders due to the potential for postcircumcision hemorrhage. It is contraindicated in preterm and ill infants as well, until they are able to safely undergo the procedure. Circumcision can be performed using a variety of surgical techniques. Clinicians are trained and experienced in the use of a particular technique, and each technique offers advantages and disadvantages over the other methods. In all cases, circumcision is accomplished by causing a crush injury to the foreskin with an instrument while shielding other parts of the anatomy. The physician must estimate the amount of foreskin to excise, detach it from the glans penis and leave the surgical instrument in place sufficiently long enough to ensure that there is a stoppage of bleeding (hemostasis) before amputation of the foreskin. The most common instruments used to perform circumcision are the Gomco clamp (67%), Mogen clamp (10%), and Plastibell device (19%). With the Gomco and Mogen clamps, the foreskin is crushed and surgically excised. In the Gomco technique, a bell-shaped apparatus is placed over the glans penis and under the foreskin to protect the glans. Then a ring is placed over the foreskin and tightened to crush the foreskin. The foreskin is excised and the clamp removed. With the Mogen clamp, the foreskin is lifted in an upward
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and outward direction and the clamp is secured around it. While the clamp is secured the foreskin is cut distal to the clamp. With the Plastibell device, a plastic shield is placed between the glans and the prepuce and secured in place with a ligature. The majority of the prepuce is removed, but the plastic ring is left in place and falls off after approximately 10 days with the remaining foreskin after it has become necrotic and sloughed off. The Mogen clamp is commonly used in religious circumcisions. It involves a less complicated procedure, resulting in a shorter surgery time (1 or 2 min vs. 5–10 min for the Gomco clamp) and less pain. The Gomco clamp is considered safer and is used more commonly in medical settings. It is associated, however, with an increased risk for excessive foreskin removal, leaving an abnormally denuded penis. The Plastibell seems to be associated with a higher risk of complications, including infection, urinary retention, strangulation of the tissue, and necrosis of the glans. Postoperative management of the circumcised penis involves dressing changes and topical administration of petroleum jelly on the healing glans until it is fully epithelialized, which usually takes about 1 week to 10 days. The penile skin is retracted regularly while it is healing to ensure that there are no adhesions forming onto the glans. The glans will appear ‘raw’ and have a yellowish exudate crust until healed.
Analgesia for Circumcision There are well-established analgesic techniques for the management of circumcision pain (Table 3). Local anesthetic infiltration techniques
Infiltration of local anesthesia is considered the most effective single analgesic method for attenuating circumcision pain. The injection technique most commonly used to administer the anesthetic is the dorsal penile nerve block (DPNB). First described in 1978, DPNB involves injecting local anesthetic at the base of the penis at Buck’s fascia. More recently, penile block has been performed by
Table 3
Analgesics for circumcision pain
Route of administration
Agent
Injection
Lidocaine Chloroprocaine Bupivacaine Lidocaine–prilocaine (EMLA) Sucrose Acetaminophen (postoperative)
Topical Oral
injecting local anesthetics in the foreskin or the subpubic space; these techniques, however, are less common than the DPNB. The anesthetic usually used is lidocaine solution because of its proven tolerability and efficacy in newborns. Vasoconstrictive drugs such as epinephrine (adrenaline) are never added because they can reduce blood supply to the penis and lead to necrosis. The total lidocaine dose used usually ranges from 0.4 to 1 ml (0.2 to 0.5 ml per injection) of a 1% solution, maximum dose 7 mg kg 1. To allow time for the anesthetic to work, it is administered 3–5 min prior to the procedure. DPNB is estimated to reduce crying time by about 50% in newborn infants undergoing circumcision. In addition, it reduces heart rate changes due to pain by about 35 beats per minute. It also maintains oxygen saturation in the blood at a 3% higher percentage, where normal values are greater than 95%. Unfortunately, lidocaine infiltration techniques cause pain due to the additional needle puncture required for their administration as well as the burning sensation from the local anesthetic itself. Studies in adults demonstrate that pain from lidocaine can be attenuated by warming the solution to body temperature prior to injection and by injecting it slowly. In addition, the solution can be neutralized by the addition of sodium bicarbonate in a ratio of 1 part sodium bicarbonate to 9 or 10 parts lidocaine. Topical anesthesia with lidocaine–prilocaine cream prior to DPNB can decrease the pain of needle puncture. DPNB is associated with injection-related complications in 7% of cases; most commonly bruising and/or hematoma. Although very effective, anesthetic infiltration techniques have not been demonstrated to prevent pain in all infants. Treatment failures have been at least partially attributed to technical failures and/or waiting an insufficient period of time for the anesthetic to work before performing the procedure. There is a potential for serious adverse effects from systemic lidocaine toxicity (e.g., seizures, dysrhythmias) that might occur after inadvertent intravascular injection of the drug. Intravascular administration is easily avoided if negative pressure is used to check for the absence of blood during injection of the local anesthetic. DPNB does not appear to affect the time to first urination postoperatively and future erections in infancy. Topical local anesthesia Lidocaine–prilocaine 5% cream (EMLA) is an oil inwater emulsion made up of equal parts of two local anesthetics, lidocaine and prilocaine. Lidocaine–prilocaine has demonstrated efficacy in reducing pain during circumcision. The usual dose is between 0.5 and 2 g applied to the penis for 60–90 min under an occlusive dressing.
