Circumcision

Anatomy and Physiology

The embryological development of the foreskin starts at 12 weeks of gestation and is generally complete by 20 weeks. The penis can be divided into the dorsal surface, ventral surface, base (proximal), shaft (middle), and glans (distal). The dorsal region contains the superficial and deep dorsal veins, paired dorsal arteries, and dorsal nerves. The dorsal nerves, which are branches of the pudendal nerves, are anesthetized during a dorsal nerve block to improve pain management during circumcisions.[20] Since some sensory innervation derives from the perineal nerve, an additional ventral penile block is needed to anesthetize the foreskin around the frenulum.[21]

The major structural components of the penis include the urethra, corpora cavernosa, corpus spongiosum, glans, and foreskin.

• The 2 corpora cavernosa are located ventral to the dorsal nerves and vasculature, which become engorged with blood to promote erection.
• The corpus spongiosum is ventral to the corpora cavernosa, which houses the urethra. The urethra starts at the bladder and runs through the prostate and the length of the penis to end at the glans of the penis.
• The foreskin covers the entire penile head and is trimmed distally during circumcision to expose the glans.[22]

The foreskin is generally at least one-third the total length of the penis and is composed of 3 layers.

• Inner foreskin: This layer is made up of squamous mucous membrane.
• Dartos or middle layer: This layer comprises a loose connective tissue layer with irregular bundles of smooth muscle.
• Outer foreskin: This layer is made up of keratinized squamous epithelium.

Indications

Medical indications for circumcision include but are not limited to phimosis, paraphimosis, balanoposthitis, balanitis, early foreskin malignancies, Zoon balanitis, the need for long-term intermittent catheterization, and recurrent urinary tract infections. In adults, a common reason is phimosis, which can cause urinary difficulties and pain during sexual activity.

Elective circumcision may be indicated in regions with higher rates of HIV infection, certain sexually transmitted diseases such as syphilis and chancroid, and human papillomavirus (HPV) infection. However, it does not offer protection against Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis.[23] Familial, religious (Jewish, Druze, and Islam), cultural indications, and personal preferences are recognized.

Contraindications

Contraindications to circumcisions include an unhealthy infant, anatomical abnormalities such as hypospadias and ambiguous genitalia, a buried or concealed penis, and uncorrected patient bleeding disorders. The general health of the infant should be assessed before the procedure. In most cases, circumcision is an elective procedure and can be delayed. The procedure should be postponed if the infant is found to have electrolyte or metabolic abnormalities such as hypoglycemia, bacterial infections, absence of urination, or a hypoxic cardiac disorder.

The penis should be evaluated for anatomical anomalies such as micropenis, a buried or concealed penis, swelling of the foreskin, congenital megaprepuce, chordee, penile edema, epispadias, penile torsion, ambiguous genitalia, penoscrotal webbing, and hypospadias. Any infant with an uncorrected bleeding problem or a strong family history of such disorders should only undergo circumcision at a healthcare facility with the proper subspecialty services.[24][25] Circumcision should not be performed within the first 12 hours after birth, in the presence of any active infection, if the patient is unwell or in the intensive care unit/neonatal intensive care unit, if the patient has neonatal jaundice, or if the patient has not yet voided.[26]

Personnel

The practice of circumcision is not limited to medical professionals. As a result, standards of pain management, hygiene, technique, and outcomes cannot be guaranteed when circumcisions are performed outside of standard medical settings. Patients and their families may interview the personnel and surgeon performing the circumcision. The surgeon can typically provide the family with a record of outcomes and review the procedure's advantages and disadvantages.

Preparation

Proper pain management is essential during circumcision procedures. Effective analgesia is highly dependent on the person performing the procedure. Many infants are treated with a combination of oral sucrose solutions, topical analgesics such as lidocaine cream 4% (LMX-4) and lidocaine 2.5%/prilocaine 2.5% cream (EMLA cream), and injected local analgesics such as lidocaine 1% without epinephrine or bupivacaine 0.25%.[27][28][29][30][31] In adults, anesthesia options may include up to 2% lidocaine without epinephrine, bupivacaine 0.5%, or a combination of both.

