Understanding Newborn Circumcision and Common Techniques
By Dr. Adam Kern, Director, Pediatric Urology
Chesapeake Urology for Children
Newborn circumcision is the most commonly performed surgical procedure in the United States. For decades, overall newborn circumcision rates within the United States have hovered around 82%, although there is significant heterogeneity amongst different geographic regions and people of different cultures. The discussion around indications for newborn circumcision is continuously evolving and will be the topic of future blog posts. Suffice it to say, the most common reasons for newborn circumcision in the U.S. are cultural.
Whenever parents elect for newborn circumcision, there are a few logistical factors to bear in mind. The majority of newborn circumcisions are necessarily performed by obstetricians, as they vastly outnumber pediatric urologists, and already have care established with the family at the time of birth. The overwhelming number of newborn circumcisions performed by obstetricians are done very competently. My recommendation is always to ask the person performing a newborn circumcision how many they typically do, and what their comfort level is performing the procedure. That is a greater determinant of outcome than any of the minutiae of the technique that they use.
As pediatric urologists, we generally recommend that, in the event of any suspicion of penile abnormality, the obstetrician or pediatrician defer circumcision until the newborn can be evaluated by a pediatric urologist. In the unlikely event that a congenital abnormality is discovered, preservation of the intact foreskin allows us to use this tissue in subsequent reconstructive procedures. So, in this case, simply don’t do a circumcision, and see a pediatric urologist first!
What is Newborn Circumcision?
We generally use the term “circumcision” colloquially, but there is a distinction between what I will refer to as “circumcision” versus “newborn circumcision”, the latter of which is the subject of this blog post. Newborn circumcision specifically means a circumcision performed within the first weeks of life. This is an important distinction because a circumcision performed within the first few weeks of life can be done using one of several techniques requiring no general anesthesia. On the other hand, a circumcision performed on a child, adolescent or adult typically requires anesthesia sedation and is done in the operating room. You may be quick to point out that in some other cultures around the world, circumcisions are performed on adolescents in a ritual manner around the age of puberty, without anesthesia. While this is correct, it is not the standard of care for medical treatment within the U.S., and therefore is why typically all circumcisions that I perform on children and adults older than the newborn period, I do in the operating room under sedation, in order to provide comfort for the patient. Circumcision under sedation will also be the topic of a coming blog post.
What distinguishes newborn circumcision from a circumcision performed on an older child or adult is that the various newborn circumcision techniques require no general anesthesia, and typically also don’t require any stitching of the foreskin. This is the most important factor, which also dictates the narrow timeframe within which newborn circumcision must be performed. Simply put, as a newborn baby boy grows, after a timeframe of approximately 4-6 weeks or a bodyweight threshold in excess of 10-12 lbs., the blood supply to the intact foreskin increases as the vasculature matures, to the point where the bleeding risk of performing a newborn circumcision without stitches becomes too great.
Therefore, if a newborn circumcision is to be performed using one of the no-stitch techniques, it is imperative that this is done within the first four weeks of life.
Of course, there are exceptions to every rule, and sometimes newborn circumcision can be slightly delayed in the case of babies born prematurely or with low birth weight. Regardless, I recommend to all new parents that, if they would like me to perform a newborn circumcision, that they contact my office as soon as possible, preferably even before the baby is born, so that we can schedule and take care of insurance pre-authorization.
– Adam J.M. Kern, M.D.
Three Types of Newborn Circumcisions
There are three typical techniques used for newborn circumcision. They are:
- Mogen clamp
- Gomco clamp
The plastibell is a plastic ring device that is placed over the intact foreskin and used to gently constrict the skin over a period of several days, causing the foreskin distal to the ring to fall off, thereby performing the circumcision. The strengths of the plastibell technique are that it has a relatively short learning curve and can be done quickly on large numbers of babies. It is an excellent choice in international settings from a population health perspective. However, it affords the pediatric urologist little opportunity to have fine control over the outcome.
A Mogen clamp is a type of sharp clamp that is used to excise a portion of the intact foreskin. The Mogen clamp has been used for a greater period of time and is the typical instrument of choice among certain practitioners who commonly perform circumcision for religious reasons, by virtue of tradition. An experienced practitioner using a Mogen clamp can perform an excellent circumcision; however, it has a somewhat steep learning curve, and given the sharp nature of the clamp, there is a very small but real risk of injury to the head of the penis.
The third common technique for newborn circumcision is the Gomco clamp. I favor this technique for when I perform newborn circumcision. The Gomco clamp allows fine control over the outcome of the circumcision, and I believe it to be the safest method. Differences in penile size and symmetry of the foreskin can often be accounted for, and there is no risk of an inadvertently retained plastibell ring afterward. I have performed many hundreds of circumcision using the Gomco clamps, with excellent results. However, if I were to give advice to a parent out of state who calls me and is searching for someone to perform a newborn circumcision locally, I would say that the most important factor, independent of technique, is to simply find a pediatric urologist who is very experienced using whatever technique they employ!
Circumcision – What Parents Can Expect
When I perform a newborn circumcision in the office, I will typically meet with the family first to perform a brief exam, and to go over what to expect both that day and in terms of recovery. I advise all parents to bring a few spare diapers, Vaseline, infant liquid Tylenol and a pacifier to the circumcision appointment. After the consultation, I have the parents step out to the waiting room for about 20 minutes while I perform the circumcision. A common question is whether parents can stay and observe the circumcision–I generally strongly discourage this, as my attention needs to be completely focused upon your baby during the procedure!
Prior to starting the circumcision, we do several things to make your baby as comfortable as possible, including gently laying them flat, giving them apple juice or sugar water, and being careful to keep them warm. At the beginning of the circumcision, I administer a local anesthesia to the penis as an injection. This is highly effective, and the method used is guided based on a large amount of experience and literature. This will also be the topic of a dedicated future post. That said, many newborns are somewhat cranky after circumcision despite the local anesthesia, and often this is due simply to the fact that we haven’t been feeding them before the procedure, and that this is often the first time in their lives that they’ve been away from mom for more than a few minutes.
It is important to keep in mind that you cannot feed your baby for a brief period of time prior to circumcision, as we need to minimize the chance that they spit up anything in their stomach during the procedure. Please be careful to check these instructions from the office at least several days prior to the appointment!
It typically takes me about 10 minutes to perform the Gomco circumcision, and then I leave the clamp in place for another 7-10 minutes, and then at that point, we reunite you with your baby. I prefer families to stay in the office for another 20 minutes or so afterward so that I can check underneath the diaper one more time prior to going home. I recommend giving a small amount of infant Tylenol for a 24-hour period after the circumcision. To promote the best possible healing, it is imperative that the area is kept covered with a coat of Vaseline for several weeks afterward, and I demonstrate to parents how to do so during the visit.
If you are a referrer seeking a consult for a newborn circumcision, or a new parent wanting to have your son circumcised by a pediatric urologist, please do not hesitate to contact my office to schedule an appointment.