Circumcision

What is a circumcision?

Circumcision is a surgical procedure to remove the skin covering the end of the penis, called the foreskin. In many cultures, circumcision is a religious rite or a ceremonial tradition. It is most common in Jewish and Islamic faiths. In the United States, newborn circumcision is an elective procedure. The National Center for Health Statistics estimates that about 64 percent of newborn boys undergo circumcision. However, this number varies among socioeconomic, ethnic, and geographic groups.

Whether or not you have your child circumcised is a deeply personal choice, and deciding if it’s right for your family will require consideration of many factors. In addition to personal, cultural, and religious aspects associated with the decision, you may have medical questions as well.

Circumcision can be done at any age. Traditionally, the most common time to do it is soon after your baby is born, or within the first month of life. Because the process is painful, a local anesthetic is used to numb the area and the surgery is performed while the baby is still awake. If the baby is older, we recommend that he be given anesthesia so there is less pain and risk of injury to the penis. As children get older, they become more aware of their sexual organs, so there are more psychological impacts associated with the surgery, and children become fearful.

What are the potential benefits of circumcision?

If your baby is circumcised, the penis becomes easier to clean for parents (and ultimately for the child), which helps reduce the risk of infection from bacteria. Other potential benefits include:

near elimination of lifetime risk of penile cancer
more than 90 percent reduction in the risk of urinary tract infections (UTI) during infancy
reduced incidence of balanitis, an infection of the glands or head of the penis, and posthitis, an infection of the prepuce (the skin covering the head of the penis)
elimination of phimosis (inability to retract the foreskin)

Most researchers generally accept that circumcised men are less likely to acquire and transmit HIV and some sexually transmitted diseases. However, if your child is not circumcised, he can do well by learning to fully pull back his foreskin around the time of toilet training and taking care to keep the entire penis clean with soap and water every day.

Is it a common practice?

Circumcision is quite common. The Centers for Disease Control and Prevention recently reviewed current trends of newborn circumcision in the U.S., and the national rate was approximately 60 percent. According to the data, circumcision rates are highest in the Midwest and Northeast and lowest in the West.

Frequently asked questions

How old should my child be for circumcision?

If the baby is older, we recommend that he be given anesthesia so there is less pain and risk of injury to the penis. As children get older, they become more aware of their sexual organs, so there are more psychological impacts associated with the surgery, and children become fearful.

What are the risks associated with the procedure?

The reported surgical complication rate is quite low (between 2 to 3 percent), and most of those are minor post-operative bleeding.
The most common complication is that not enough foreskin is removed, leading parents to request an operative circumcision revision.
Serious or life-threatening problems such as damage to the penis or major bleeding are extremely rare.

If your baby has active issues with heart or lung function or a bleeding disorder, circumcision may be unsafe and should be delayed. There are also congenital findings that may require more extensive repair.

Circumcision should be delayed if the opening of the urethra is not at the tip of the penis, the penis is notably curved, or the penis is relatively small. Always consult a pediatrician when weighing whether or not you wish to circumcise your son, or when establishing a timeline for the procedure.

How is circumcision performed?

Most newborns are held still or placed into a circumcision brace. The baby is comforted and may receive a local anesthetic (numbing medication) to reduce discomfort. The skin covering the tip of the penis is removed with a protective device, and then gauze with petroleum jelly or antibiotic ointment is applied. In older children and adults, the procedure is commonly performed under general anesthesia.

Is it extremely painful for the child?

Despite what many people may believe, this is not an extremely painful procedure. If local anesthesia is given, the child will feel pressure and movement but not pain. The child may be briefly upset while he is being held in place. If the circumcision is performed under general anesthesia, he will not experience any pain during the procedure. Once the procedure is completed the child will not have pain with urination since the urethra (urinary tube from the bladder through the penis) is left untouched during circumcision.

What is the recovery process?