Positioning, swaddling, and sucrose pacifiers are not considered adequate analgesic measures for neonates. Topical anesthetic creams may be adequate but typically require 30 minutes or more. Additional time is recommended for EMLA cream. In addition, these creams can cause skin irritation in low-birth-weight and premature infants, in whom penile nerve blocks are therefore recommended.[32] Ring and dorsal penile nerve blocks are generally more effective compared to topical anesthetics.[33] Combining a topical anesthetic cream and locally injected anesthesia provides superior pain relief.[34][35]

Older children typically require general anesthesia for circumcision procedures. Local anesthesia (penile block) with sedation, regional anesthesia, or general anesthesia may be used in adults. The sensory innervation of the penis is primarily from the S2 to S4 dorsal nerve roots to branches of the pudendal nerve. These branches form the dorsal nerves of the penis. However, the frenulum also receives innervation from a branch of the perineal nerve.[36] This phenomenon explains why the frenulum area may retain some sensation after a penile dorsal nerve block. The root of the penis has sensory innervation from the ilioinguinal nerve.[22][37]

A ring penile block requires at least 2 separate injections, one administered around the base of the penis on either side, resulting in a complete ring of anesthetic. The dorsal nerves of the penis are located just beneath Buck's fascia and lateral to the penile arteries within the neurovascular bundle.[20] A penile dorsal nerve block utilizes local anesthetic injected under the fascia on either side of the penile suspensory ligament inferior to the pubic ramus. However, this method does not adequately anesthetize the frenulum, which retains sensory innervation from the perineal nerve. A partial ventral ring block at the penile base can eliminate this.[21][26]

Technique or Treatment

Various methods are employed for circumcision. The objective of each method is to remove both the inner and outer preputial skin without injuring the underlying glans and urethra.

Neonatal and Infant Circumcision

The procedure should take only a few minutes when performed on newborns. However, it is more complicated when performed on adults. The duration of healing and outcome depend on the procedure employed and the surgeon's proficiency and experience. The 3 most common methods used for neonatal circumcision are discussed below.

Bell, ring, or clamp techniques for infants and neonates

Several devices use a clamp, cover, or shield over the glans, all yielding similar outcomes. The choice of device depends on the availability of the device and the surgeon's preference and experience.

Before starting any of these procedures, topical anesthetic should be applied well in advance (30 minutes), local anesthetic should be injected (optional), and appropriate antiseptic should be applied.

• The foreskin edges are grabbed on opposite sides, typically at 3 and 9 o'clock, using hemostats, and antiseptic is applied to the glans and the interior of the foreskin.
• Another hemostat, Kelly clamp, or straight clamp is passed inside the foreskin and gently moved from side to side to break up any adhesions.
  • Care is taken to avoid any injury to the frenulum.
  • Adhesions between the glans and the foreskin are normal in neonates, giving them a physiological phimosis.
• Opening the clamp allows stretching, widening, and enlargement of the distal lumen of the foreskin, which improves access and allows for better visualization of the glans and urethra before proceeding.
  • Ensuring that the clamp is not inside the urethra is important.

Bell or clamp-type circumcision procedures are typically performed and most appropriate for patients up to 3 months or 5.5 kg in weight. However, they can also be safely performed in older, heavier males.[38][39][40][41][42][43][44][45][46][47]

Disposable plastic bell with delayed sloughing

This simple technique utilizes delayed sloughing of the foreskin from a carefully placed suture or ties over a plastic bell shield for the glans. The procedure is relatively easy to perform with a low risk of bleeding, but problems with a retained ring have been reported. The device is available in various sizes based on the diameter of the glans, with 1.3 cm being the most common. The device has also been used for WHO-sponsored mass circumcision programs in countries with high endemic HIV rates, with a usage rate of about 20%.

