Circumcision has become highly controversial. Whether you decide to have your newborn boy circumcised is up to you. Read on for the pros and cons of the procedure.
Circumcision is the surgical removal of the skin covering the head (glans) of the penis. It is often done by the obstetrician who delivers the baby when the baby is one or two days old and still in the hospital. Healthcare providers generally believe that the benefits outweigh the risks, while at the same time saying the decision is completely up to the parents.
If done in a nonmedical setting, the person performing the procedure should be well-trained, use pain medication, and know how to prevent infection.
If parents choose not to have their baby circumcised as a newborn, later in life he could decide to be circumcised. While the procedure is the same, the recovery is longer for an older patient and the risk of complications is greater.
You should think about how to make this decision as soon as you are pregnant, so you can ask questions and make an informed choice.
Circumcision
In the US up to 60% of baby boys are circumcised. Worldwide the highest rates are in Israel, the US, the Middle East, and South Korea. Jews and Muslins perform circumcision as part of their religions.
Reasons for choosing it
- Hygiene is easier.
- Circumcision decreases the incidence of urinary tract infections, even though UTIs are fairly low in males.
- It lowers the risk of certain sexually transmitted infections (such as HPV, the virus that causes certain cancers)
- It essentially eliminates the risk of penile cancer.
- It is believed to decrease the risk of cervical cancer in female partners.
Why it would not be an option shortly after birth
- The baby would remain uncircumcised if he has a blood clotting disorder.
- He would not be circumcised if he were premature. He could be circumcised later.
- If he has abnormalities of the penis and urethra (a condition called hypospadias), he would not be circumcised until the problems are resolved.
The procedure
The baby lies on his back. The doctor cleanses the penis and applies an anesthetic. The doctor attaches a device to the penis and either ties a string in place (Plastibell) which then falls off 10-12 days later with the skin, or the doctor uses a scalpel and removes the foreskin. It takes 10-20 minutes. It causes pain for a few hours, which is managed with pain medications and anesthetics during and after the procedure.
Circumcision is similar for older boys and men, but the patient may be under general anesthesia. The procedure is the same, except that adults have stitches. Recovery takes longer than it does for newborns and the risk of infection is slightly increased in adults.
If circumcision is done in the first few weeks after birth, no anesthesia is needed and the baby boys have no memory of the procedure. They are bothered for a short time, but are fine within a day. After the first month, anesthesia is needed. General anesthesia is risky until the baby reaches 6 months of age, so circumcision is either done shortly after birth (ritual circumcision in the Jewish tradition is done on day 8) or it must be postponed until after 6 months of age.
After the procedure on a newborn
Follow the steps below to help healing after the surgery.
- Allow 7-10 days for healing. During this time, the tip looks red, swollen, or bruised.
- Be careful of the penis while holding the baby.
- The doctor bandages with gauze over the penis. Apply petroleum jelly to the penis tip to keep it from sticking to the diaper. Change the bandage with each diaper change.
- If there’s a ring, it will fall off without help in 10-12 days. Talk to the baby’s pediatrician if it doesn’t.
- A small amount of blood after the procedure is normal, but if bleeding continues, try to stop it with pressure applied for a few minutes. Do not remove the compress during this time. If the bleeding continues after that, take the baby to the emergency room right away.
- If any blood stain on the baby’s diaper is the size of a quarter or larger, call the pediatrician.
- Once the penis heals, wash it with soap and water as normal.
Complications
If any of the following conditions occur, talk to your pediatrician.
- The foreskin was cut too long or short (If too long, a second circumcision, called a revision, may be necessary).
- The penis does not heal.
- The foreskin reattaches to the end of the penis.
- The baby doesn’t begin urinating normally within 12 hours after procedure.
- There is persistent bleeding.
- A foul-smelling drainage comes from tip after seven days.
- The redness or swelling doesn’t stop or gets worse after three days.
- The plastic ring remains in place for two weeks after the procedure.
- The baby develops a fever of 100.4 ⁰ or higher.
Revision
A revision, or second surgery on the penis, is done by a urologist in a hospital, who diagnoses the problem. It is usually a very successful procedure.
The most common reasons for a revision are as follows:
- Too much foreskin remains (redundant prepuce); it can cause scar tissue as the infant grows and develops more fat in penile area.
- Buried penis. The penis drops back into the fatty area surrounding it, seeming to be trapped. It makes urination difficult, and skin infection around the penis is more likely.
- Skin bridge. The shaft of the penis becomes attached to the tip of the penis.
Be on the lookout for any of these conditions. They will not improve and may become worse. Consult the pediatrician.
After the revision, leave the bandage on for 24-48 hours. Remove the bandage then, but continue using lubricating ointment like Aquaphor for 7 to 10 days. This prevents the stitches from sticking to the diaper.