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Lidocaine–prilocaine is less effective than local anesthetic infiltration methods, reducing crying time by 15% and heart rate by 15 beats per minute. Lidocaine–prilocaine is frequently associated with transient minor skin reactions such as pallor or redness. Allergic reactions are rare. Methemoglobinemia is the main systemic adverse effect that can occur following its use, and is a condition characterized by the inability of hemoglobin in red blood cells to carry oxygen to the tissues. To date, methemoglobinemia has only been reported when overdoses of lidocaine–prilocaine cream were administered to infants. Fortunately, if it occurs, methemoglobinemia is easily diagnosed by changes in skin color (cyanosis) due to poor tissue oxygenation. It is also completely reversible by giving methylene blue, the antidote.
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feel pain beyond the first post-operative day and that they should receive analgesics.
Summary This article summarizes the most common planned surgical procedure in male infants, circumcision. It reviews the history of circumcision, the benefits and risks associated with the procedure, and the analgesic interventions used to minimize pain. Current evidence suggests that routine circumcision is not advocated based on health benefits. However, the benefits of circumcision must be weighed against the risks for individual infants and their families. See also: AIDS and HIV.
Sucrose
Sucrose (sugar) solutions have analgesic and calming effects when given to young infants undergoing painful procedures. It is not clear how sucrose works to reduce pain but it may involve stimulation of the body’s own natural painkillers (opioids) and distraction. Sucrose can be administered by mouth approximately 2 min prior to circumcision using either a syringe or a nipple/pacifier that is dipped in a sucrose solution. Sucrose solutions can be prepared by mixing one packet of sugar with 10 ml of water. Sucrose is not as effective as local anesthetics, however, and is optimally used in combination with local anesthetics. In addition, specially designed restraint chairs can be used that minimize infant stress associated with being restrained. Acetaminophen
Postoperative circumcision pain management has been a neglected area of study despite general recognition that there continues to be pain from the wound after the procedure and that urination, defecation, and diaper and dressing changes will further intensify postoperative pain. Although lidocaine used during circumcision may provide some postoperative pain relief, the duration of action is only a few hours. The duration of postoperative pain relief can be increased with the use of longer-acting local anesthetics during circumcision, such as bupivacaine. However, acetaminophen should be added to reduce postoperative pain. Acetaminophen is safe in newborn infants and has been administered in doses of 15 mg kg–1 by mouth prior to circumcision and 6-hourly postoperatively for the first postoperative day. It is unclear whether acetaminophen or other pain relievers are useful or safe beyond the first postoperative day because they have not been evaluated. However, given that it takes up to 10 days for the wound to heal, it is likely that infants continue to
Suggested Readings Alanis M and Lucidi R (2004) Neonatal circumcision: A review of the world’s oldest and most controversial operation. Obstetrical & Gynecological Survey 59: 379–395. American Academy of Pediatrics (1999) Circumcision policy statement. American Academy of Pediatrics: Task force on circumcision. Pediatrics 103: 686–693. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambeisoce J, Sitta R, and Puren A (2005) Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Medicine 2(11): e298. Brady-Fryer B, Wiebe N, and Lander JA (2004) Pain relief for neonatal circumcision. The Cochrane Database of Systematic Reviews. The Cochrane Library, 4. Castellsague X, Bosch FX, Munoz N et al. (2002) Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. New England Journal of Medicine 346(15): 1105–1112. Declaration of the First International Symposium on Circumcision (1989) The Truth Seeker 1(3): 52. Fergusson DM, Boden JM, and Horwood J (2006) Circumcision status and risk of sexually transmitted infection in young adult males: An analysis of a longitudinal birth cohort. Pediatrics 118: 1971–1977. Holman JR, Lewis EL, and Ringler RL (1995) Neonatal circumcision techniques. American Family Physician 52: 511–518. Learman LA (1999) Neonatal circumcision: A dispassionate analysis. Clinical Obstetrics and Gynecology 42: 849–859. Lerman SE and Liao JC (2001) Neonatal circumcision. Pediatric Urology 48: 1539–1557. Singh-Grewal D, Macdessi J, and Craig J (2005) Circumcision for the prevention of urinary tract infection in boys: A systematic review of randomised trials and observational studies. Archives of Diseases in Childhood 90: 853–858. Taddio A (2001) Pain management for neonatal circumcision. Paediatric Drugs 3: 101–111.