• A straight clamp or Kocher is placed longitudinally on the dorsal foreskin, with 1 jaw on the inside mucosal surface and the other outside, to a point even with the distal glans penis.
• Two hemostats are placed laterally on either side of the distal dorsal foreskin and then lifted, separated, and held apart to facilitate the proper clamp placement. This action stretches the lumen open and elevates the anterior foreskin away from the glans.
• The clamp's tip is angled upwards (dorsally) to ensure a visible and palpable bulge through the foreskin.
• This action helps prevent a possible closure of the instrument with 1 of the jaws in the urethra.
• If uncertainty exists, the clamp should be removed and reapplied.
• When the clamp's position has been verified, the instrument is closed tightly, compressing and crushing the dorsal foreskin, and left in place for at least 10 to 15 seconds to achieve hemostasis.
• The straight clamp is removed, and a longitudinal incision is made with scissors on the dorsal side of the foreskin along the line of the previously compressed tissue to the level of distal glans.
• The plastic bell shield is placed over the glans.
• The foreskin is then pulled forward, covering the bell and the glans.
• The foreskin is stabilized by using hemostats to clamp it to the handle.
• The instrument is properly positioned when the grooved ring is below the apex of the dorsal slit incision.
• A suture, tie, or thread is then tied securely around the foreskin so that the tie lies in the external groove of the buried ring.
• The excess foreskin is then resected with a scalpel. 
• The handle is broken off, leaving the ring and tie in place.
• Scissors or a scalpel may be used to cut the remaining foreskin about 2 mm distal to the circumferential ligature or tie.
• The patient is discharged.
• The bell and the remaining foreskin fall off spontaneously in 3 to 7 days.
• A shorter time to spontaneous sloughing of the ring is associated with younger patient age, smaller size of the suture tie, polypropylene suture material, and increased frequency of patient sitz baths.[48][49][50][51][52][53]

Gomco clamp

This widely used method (about 70%) was introduced in 1950 but is heavy and complicated. Pulling the foreskin through the opening in the base can be challenging. If the device is not sized correctly or fails to fit together properly, a different technique should be used or the procedure should be rescheduled. The device is available in various sizes based on the diameter of the glans, with 1.3 cm being the most prevalent. Gomco clamps have also been used for WHO-sponsored mass circumcision programs in countries with high endemic HIV rates.

• The Gomco clamp has multiple parts and sizes. Ensure all components fit, the device is properly assembled, the bell fits tightly into the base without gaps, and the correct size is used.
• A straight clamp or Kocher is placed longitudinally on the dorsal foreskin, with 1 jaw on the inside mucosal surface and the other outside, to a point about 3 mm from the corona.
• Two hemostats placed laterally on either side of the distal dorsal foreskin are lifted, separated, and held apart to facilitate the correct clamp placement. This action stretches the lumen open and elevates the anterior foreskin away from the glans.
• The clamp's tip is angled upwards (dorsally) to ensure a visible and palpable bulge through the foreskin.
• This action helps prevent a possible closure of the instrument with 1 of the jaws in the urethra.
• If uncertainty exists, the clamp should be removed and reapplied.
• When the clamp's position has been verified, the instrument is closed tightly, compressing and crushing the dorsal foreskin, and left in place for at least 10 to 15 seconds to achieve hemostasis.
• The straight clamp is removed, and a longitudinal incision is made with scissors on the dorsal side of the foreskin along the line of the previously compressed tissue.
• The bell portion of the device is placed inside the foreskin and over the glans. The glans should be completely covered to avoid injury.
• The foreskin is pulled through the hole in the base. This step is typically the most challenging part of the procedure and may be accomplished in several ways:
• Use 1 or 2 hemostats, a towel clip, or a sterile safety pin placed through the base plate's opening and the edges of the incised foreskin.
• Gentle traction is applied to guide the foreskin through the opening of the Gomco device.
• Twisting, folds, or excessive traction should be avoided, especially around the frenulum.
• The previously cut edges of the dorsal foreskin are manually approximated.
• The apex of the dorsal slit incision should be visible above the base plate when properly positioned.
• Once properly positioned, the traction can be released, and the compression nut tightened.
• To achieve hemostasis, the device is left clamped in place for 5 minutes. Shorter times may also work, but 5 minutes is the standard duration.
• A scalpel can be used to resect excess foreskin above the Gomco base.
• After sufficient time, the device can be removed.
• If adherent, the bell can be gently separated from the glans manually, with gause or a blunt probe.
• Some recommendations include the application of cyanoacrylate tissue adhesive on the cut edge, particularly when this technique is performed on older adults.
• A dressing, which may include antibiotic ointment or petroleum jelly-infused gauze, and a compression wrapping should be applied.
• The patient should be observed for bleeding, with a recommended observation time of at least 30 minutes.
• A study comparing the Gomco and the Bell procedures revealed higher parent satisfaction with the Gomco, although the results were objectively comparable.[42][44][54][55][56][57][58]

Mogen clamp

This method is faster, easier, and less painful compared to the Gomco clamp but is also riskier and requires a higher degree of technical expertise. No protective shield or bell exists over the glans; therefore, an injury to the urethra or head of the penis is more likely if performed improperly.