Risks
- Anesthesia-airway complications (if done later in life and under general anesthesia)
- Reaction to anesthesia (if done later in life and under anesthesia)
- Bleeding (rare)
- Infection (rare)
- Excess skin following the procedure
- Meatitis (inflamed opening of the penis)
- Meatal stenosis (narrowed opening at the tip of the penis; treated with steroid cream or surgery)
- Penile adhesion and skin bridge
With a penile adhesion, the skin of the shaft sticks to the coronal margin (edge that surrounds the tip of the penis). This can be avoided by keeping the incision clean and applying aquaphor or vaseline to the incision to prevent adhesions.. Adhesions can possibly lead to skin bridges, which are thicker than the foreskin. Some resolve on their own, but some need treatment with creams or surgery. They make the penis look buried. See a pediatric urologist for this condition.
Benefits
- Circumcision decreases the risk for urinary tract infection in infants. A circumcised penis is easier to clean than an uncircumcised one.
- Circumcision reduces the risk in adulthood of infection from the human papillomavirus (HPV). HPV can cause genital warts; it can also increase the risk of genital cancers.
- Circumcision dramatically decreases the risk of developing penile cancer.
- It may decrease the risk of spreading genital herpes and syphilis.
- Some feel it provides aesthetically better results.
- It lowers the risk of an uncomfortable or infected penis, including the following conditions in uncircumcised men:
- Balanitis: pain, swelling, and irritation of the glans (head) of the penis. It occurs most often in uncircumcised males.
- Phimosis: the foreskin cannot be retracted from its position covering the tip of the penis; this condition may be caused by an especially tight foreskin and can be the site of bacterial infections.
- Paraphimosis: the foreskin cannot be pulled down over the penis; it has gotten stuck out of place.
- Circumcision reduces the risk of developing cervical cancer in the man’s female sexual partners.
- Circumcision doesn’t affect fertility or sexual pleasure.
When to delay circumcision
Babies with some conditions should not be circumcised until after the condition is resolved. These include
- Penile torsion (chordee). The uncircumcised penis appears twisted. It is present from birth and can happen in 1 in 80 newborn boys. See a pediatric urologist for this condition. It can be easily treated surgically, usually between 6 and 18 months of age. But unless the torsion is at least 90⁰, it doesn’t require treatment. Whether the boy has or does not have surgery should not affect long-term health or reproductive ability.
- Hypospadias. The hole that carries urine out of the penis is not at the tip, because the urethra, the tube that carries urine from the bladder, did not develop properly inside the penis. It can cause difficulties during urination and later with sexual intercourse. It can be repaired surgically at a few months of age. Please see Hypospadias for more complete information.
Circumcision is usually done in obstetric facilities. A lack of consensus among these providers about what constitutes “suitability to circumcise” in newborn boys has been addressed by the American Urology Association (AUA). “Suitability” refers to genitalia with problematic structures. If the baby’s genitalia are free of these problematic structures, he is suited to circumcise. If a baby with problematic structures is circumcised anyway, he could experience an adverse newborn circumcision outcome (ANCO) as he grows up. The AUA wants to standardize hospital circumcision by promoting objective criteria for a suited-to-circumcise diagnosis and thus decrease ANCOs.
Care of the uncircumcised penis
All boys are born with foreskin covering the tip of the penis. At birth, the foreskin cannot be pulled back to reveal the tip, but for uncircumcised boys it separates (retracts) from the tip over time. Retraction can happen shortly after birth, or it may take several years. You or the boy, himself, should not force the foreskin to retract, because bleeding and discomfort could follow.
Teenage boys should learn how to clean the foreskin and should do so every day using the following steps:
- Very gently pull the foreskin back from the tip of the penis.
- Use soap and water to wash the tip and the inside the foreskin. Dry the inside of the foreskin thoroughly.
- When finished, push the foreskin back in place over the tip of the penis.
Sexually transmitted diseases
Evidence shows that circumcision helps reduce a man’s risk of getting HIV from a woman with HIV by up to 60%. It may also help prevent transmission of genital HPV and genital herpes.
The choice is yours.
The American Urological Association (AUA) and American Academy of Pediatrics (AAP) recommend getting your baby boy circumcised. The AAP furthermore recommends that the doctor performing it use pain medication.
The AAP updated its circumcision policy in 2012 by citing the “prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV” from recent studies as reasons for the endorsement. It also noted that “the American College of Obstetricians and Gynecologists has endorsed this statement.” While the AAP does not recommend routine circumcision for all newborn males, it states that benefits outweigh risks.
If you decide not to use circumcision, get training from your healthcare provider about how to teach your son to clean the foreskin. During the first few years of his life, the boy’s foreskin stays attached to the penis and won’t retract. Don’t force it. When your son is old enough, at 3 or 4, teach him how to clean the penis and foreskin using the three steps above. These steps will help him avoid conditions that may require surgery later, or infections that may cause pain and discomfort.