Relevant Websites http://www.aap.org – American Academy of Pediatrics, Dedicated to the Health of all Children. http://www.cps.ca – Canadian Paediatric Society.
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Circumcision A Taddio, The Hospital for Sick Children, Toronto, ON, Canada and University of Toronto, ON, Canada ã 2008 Elsevier Inc. All rights reserved.
Glossary Circumcision – The surgical removal of the foreskin from the penis. Phimosis – Inability to retract the foreskin due to a narrow preputial ring. Preputial – Space between the foreskin and penis.
Introduction Circumcision is the most common surgical procedure performed in male infants in the newborn period. It originated over 5000 years ago and has become an important ritual in several cultures worldwide. Circumcision has been promoted for its health benefits including protection against urinary tract infection (UTI) in infancy, penile cancer, and HIV infection. However, it may cause numerous complications, including pain, bleeding, infection, phimosis, meatitis, and other adverse effects. Nonritual circumcisions are not routinely recommended by medical associations except in very select situations. For infants undergoing circumcision, established analgesic interventions should be used to minimize pain. These include injectable and topical local anesthesia, sucrose solutions, and acetaminophen.
History of Circumcision Male newborn infant circumcision is the most common planned surgical procedure, estimated to be practiced by 15% of the world’s male population. It is the subject, however, of continual controversy. It has been debated as a matter of hygiene, religious ritual, and infant mutilation. Although the origin of the procedure is unknown, one of the first records of circumcision dates back to Egyptian times, over 5000 years ago. The reason for circumcision may have involved a hygienic measure to combat either dry, dusty, and hot environments or disease. However, it may also have been performed for punitive reasons (attenuation of castration, as castration was often a mortal injury), as a pubertal or premarital rite, as an absolution against vaginal blood, or as a mark of slavery. For certain religious and cultural groups, circumcision is an important ritual. These groups include members of the Jewish religion as well as Muslims, black Africans, Australian
aborigines, and other groups around the world. There is a sociological component of circumcision as well. Circumcision provides a rite of passage for socialization and kinship. Written documentation of circumcision appears in the Bible, where the ritual was elevated to a religious act by the Jews. In the biblical Covenant of God with Abraham, the ‘father of the Hebrew nation’, circumcision is described as a sacrifice of the foreskin to be performed in male newborn infants on the eighth day of life. The act of circumcision, however, has been continuously debated. In the early Christian era, Christians debated the need to be circumcised in order to be ‘saved’ and circumcision was cast as a mutilation, which led to a revolt of Jews against Rome. The health benefits of circumcision became prominent in the nineteenth century. One of the theories promoted at that time was that circumcision prevented masturbation, which was the source of a variety of illnesses. Circumcision was believed to cure or prevent alcoholism, seizure disorders, asthma, gout, rheumatism, and many other conditions. In addition, circumcision was believed to act as a moderator of excessive sexual activity, making the practice consistent with mid-Victorian attitudes that sex was sinful. Circumcision became widespread in Englishspeaking countries around the turn of the century and was reinforced in the US in World War II due to hygienerelated urogenital disorders in noncircumcised soldiers. It began to be questioned by the medical community shortly thereafter, however, due to unproven benefits, and by the 1970s, national medical organizations declared that the procedure was not medically justified. The practice became virtually abandoned in the UK and uncommonly performed in other English-speaking countries except for in the US. In fact, the practice of routinely performing nonritual circumcisions in male newborn infants is unique to the US. In the US, the potential health benefits of circumcision were increasingly evaluated to justify prophylactic circumcision. In contrast, in Europe, studies of the natural course of foreskin development were undertaken that supported the conclusion that the procedure was unnecessary. There was also increasing opinion in Europe that experiences in the newborn period influenced emotional and psychological development in infants. Accordingly, gentle birth and gentle newborn experiences were promoted rather than violent birth and painful newborn circumcision. In 1985, in response to consumer demand for accurate information regarding circumcision, the National
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Organization of Circumcision Information Resource Centres (NOCIRC) was founded. It held its first international symposium in 1989 and declared that all human beings have a right to an intact body, including foreskin. Moreover, it stated that parents do not have the right to surgically remove the normal genitalia of their children and that physicians have the responsibility to refuse such procedures. It proclaimed that physicians practicing circumcision are violating the first maxim of medical practice, ‘‘First Do No Harm,’’ as well as the United Nations Declaration of Human Rights ‘‘No one shall be subjected to torture or to cruel, inhuman, or degrading treatment.’’ There is an ethical dilemma due to the fact that circumcision is not a medically necessary procedure but acceptable based on religio-cultural beliefs. From a human rights perspective, the right of parents to authorize the procedure on their child’s body for nontherapeutic reasons has been questioned. The best interests of the child are of paramount importance in such debates.