This technique is frequently used for religious neonatal circumcisions. The clamp comprises 2 metal plates connected with a hinge joint at one end. A 3-mm slit exists between the 2 plates, which is designed to allow the foreskin to pass through but not the glans or penile shaft. Postoperative bleeding is less likely after a Mogen clamp procedure compared to a Gomco clamp. Mogen clamps have also been used for WHO-sponsored mass circumcision programs in countries with high endemic HIV rates, with a usage estimated at about 10%.

• A dorsal slit (as described above) is only required if necessary to retract the foreskin to inspect the head of the penis and the urethra.
• A hemostat is placed on the dorsal edge of the foreskin in the midline.
• The glans are secured proximally between the thumb and forefinger of 1 hand.
• While holding the glans securely proximal to the clamp, the Mogen device is placed between the hemostat and the glans.
• The clamp should be tilted parallel to the edge of the corona, which means the dorsal clamp edge is angled slightly toward the patient—the grooved side is facing the penis. 
• Any tension on the foreskin should be released, and special attention should be given to ensure that the frenulum is well positioned on the patient's (proximal) side of the clamp to avoid bleeding and traumatic penile injuries. Incomplete disruption of ventral penile adhesions may contribute to this problem.
• When the glans and frenulum are protected proximally and only the excess foreskin is distal to the clamp, the clamp can be safely closed and locked.
• The excess foreskin is excised with a scalpel.
• Compression from the clamp provides hemostasis and should remain in place for 5 minutes.
• When the clamp is opened, the remaining foreskin is stuck together over the glans. A probe or hemostat can easily separate the tissue.
• Some experts recommend applying cyanoacrylate tissue adhesive on the cut edge, particularly when this technique is used on older adults.
• A dressing of gauze with petroleum jelly should be applied.
• The patient should be observed for bleeding, with a recommended observation period of At least 30 minutes.[26][43][45][59][45][60][61]

Adult Circumcision

Two basic versions of performing a standard surgical circumcision are recognized: the dorsal slit technique and the sleeve technique. These techniques differ primarily in the method of cutting and removing the foreskin. Results are comparable, and neither is preferred over the other. Using a combination of the 2 techniques is also acceptable.

A frenuloplasty may be necessary in selected cases if the frenulum is tight or pulling and may become uncomfortable for the patient. A frenuloplasty is typically performed using a hemostat to create and spread open a channel just beneath the frenulum, and then cautery is used to divide it. This approach allows the ventral portion of the glans to move distally, removes any angulation, and releases tethering but leaves a larger skin defect, which should be closed before the remainder of the circumcision.[59][62][63][64][65]

Dorsal slit technique of circumcision 

The dorsal slit technique is preferred for adults with tight phimosis or a history of paraphimosis that has been previously reduced. 