Newborns and infants recover very quickly from the procedure, usually within 12 to 24 hours. Young children recover in one to two days. Older children and young adults recover in three to four days. After circumcision, there may be temporary skin bruising or mild swelling that can last for several weeks.

How we approach circumcision

Our specialists in the Department of Surgery and the Department of Urology are highly skilled in performing circumcisions. We also perform more than 300 recircumcision procedures a year, many of which we strongly believe could be prevented by having the initial circumcision performed correctly by an experienced team like ours.

Circumcision | Recircumcision

It is widely recognized by pediatric urologists that male circumcision reduces the risk of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV. Although the majority of circumcisions in infants occur without complication, a percentage of children require urology intervention.

Boston Children’s Hospital urologist Erin R. McNamara, MD, MPH, discusses the complications associated with circumcision, why a revision is necessary and when to see a pediatric urologist.

Why is a circumcision revision necessary?

When a child is circumcised, sometimes the skin from the penis attaches to the head of the penis and forms adhesions. This usually occurs because too much skin was left behind during the original circumcision (incomplete circumcision/redundant foreskin). The extra skin covers the head of the penis, and it can cause mild adhesions or completely cover the penis to the point where it no longer looks circumcised. It depends on how much extra skin is left behind. The redundant skin also can be uneven with more extra skin on one side versus the other side.

Often, a revision is done because the redundant skin may lead to irritation or infection. These infections may be due to the adhesions or if the adhesions are so dense (penile skin bridges) that they can actually cause discomfort or curvature of the penis with erections. These are the only health indications for doing a revision. Revisions are also done if there is so much skin that it doesn’t look circumcised or if the skin left behind is uneven. The child will not “grow into” the extra skin so we often make the recommendation for revision if there is a lot of extra skin and the adhesions keep coming back.

What are the common complications of a neonatal circumcision?

Fortunately there are no “common” complications of neonatal circumcision since it is such a safe procedure. Occasionally, a child can have bleeding that either stops with a pressure dressing or, very rarely, a suture. Other things that can happen are injuries to the glans or the urethra if the clamp that is used for circumcision is not placed correctly.

Hypospadias: Rarely, a patient will have a hypospadias, which goes undetected until after the circumcision. This is unfortunate because urologists use the foreskin to fix the hypospadias.

Another rare complication is taking too much skin off during a circumcision, so the shaft of the penis is not covered with skin. This will sometimes need to be fixed in the operating room.

Incomplete circumcision: More commonly, too little skin is removed (also called an incomplete circumcision), and there is redundant foreskin. When this occurs, the child may have a build up of normal skin cells, or smegma, underneath the extra skin, which leads to irritation, infection, or adhesions of the skin to the head of the penis.

When should the child be seen by a pediatric urologist?

If he has had any skin infections or the parents have concerns about the circumcision, the child should see a specialist. Some pediatric urologists can lyse the adhesions in the clinic with local numbing medicine. However, if extra skin is causing the problem, this will need to be addressed in the operating room under anesthesia. Consultation with a pediatric urologist is the only way to determine if a revision is necessary.

How do you perform a circumcision revision?

Once under anesthesia, we put local anesthetic near the penis to minimize post-procedure pain. At this point, we safely lyse or remove the penile adhesions. If the adhesions are dense, we cut them and remove the extra skin so there is no redundant skin left behind. We make sure there are no small vessels bleeding and place small stitches. Sometimes a dressing is placed with bacitracin, and the child is woken up and goes to the recovery room. They go home that same day.

Is there anything else parents should know about circumcision revision?

Fortunately, this is a very minor procedure. Anesthesia is safe in this age group, and a revision circumcision does not take a long time. The adhesions will continue to come back unless the extra skin is removed. The extra skin that is removed will make the penis look like a circumcised penis. Once the circumcision has been revised, it is extremely rare for any further problems to occur.

Erin McNamara, MD, MPH, is a urologist at Boston Children’s Hospital and an instructor in surgery at Harvard Medical School.

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