What is Circumcision? The male penis consists of a shaft, glans (cone-shaped end), urethral opening, foreskin or prepuce (redundant fold of penile skin which overlaps the glans penis), and the frenulum (fold of skin connecting the inner foreskin to the glans penis). The skin on the penile shaft and the outer part of the foreskin are similar; both are keratinized, stratified squamous epithelium, and barriers against infectious microorganisms. The inner part of the foreskin, however, is a mucosal membrane, and rich in blood supply and nerves, making it very sensitive to touch. At the time of birth, the foreskin is fused to the glans penis, and may not be retracted. If left unmanipulated, the foreskin separates from the glans penis over the first few years of life through physiologic processes including growth of the penis, accumulation of skin debris, and intermittent penile erections. Circumcision is a surgical procedure that involves removal of the foreskin. Removal of the foreskin during circumcision removes a natural protective barrier for the glans penis against irritation and infection from urine and feces. There is a compensatory effect, however, in that there is development of a thicker, tougher skin over the glans which may be more resistant to disease.
reasons. There are studies demonstrating both health benefits and complications of the procedure. Circumcision has benefits as a preventive health measure against conditions such as UTI, penile inflammatory conditions, penile cancer, and sexually transmitted diseases, including HIV. However, the benefits are counter-balanced by risks, including surgical complications and infant pain. Benefits of Circumcision There are several potential benefits of circumcision on future health (Table 1). Urinary tract infection Circumcision is associated with a significant reduction in the risk of UTI in boys. It has been postulated that the foreskin of uncircumcised males, which fosters a moist and warm environment, is conducive to the growth of infectious organisms. Circumcision may therefore prevent periurethral colonization of the foreskin by bacteria. Assuming that the incidence of UTI is 1% in the first year of life, there is a 10-fold reduction in risk to 0.1%. Most UTIs are uncomplicated, that is, they are diagnosed and treated with antibiotics, and do not lead to significant morbidity and mortality. A reduced incidence of UTI, therefore, does not lead to medical justification of routine circumcision of normal boys. Male infants with a history of recurrent UTI or underlying renal tract anomalies, however, may benefit from circumcision. In these infants, the risk of UTI ranges from 10% to 30%, respectively and circumcision may result in a substantial reduction to 1% to 4% respectively, in the occurrence of UTI. Penile cancer Circumcision may protect men against penile cancer. However, penile cancer is a rare disease; the incidence of it is extremely low (approximately 1 case per 100 000 males in the US). Furthermore, there is a strong relation between penile hygiene and penile cancer, such that good hygiene practices significantly reduce the risk of cancer. It has been estimated by Learman that more than 322 000 neonatal circumcisions would be required to prevent one
Table 1
The Debate over the Health Benefits of Circumcision There is currently widespread debate over whether newborn infants should be routinely circumcised for health
Potential benefits of circumcision
Prevention of Urinary tract infection Penile cancer Sexually transmitted disease, including HIV Penile inflammatory disorders
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case of penile cancer per year and estimates suggest that there are more deaths from circumcision than penile cancer each year. Sexually transmitted diseases, cervical cancer, and HIV infection
There is some evidence that circumcision reduces the risk of sexually transmitted diseases such as herpes, gonorrhea, Chlamydia, and syphilis. In a recent report by Fergusson, it was estimated that the overall rate of sexually transmitted diseases could be reduced from 10% to 5% if all males were circumcised. In addition, circumcision has been suggested to be protective against cancer of the cervix in women. Uncircumcised men have been reported to be three times more likely to be carriers of human papilloma virus, the infectious agent that is involved in development of cervical and penile cancer, compared to circumcised men (absolute risk, 20% vs. 6%, respectively). There are many factors that are believed to be important to overall infection transmission rates. For example, geographic location, access to healthcare, lifestyle, race, socioeconomic status, and sexual habits, all affect the pathogenesis of venereal diseases. The higher risk of sexually transmitted diseases in noncircumcised males is postulated to be due to the combined effects of overgrowth of pathologic organisms and susceptibility of the uncircumcised penis to minor trauma and ulcerative disease during intercourse. This, in turn, increases the risk of infection in males and their sexual partners. In addition, it is believed that the inner mucosal layer of the foreskin contains cells that are specific HIV-target cells and therefore facilitate HIV transmission. The role of circumcision in the epidemiology of disease appears to be particularly important for HIV infection, a condition that is associated with significant worldwide morbidity and mortality. Circumcision has been investigated as a prophylactic measure against HIV infection in regions of high disease prevalence and poor hygiene, such as subSaharan Africa. In a recent report by Auvert, there was a 60% reduction in the chance of becoming infected with HIV in sub-Saharan African men who were circumcised at the beginning of a 14-month observation period when compared to a group of men who were circumcised after the observation period (absolute risk, 1.8% vs. 4.4%, respectively). It is believed that, in the future, male circumcision will become a valuable tool for reducing men’s (as well as women’s) risk of acquiring HIV infection in communities where HIV is common. Penile inflammatory disorders