• A straight clamp or Kocher is placed longitudinally on the dorsum of the foreskin, with 1 jaw on the inside mucosal surface and the other outside, to a point about 3 to 5 mm from the corona.
• Two hemostats are placed laterally on either side of the distal dorsal foreskin and lifted, separated, and held apart to facilitate the correct clamp placement. This action stretches the lumen open and elevates the anterior foreskin away from the glans.
• The clamp's tip is angled upwards (dorsally) to ensure a visible and palpable bulge through the foreskin.
• This action helps prevent a possible closure of the instrument with 1 of its jaws in the urethra.
• If uncertainty exists, the clamp should be removed and reapplied.
• When the clamp's position has been verified, the instrument is closed tightly, compressing and crushing the dorsal foreskin, and left in place for at least 3 minutes to achieve hemostasis.
• The straight clamp is removed, and a longitudinal incision is made with scissors on the dorsal side of the foreskin along the line of the clamped and compressed tissue.
• Countertraction is provided by hemostats placed on either side of the dorsal foreskin.
• These hemostats are then held, lifted, and separated, stabilizing the tissues and facilitating the incision.
• Large veins may be ligated, and smaller ones cauterized.
• Any sebum is cleaned away and removed.
• An antiseptic solution is applied to the interior surface of the previously closed foreskin and glans.
• Optionally, a similar ventral incision is made using the same straight clamp compression technique.
  • Care should be taken to avoid injuring the frenulum if this is done.
  • The clamp should not extend closer to the glans than the base of the frenulum on the ventral side.
  • The ventral incision is substantially shorter compared to the dorsal incision.
  • The dorsal incision should always be done first to place the ventral clamp under direct vision.
• The frenulum should not be resected or injured, leaving a V-shaped area untouched.
• The foreskin should be removed with care to avoid tissue damage. Trimming can always be done later.
  • The foreskin may be held with hemostats at a perpendicular angle from the penile shaft and excised with a scalpel or scissors.
  • Circumferential skin markings can be drawn on the internal mucosal and external epithelial surfaces of the foreskin, ensuring no less than 0.5 cm or more than 1 cm of skin proximal to the corona. The resection then follows the previously placed markings.
  • Hemostats may be placed circumferentially around the edge of the foreskin and held or draped over a hand to stretch the skin out and facilitate the resection using scissors (preferred) or a scalpel.
• Large veins may be ligated, and smaller ones cauterized.
• Hemostasis is now critically important and is typically achieved with electrocautery.
• Trimming of the skin edges may be done carefully with scissors to achieve a smooth edge.
• The ventral resection should reflect the natural V-shape of the frenulum.
• Additional length of the penile shaft skin is often required to achieve a tension-free anastomosis with the distal edge.
• This adjustment is accomplished by blunt and sharp dissection of the penile shaft skin from the body of the penis, a process sometimes called degloving, to the base of the penis, if necessary. This procedure frees up the skin, allowing it to reach the glans easily without tension.
• Four separate stay sutures are placed at 12, 3, 6, and 9 o'clock, respectively, with the tail left long to facilitate grasping them with a hemostat. This technique can help make suturing easier for closure.
• An assistant holding up and separating 2 adjacent hemostats, each attached to the long tie end of one of the initial stay sutures, can stabilize the penis during closure, facilitating the repair and avoiding inadvertent twisting of the skin.
• Closure is performed using absorbable interrupted sutures, typically 000 and 0000, placed no more than 0.5 cm apart. 
• Before starting the closure, it is important to ensure that there is no twisting or rotation of the skin.
• A U-shaped suture is often used around the frenulum but is not required.
• Antibiotic ointment, a strip of non-adherent dressing material, a rolled dressing sponge, and an elastic compression dressing are applied.
• The head of the penis should be left exposed.
• Petroleum jelly or antibiotic ointment should be applied to the exposed head of the penis.[66][67]

Sleeve technique of circumcision 

The sleeve technique is similar to the dorsal slit procedure described above and can be performed on both children and adults. 

• The foreskin is gently pulled proximally over the glans.
• A marking pen is used circumferentially to identify the internal incision line, which should be distal to the corona but no more than 1 cm away. 
• Applying gentle manual pressure on the prepubic fat pad at the penile base helps ensure the proper placement of the incisional lines.
• The natural V-shape around the frenulum should be preserved.
• The foreskin is replaced over the glans, and a similar line is made with the marking pen.
• The marked lines are now carefully incised with a scalpel through the skin.
• Using a marking pen to outline the incision lines is optional but highly recommended for less experienced surgeons.
• Care should be taken to avoid injury to the frenulum and minimize excessive bleeding.
• A longitudinal cut can now be made between the 2 circumferential incisions.
• If still intact, the Dartos layer may be cut with scissors or a scalpel, and the resulting skin strip, along with the foreskin, can be removed.
• After hemostasis with electrocautery, the edges can be sutured with interrupted absorbable material, as detailed above in the description of the dorsal slit technique.[59][62]

Dorsal slit procedure (circumcision alternative)

The dorsal slit surgical procedure can be a viable alternative to circumcision in certain situations, particularly in emergencies such as paraphimosis or in patients with severe phimosis and urinary retention preventing the placement of a Foley catheter in the emergency department. The procedure can also be performed in the operating room when a patient is being prepared for an unrelated surgical procedure that requires access to the penis or urethra. The primary advantage of the procedure is the speed at which the phimosis is relieved, which does not require the resection or removal of any skin. The main drawback is that the procedure is not as cosmetically or aesthetically appealing as traditional circumcision.

Compared to a circumcision, a dorsal slit surgery is quicker, technically easier to perform, and bleeds less. No differences are apparent between the 2 regarding the incidence of stenosis, the degree of pain after surgery, the likelihood of reoperation, or the functionality of the result.

• A large straight clamp or Kocher clamp is placed longitudinally along the dorsal foreskin, with 1 jaw on the inside mucosal surface and the other outside, to a point about 3 mm from the corona.
• Two hemostats are placed laterally on either side of the distal dorsal foreskin and lifted, separated, and held apart to facilitate the correct clamp placement. This action stretches the lumen open and elevates the anterior foreskin away from the glans.
• The clamp's tip is angled upwards (dorsally) to ensure a visible and palpable bulge through the foreskin.
• This action helps prevent a possible closure of the instrument with 1 of the jaws in the urethra.
• If uncertainty exists, the clamp should be removed and reapplied.
• When the clamp's position has been verified, the instrument is closed tightly, compressing and crushing the dorsal foreskin, and left in place for at least 3 minutes to achieve hemostasis.
• The straight clamp is removed, and a longitudinal incision is made with scissors along the line of the previously compressed tissue to within 1 cm of the corona.
• Countertraction from hemostats placed on either side of the dorsal foreskin helps stabilize the tissues and facilitate making the incision.
• Bleeding vessels may be electrocauterized or tied off.
• Any sebum is cleaned away and removed.
• An antiseptic solution is applied to the interior surface of the previously closed foreskin and glans.
• An absorbable 000 running continuous suture is used to oversew (close) the cut skin edge on either side.
• Sutures should be placed about 0.5 cm apart.
• The right and left sides are sutured separately to avoid a purse-string effect.
• Interrupted absorbable sutures may then be placed about 1 cm apart along the oversewn edge, which is optional but recommended.
• A dressing of gauze with petroleum jelly or antibiotic ointment should be applied.[68][69]

Postoperative Care

Dressings for these techniques are typically allowed to fall off spontaneously or by 72 hours, although there is no definitive standard. Wound cleaning for neonates should involve water only, as most other soaps and wipes may be too irritating. A modified compression dressing has been described for patients at high risk of bleeding after circumcision. This dressing involves using an inner layer that covers the entire penile shaft and an external layer that provides additional compression to the distal portion just over the incision line.[70] Healing is typically completed within 4 weeks following the procedure. However, for adult patients, postoperative care includes avoiding sexual activity for at least 6 weeks following the procedure.

Complications

Circumcision does not lower the risk of gonorrhea, chlamydia, or syphilis. However, circumcised heterosexual males experience an average 40% to 60% reduction in acquiring HIV in regions with a high endemic HIV-positive heterosexual population, such as various areas in Africa. A lower prevalence of HPV infection and herpes simplex virus type 2 transmission is observed.[71] Surgical risks include, but are not limited to, pain, bleeding, infection, incision or injury of the glans and urethra, necrosis of the glans, foreskin adhesions, phimosis, wound dehiscence, persistent distal penile edema, urethrocutaneous fistula formation, meatal stenosis, failure to leave enough shaft skin for closure, postoperative trapped penis, or penile loss.[32][39][72]

Meatal stenosis is minimized by applying petroleum jelly to the glans, starting immediately after the circumcision.[73] Epidermal inclusion cysts may form if skin folds are buried and sloughed skin is not expressed.[41] Bleeding is the most common complication after neonatal circumcisions, but this typically resolves with manual pressure and topical thrombin.[61] Severe bleeding may occur in patients with previously undiagnosed coagulation disorders such as hemophilia.[74] Wound dehiscence is very common after circumcisions. These typically heal by secondary intention without further intervention.

Any remaining redundant foreskin may require a corrective procedure at a later date. Excessive removal of penile shaft skin can result in tethering, loss of effective penile length, pain with erections, or a buried penis. Penile reconstruction with split-thickness skin grafts may be required to repair. Hypersensitivity of the glans is common immediately after circumcision procedures, but this is typically temporary. Meatal stenosis and excessive skin bridging are more common in patients with balanitis xerotica obliterans or lichen sclerosis. Steroid cream applications and regular meatal dilatation can typically control these problems.[75][76][77]

Obese patients with a substantial fat pad around the penile base can be advised to evert the penis at least daily for cleaning to minimize the formation of unwanted skin bridges and adhesions. If untreated, this can cause the penis to become imprisoned below skin level, resulting in a trapped or buried penis. Electrocautery should never be used with any metal clamps or instruments. For example, electrocautery with a Gomco clamp in place can cause burning and necrosis of the glans penis.[78]