There are some medical complications that may arise in the development of the foreskin in uncircumcised boys
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that eventually leads to them being circumcised at an older age. These include phimosis (intractable foreskin), paraphimosis (retraction and constriction of the foreskin), balanitis (inflammation of the glans penis), posthitis (inflammation of the foreskin), and balanoposthitis (inflammation of the glans penis and foreskin). Being circumcised at a later age is associated with increased costs due to a more complicated surgical procedure that may involve general anesthesia as well as profoundly negative psychological effects in the child from fear of mutilation and pain. Circumcision has been advocated by some as a preventive measure against a future need for circumcision in boys by preventing these conditions from arising. The percentage of uncircumcised male children who require circumcision later due to such complications is not well documented; in the US, it is estimated to be in the order of 5–10%. It is important to make a distinction between ‘physiological’ and ‘pathological’ phimosis. Pathologic phimosis is due to recurrent infection of the foreskin causing scarring and narrowing of the preputial (between foreskin and penis) ring. Physiologic phimosis is an asymptomatic nonretractible foreskin. The underlying reason for many cases of postinfancy circumcision has been suggested to be from forceful retraction of the foreskin of infants by parents who are trying to ‘clean’ the penis, leading to complications. The proper care of the foreskin in uncircumcised male infants involves avoiding any manipulation. During infancy, when the foreskin and glans are attached to one another, external washing with water are sufficient. When the foreskin and glans have separated, then retraction of the foreskin and washing with water can be done. Phimosis is a diagnosis that is often made prematurely, but does not usually require treatment. It has been suggested that the diagnosis of phimosis should not be made before the age of 18 years in uncircumcised males, and that some men are never able to retract their foreskins. In these men, the preputial space cleans itself by secretions of the prostate, seminal secretions’, and mucin secretions. The sloughed epithelial cells (smegma), which lubricate and protect the glans, are broken down by these secretions as well. If treatment is needed, then nonsurgical techniques such as gentle stretching and topical steroids (such as 1% hydrocortisone or 0.05% betamethasone 2–4 times daily for 4–12 weeks) are tried first before circumcision is performed. Complications of Circumcision Circumcision is a surgical procedure and like all surgical procedures, is associated with a risk of complications (Table 2). The overall complication rate is estimated to be between 2% and 10%.
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Table 2
Potential risks of circumcision
Acute
Subacute
Pain Bleeding Infection Amputation
Phimosis Skin bridges Inclusion cyst Meatitis Urethrocutaneous fistula Penile sensation Inadequate foreskin removal
Pain
Circumcision causes intense pain in newborn infants, which is evident by striking changes in physiologic and behavioral parameters. The physiological manifestations of pain include activation of the sympathetic autonomic nervous system and the ‘flight or fight’ response. Behavioral responses to pain including facial grimacing expressions and intense crying. In the immediate postoperative period, continued pain from the wound causes frequent crying and fewer infant interactions with mothers. Circumcision pain may cause long-term changes in pain responsiveness as well, due to ‘imprinting’ of pain in their memory. In two separate studies, the pain response during routine immunization 4 to 6 months after circumcision was more intense among circumcised male infants compared with uncircumcised male infants. Administration of anesthesia for circumcision partially attenuated the hypersensitivity to future pain. Until recently, most circumcisions were performed without the benefits of analgesia. Analgesics were not administered routinely because of the beliefs that newborn infants could not feel pain or that it was unimportant to manage, and because of concerns regarding the adverse effects of drugs. It is now recognized that the pain from circumcision is clinically important and should be prevented. Effective pain-relieving medications have also been evaluated and demonstrated to be safe. In its 1999 policy statement on circumcision, the American Academy of Pediatrics (AAP) recommended that if circumcision is to be performed on an infant, adequate analgesia should be provided. Bleeding
Bleeding occurs in approximately 1% of circumcision cases. Most episodes are minor and only require administration of pressure on the wound for treatment. Rarely, bleeding can be sufficiently severe so as to require medical intervention (such as silver nitrate, dilute lidocaine with epinephrine, fibrin, sutures, blood transfusion). Circumcision is contraindicated in infants with clotting abnormalities or a family history of bleeding disorders due to the risk of hemorrhage.