A retained piece of a disposable circumcision device can become a problem. The penile skin can become twisted if adequate attention is not paid to this potential problem during closure. Poor wound healing may occur if too much tension occurs on the incision line from the removal of too much skin or inadequate undermining of the remaining penile shaft skin. A poor cosmetic result is possible. Rare cases of accidental total or partial penile amputations and necrotizing fasciitis have been reported after neonatal circumcision, but these are extremely rare.[79][80][81][82][83] Fatalities after circumcisions are also extremely rare but have been reported.[84][85][86][87]

Clinical Significance

The Debate Over Elective Neonatal Circumcision: Benefits and Drawbacks 

In many cases, the issue of neonatal circumcision is easily resolved by the family for religious or cultural reasons. The circumcision may be traditional in many families or may be a medical contraindication. In the United States, the percentage of circumcisions being performed has been slowly decreasing, but this tends to be a cyclic phenomenon. The United States is the only developed country where the majority of male neonates are circumcised electively. According to the National Center for Health Statistics, currently, about two-thirds of newborn males are circumcised.[23][72][88][89][90][91][92][93][94][95][96][97][98][99][100][101]

A summary of the benefits and suggested drawbacks follows:

Benefits

• Circumcision reduces the risk of balanitis, balanoposthitis, candidal infections, inflammatory skin conditions of the glans and foreskin, phimosis, paraphimosis, penile cancer, and sexually transmitted diseases such as syphilis and chancroid.
• Less exposure to HIV and HPV occurs.
• The lifetime risk of urinary tract infections is reduced by 20%.
• Male genital hygiene is significantly improved.
• The procedure eliminates smegma and associated unpleasant odors.
• The risk of cervical cancer and sexually transmitted infections in future female sexual partners is reduced.
• Eliminates the need for an adult circumcision later in life.
• Over half of all uncircumcised men ultimately develop a foreskin-related side effect.
• No proven deleterious effect on future sexual pleasure, satisfaction, activity, or sensitivity.
• Locally injected anesthesia, oral sucrose solutions, topical analgesics such as lidocaine cream 4% (LMX-4), and lidocaine/prilocaine cream can effectively minimize any pain without a regional or general anesthetic.
• The reported complication rate of neonatal circumcisions is only 1.5% when properly performed.
• Strong evidence suggests that neonatal circumcisions eliminate the risk of penile cancer, which, though rare, are potentially lethal with high morbidity.
• The use of HPV vaccines has not yet been proven to reduce the future risk of penile cancer as well or as completely as neonatal circumcision.
• A systematic review concluded that there is high-quality evidence supporting the substantial medical benefits of neonatal circumcision, both immediately and long-term. Therefore, discouraging or denying access to this procedure is unethical based on the United Nations Convention on the Rights of the Child, which emphasizes a child's right to health. 

Drawbacks

• Circumcisions have side effects and complications.
• The procedure offers no protection from chlamydia, gonorrhea, or trichomonas infections.
• Variable social acceptability.
• Potential for significant pain to the neonate, which could have long-lasting psychological effects.
• Removing the foreskin is unnatural.
• The foreskin provides critical protection to the glans during early childhood and should not be removed.
• Circumcision negatively affects future sexual enjoyment.
• The procedure is permanent, painful, non-therapeutic, and irreversible.
• The surgery may cause excessive bleeding, which can be dangerous in a neonate.
• Phimosis can often be treated successfully with topical steroids and gentle stretching.
• Although very rare, necrotizing fasciitis, penile necrosis, and deaths have been reported following circumcisions.
• The surgeon or pediatrician may leave too much skin or remove too much, resulting in the need for a surgical revision at a later date and a poor cosmetic result.
• The health benefits of circumcision have been greatly overblown.
  • At least 1000 or more neonatal circumcisions are needed to prevent 1 penile malignancy.
  • The increased use of HPV vaccines is likely to reduce the future penile cancer risk, possibly as much as from circumcision.
• Neonatal circumcisions are unethical and unlawful as clinicians have a legal and ethical duty to protect children from unnecessary surgical interventions. 

No uniform opinion exists among clinicians on this issue. Pediatric and OB-GYN clinicians tend to be more reluctant to suggest neonatal circumcisions, as they are likely to observe their immediate associated side effects, problems, and complications. Urologists tend to recommend the procedure in neonates to avoid the need for medically necessary circumcisions in adulthood and to eliminate the risk of preventable complications, including some serious conditions such as balanitis, HIV infection, paraphimosis, and penile carcinoma caused by failing to perform the circumcision during infancy.