Infection Infection occurs slightly less frequently than bleeding. Usually, infection is limited to the wound and can be treated with topical antibiotics. Rarely, however, it spreads and can become life threatening. Phimosis Phimosis is a relatively common complication of inadequate circumcision. It results from the insufficient removal of foreskin and resulting contraction of scar tissue during healing. It may lead to obstruction of urinary flow and infection as well. When present, this complication leads to a repeat circumcision in approximately 10% of cases. Skin bridges Skin bridges are connections between the penile shaft and glans penis. They are thought to form when the glans sustains a minor injury during circumcision and fuses with the circumcision wound. Skin bridges can cause curvature of the penis and pain during erections. They are treated by surgical division under local anesthesia. Inclusion cysts Inclusion cysts are due to excess skin that folds inward or by smegma in the circumcision wound. They can become large and infected, and may require surgical excision. Urethrocutaneous fistula A fistula (abnormal opening) may be caused by injury to the urethra, usually by entrapment of the urethra in the clamp during circumcision or necrosis during aggressive treatment for circumcision bleeding. The complication requires surgical intervention in the first year of life. Meatitis The foreskin protects infants from irritation due to incontinence. Meatitis, an inflammatory condition of the urethral opening (meatus), is a common complication of circumcision, occurring in between one-tenth to onethird of infants. It is caused by injury to the penis from ammonia in wet diapers. Meatal stenosis (narrowing of the urinary opening), ulcers, and infections may also occur. These complications virtually never occur in noncircumcised penises. Penile injury Traumatic penile amputation is a complication of circumcision. The risk of this complication is not well
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documented but believed to be rare. It is immediately treated with microreplantation with variable success. The risk of amputation appears to be greater for the Mogen clamp compared to other instruments. Inadequate foreskin removal
The amount of foreskin removed may be either insufficient, excessive, or the pattern of removal may be asymmetrical, leading to poor cosmetic results. In addition, penile curvature from scarring skin may occur. Penile sensation
The clinical significance of removal of the foreskin on genital sensations has been a topic of much debate. Studies do not demonstrate a clear pattern of effects of circumcision on either penile sensation or sexual satisfaction. It has been suggested, however, that these studies are flawed because the differences are not in sensation of the glans, but rather, in alterations in sensation due to removal of the foreskin. The foreskin is rich in nerves and provides a gliding mechanism for the penis during intercourse. Moreover, the foreskin contains smegma, the exudates of dead skin cells and oils that may prevent the loss of vaginal secretions. The presence of the foreskin may therefore enhance sexual satisfaction in noncircumcised males. In support of this hypothesis are testimonials from men who were circumcised as adults claiming that sensitivity was lost after the foreskin was removed and that sexual satisfaction was harder to achieve. A number of circumcised men have subsequently undergone foreskin restoration, a practice that dates back to the first century, in order to regain their lost foreskin.
The Circumcision Decision Deciding whether or not to circumcise an infant is a decision that is currently made by the parents. In Western society, the overall rate of complications from circumcision is similar, if not higher, than the rate of benefits, and circumcision has not been accepted as a universal public health measure by national organizations such as the AAP and the Canadian Paediatric Society (CPS). Despite these position statements, however, there is no clear effort to try to eliminate routine circumcision by the medical community. There are other important determinants of circumcision practices, such as infant-specific benefit– risk assessments, cultural, religious, and economic considerations. Parents’ decisions about whether or not to circumcise their male infants are usually based on religious, cultural, or personal beliefs rather than on the health
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benefits and risks of circumcision, and, as such, circumcision will continue to be practiced unless attitudes and traditions are altered. The most prevailing reasons for nonritual circumcision are that the boy’s penis must be identical to the father’s penis or that the appearance of an uncircumcised penis is unappealing. It must be recognized that these attitudes are culturally based, and the reverse may be said for circumcised penises by the majority of the world’s population who does not circumcise.