For example, penile cancer is quite rare (1:100,000) but only found in men who did not undergo a neonatal circumcision.[102][103][104] When encountered, the 5-year relative mortality rate for penile cancer in the United States is 35%. Witnessing even one patient's preventable death due to penile cancer can prompt any urologist or oncologist to strongly advocate for neonatal circumcisions.

A recent evidence-based risk-benefit analysis found that the proven medical benefits far outweighed the negatives (by 200:1), and the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and many others agree.[105][106][107] Nevertheless, this remains a controversial issue, and some families have strong opinions on the subject. The clinician's role is not to argue with patients or their families but to educate them on the issue's pros and cons, correct any erroneous facts or misconceptions they may have, and then allow them to make an informed decision.[108]

The family's preferences should generally be followed unless medically contraindicated. To facilitate this, the parents and family should be fully informed of the factual evidence in favor and against neonatal circumcisions well before delivery. Healthcare professionals should remain objective and factual without letting their personal preferences or biases affect the presentation of appropriate, objective, and unbiased information to the family.

Current Professional Society Recommendations

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists

In an update to the 1999 American Academy of Pediatrics (AAP) recommendations, new evidence indicated that the health benefits significantly outweighed the drawbacks and complications of newborn male circumcisions. A reduction in urinary tract infections, sexually transmitted diseases, acquisition of HIV, reduced HPV, and penile cancer was evidenced. Circumcision was not associated with a decrease in sexual function or satisfaction. All families should be given the proper, complete, and unbiased objective information regarding circumcision. The American College of Obstetricians and Gynecologists (ACOG) endorsed these statements.[32][109][110]

American Academy of Family Physicians

Family physicians should provide the family with complete information in an unbiased manner. Neonatal circumcision has potential health benefits in the reduction of urinary tract infections, sexually transmitted diseases, phimosis, paraphimosis, balanitis, and penile cancer. However, circumcision is not without complications. Now, the HPV vaccine alone may aid in the reduction of penile cancer without the need for circumcision.

American Urological Association

The circumcised newborn infant experiences the reasonable risks and complications associated with the procedure. During the first 3 to 6 months of life, the incidence of urinary tract infections is significantly higher in uncircumcised boys. Future risks of penile cancer, HIV and HPV infections, phimosis, paraphimosis, and balanitis are reduced—the circumcised adult benefits from these reduced health problems. The benefits and risks should be thoroughly discussed with the family.

Concern Over Clinical Training

Circumcision is a common elective surgical procedure frequently performed by non-surgeons who are not always well-trained in the procedure, the indications, or the contraindications. About 70% of obstetricians, 60% of family practitioners, and 35% of pediatricians perform neonatal circumcisions. Although urologists or general surgeons typically perform adult circumcisions, this is not true for most neonatal procedures in the community, which are frequently completed by non-surgeons who have often received only informal and unstructured training and cannot properly manage common postoperative complications.[111] 

Enhancing Healthcare Team Outcomes

This review is intended to thoroughly discuss the procedural steps, indications, and current recommendations regarding circumcision. This is a controversial topic, and healthcare team members must be aware of the evolving view of circumcision. The AAP revised the 1999 policy on the procedure to be more pro-circumcision, reigniting the debate. The anti-circumcision papers cite many reasons for not undergoing the procedure. Bringing female circumcision and genital mutilation to the mainstream has placed male circumcision under a similarly focused spotlight. The procedure is sometimes described as a painful ordeal that is needed to push the male into manhood. This trauma can then lead to sexual difficulties.

The procedure should be delayed until the individual can decide for himself. However, delaying the procedure overlooks the fact that the procedure is a more significant surgery in adults and loses many known health benefits if conducted outside the neonatal period. Healthcare professionals may hold differing views on the benefits of circumcision and are likely to have individual opinions. Healthcare professionals help families with both the advantages and disadvantages of the procedure to make a well-informed decision.[45][96] For example, HPV transmission can be reduced by circumcision. Clinicians must be educated about and understand religious doctrines, research findings, and cultural circumcision teachings. The data must be provided to each family in an unbiased manner.[88][112][113][114][115][116][117][118] Clinicians must also be able to relate the data to any unique family situation.