The Circumcision Procedure It is currently estimated that 60% of male infants in the US are circumcised. For these infants, every possible measure should be undertaken to ensure that the procedure is successful and that the infant’s pain is minimized. Careful inspection of infant anatomy is important before performing circumcision as the procedure is contraindicated in the presence of certain anatomic abnormalities, including; hypospadias and epispadias (birth defects of the penis and urethra in which the urethra opening does not appear at the head of the penis but on the ventral or dorsal aspect of the shaft), displacement of urethral meatus, and an abnormally short penile shaft. This is because foreskin tissue may be needed for their future repair. In addition, circumcision is contraindicated in infants with bleeding disorders or a family history of bleeding disorders due to the potential for postcircumcision hemorrhage. It is contraindicated in preterm and ill infants as well, until they are able to safely undergo the procedure. Circumcision can be performed using a variety of surgical techniques. Clinicians are trained and experienced in the use of a particular technique, and each technique offers advantages and disadvantages over the other methods. In all cases, circumcision is accomplished by causing a crush injury to the foreskin with an instrument while shielding other parts of the anatomy. The physician must estimate the amount of foreskin to excise, detach it from the glans penis and leave the surgical instrument in place sufficiently long enough to ensure that there is a stoppage of bleeding (hemostasis) before amputation of the foreskin. The most common instruments used to perform circumcision are the Gomco clamp (67%), Mogen clamp (10%), and Plastibell device (19%). With the Gomco and Mogen clamps, the foreskin is crushed and surgically excised. In the Gomco technique, a bell-shaped apparatus is placed over the glans penis and under the foreskin to protect the glans. Then a ring is placed over the foreskin and tightened to crush the foreskin. The foreskin is excised and the clamp removed. With the Mogen clamp, the foreskin is lifted in an upward
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and outward direction and the clamp is secured around it. While the clamp is secured the foreskin is cut distal to the clamp. With the Plastibell device, a plastic shield is placed between the glans and the prepuce and secured in place with a ligature. The majority of the prepuce is removed, but the plastic ring is left in place and falls off after approximately 10 days with the remaining foreskin after it has become necrotic and sloughed off. The Mogen clamp is commonly used in religious circumcisions. It involves a less complicated procedure, resulting in a shorter surgery time (1 or 2 min vs. 5–10 min for the Gomco clamp) and less pain. The Gomco clamp is considered safer and is used more commonly in medical settings. It is associated, however, with an increased risk for excessive foreskin removal, leaving an abnormally denuded penis. The Plastibell seems to be associated with a higher risk of complications, including infection, urinary retention, strangulation of the tissue, and necrosis of the glans. Postoperative management of the circumcised penis involves dressing changes and topical administration of petroleum jelly on the healing glans until it is fully epithelialized, which usually takes about 1 week to 10 days. The penile skin is retracted regularly while it is healing to ensure that there are no adhesions forming onto the glans. The glans will appear ‘raw’ and have a yellowish exudate crust until healed.
Analgesia for Circumcision There are well-established analgesic techniques for the management of circumcision pain (Table 3). Local anesthetic infiltration techniques
Infiltration of local anesthesia is considered the most effective single analgesic method for attenuating circumcision pain. The injection technique most commonly used to administer the anesthetic is the dorsal penile nerve block (DPNB). First described in 1978, DPNB involves injecting local anesthetic at the base of the penis at Buck’s fascia. More recently, penile block has been performed by
Table 3
Analgesics for circumcision pain
Route of administration
Agent
Injection
Lidocaine Chloroprocaine Bupivacaine Lidocaine–prilocaine (EMLA) Sucrose Acetaminophen (postoperative)
Topical Oral
injecting local anesthetics in the foreskin or the subpubic space; these techniques, however, are less common than the DPNB. The anesthetic usually used is lidocaine solution because of its proven tolerability and efficacy in newborns. Vasoconstrictive drugs such as epinephrine (adrenaline) are never added because they can reduce blood supply to the penis and lead to necrosis. The total lidocaine dose used usually ranges from 0.4 to 1 ml (0.2 to 0.5 ml per injection) of a 1% solution, maximum dose 7 mg kg 1. To allow time for the anesthetic to work, it is administered 3–5 min prior to the procedure. DPNB is estimated to reduce crying time by about 50% in newborn infants undergoing circumcision. In addition, it reduces heart rate changes due to pain by about 35 beats per minute. It also maintains oxygen saturation in the blood at a 3% higher percentage, where normal values are greater than 95%. Unfortunately, lidocaine infiltration techniques cause pain due to the additional needle puncture required for their administration as well as the burning sensation from the local anesthetic itself. Studies in adults demonstrate that pain from lidocaine can be attenuated by warming the solution to body temperature prior to injection and by injecting it slowly. In addition, the solution can be neutralized by the addition of sodium bicarbonate in a ratio of 1 part sodium bicarbonate to 9 or 10 parts lidocaine. Topical anesthesia with lidocaine–prilocaine cream prior to DPNB can decrease the pain of needle puncture. DPNB is associated with injection-related complications in 7% of cases; most commonly bruising and/or hematoma. Although very effective, anesthetic infiltration techniques have not been demonstrated to prevent pain in all infants. Treatment failures have been at least partially attributed to technical failures and/or waiting an insufficient period of time for the anesthetic to work before performing the procedure. There is a potential for serious adverse effects from systemic lidocaine toxicity (e.g., seizures, dysrhythmias) that might occur after inadvertent intravascular injection of the drug. Intravascular administration is easily avoided if negative pressure is used to check for the absence of blood during injection of the local anesthetic. DPNB does not appear to affect the time to first urination postoperatively and future erections in infancy. Topical local anesthesia Lidocaine–prilocaine 5% cream (EMLA) is an oil inwater emulsion made up of equal parts of two local anesthetics, lidocaine and prilocaine. Lidocaine–prilocaine has demonstrated efficacy in reducing pain during circumcision. The usual dose is between 0.5 and 2 g applied to the penis for 60–90 min under an occlusive dressing.
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Lidocaine–prilocaine is less effective than local anesthetic infiltration methods, reducing crying time by 15% and heart rate by 15 beats per minute. Lidocaine–prilocaine is frequently associated with transient minor skin reactions such as pallor or redness. Allergic reactions are rare. Methemoglobinemia is the main systemic adverse effect that can occur following its use, and is a condition characterized by the inability of hemoglobin in red blood cells to carry oxygen to the tissues. To date, methemoglobinemia has only been reported when overdoses of lidocaine–prilocaine cream were administered to infants. Fortunately, if it occurs, methemoglobinemia is easily diagnosed by changes in skin color (cyanosis) due to poor tissue oxygenation. It is also completely reversible by giving methylene blue, the antidote.
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feel pain beyond the first post-operative day and that they should receive analgesics.
Summary This article summarizes the most common planned surgical procedure in male infants, circumcision. It reviews the history of circumcision, the benefits and risks associated with the procedure, and the analgesic interventions used to minimize pain. Current evidence suggests that routine circumcision is not advocated based on health benefits. However, the benefits of circumcision must be weighed against the risks for individual infants and their families. See also: AIDS and HIV.
Sucrose
Sucrose (sugar) solutions have analgesic and calming effects when given to young infants undergoing painful procedures. It is not clear how sucrose works to reduce pain but it may involve stimulation of the body’s own natural painkillers (opioids) and distraction. Sucrose can be administered by mouth approximately 2 min prior to circumcision using either a syringe or a nipple/pacifier that is dipped in a sucrose solution. Sucrose solutions can be prepared by mixing one packet of sugar with 10 ml of water. Sucrose is not as effective as local anesthetics, however, and is optimally used in combination with local anesthetics. In addition, specially designed restraint chairs can be used that minimize infant stress associated with being restrained. Acetaminophen
Postoperative circumcision pain management has been a neglected area of study despite general recognition that there continues to be pain from the wound after the procedure and that urination, defecation, and diaper and dressing changes will further intensify postoperative pain. Although lidocaine used during circumcision may provide some postoperative pain relief, the duration of action is only a few hours. The duration of postoperative pain relief can be increased with the use of longer-acting local anesthetics during circumcision, such as bupivacaine. However, acetaminophen should be added to reduce postoperative pain. Acetaminophen is safe in newborn infants and has been administered in doses of 15 mg kg–1 by mouth prior to circumcision and 6-hourly postoperatively for the first postoperative day. It is unclear whether acetaminophen or other pain relievers are useful or safe beyond the first postoperative day because they have not been evaluated. However, given that it takes up to 10 days for the wound to heal, it is likely that infants continue to
Suggested Readings Alanis M and Lucidi R (2004) Neonatal circumcision: A review of the world’s oldest and most controversial operation. Obstetrical & Gynecological Survey 59: 379–395. American Academy of Pediatrics (1999) Circumcision policy statement. American Academy of Pediatrics: Task force on circumcision. Pediatrics 103: 686–693. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambeisoce J, Sitta R, and Puren A (2005) Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Medicine 2(11): e298. Brady-Fryer B, Wiebe N, and Lander JA (2004) Pain relief for neonatal circumcision. The Cochrane Database of Systematic Reviews. The Cochrane Library, 4. Castellsague X, Bosch FX, Munoz N et al. (2002) Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. New England Journal of Medicine 346(15): 1105–1112. Declaration of the First International Symposium on Circumcision (1989) The Truth Seeker 1(3): 52. Fergusson DM, Boden JM, and Horwood J (2006) Circumcision status and risk of sexually transmitted infection in young adult males: An analysis of a longitudinal birth cohort. Pediatrics 118: 1971–1977. Holman JR, Lewis EL, and Ringler RL (1995) Neonatal circumcision techniques. American Family Physician 52: 511–518. Learman LA (1999) Neonatal circumcision: A dispassionate analysis. Clinical Obstetrics and Gynecology 42: 849–859. Lerman SE and Liao JC (2001) Neonatal circumcision. Pediatric Urology 48: 1539–1557. Singh-Grewal D, Macdessi J, and Craig J (2005) Circumcision for the prevention of urinary tract infection in boys: A systematic review of randomised trials and observational studies. Archives of Diseases in Childhood 90: 853–858. Taddio A (2001) Pain management for neonatal circumcision. Paediatric Drugs 3: 101–111.
Relevant Websites http://www.aap.org – American Academy of Pediatrics, Dedicated to the Health of all Children. http://www.cps.ca – Canadian Paediatric Society.