The Circumcision Procedure

Neonatal circumcision, performed soon after birth, can be done by a pediatrician or an obstetrician in the hospital within hours of delivery. However, most patients are referred to a urologist after they are six months old; after this age the procedure must take place in a hospital operating room or at an outpatient surgery center.

Depending on the age of the patient, the patient needs either mild sedation or general anesthesia. Afterward, the physician applies a local anesthesia to the penis to reduce the infant’s post-operative discomfort. All of the stitches from the surgery will dissolve on their own and need no removal. It can take up to two weeks for the sutures to completely disappear.

At the conclusion of the procedure, the urologist covers the penis in a dressing, recommending that the dressing stay for three days, although it usually falls off sooner. Some bleeding on the gauze is normal.

After removal of the dressing, the penis is generally bruised and swollen, taking three to four weeks until it starts to look normal. Also, there may be some intermittent bleeding from the incision.

Please be patient with recovery. Call the doctor if a fever, excessive swelling or bleeding develops, or if there are any unanswered questions. The doctor will provide a prescription for pain medicine, though sometimes an over-the-counter pain reliever such as Tylenol is adequate.

Complications

  • Buried penis is when the penile shaft buried below the surface of the pubic skin. It is recommended that after the circumcision you push at the base of the penis to expose the glans. This maneuver can help reduce the risk of a buried penis.
  • Chordee is an abnormal bend of the penis, caused by scar tissue on the penis. This rarely occurs.
  • Complications from the anesthetic are a risk of virtually any surgery.
  • Meatal stenosis is the narrowing of the urine channel (urethra) at the top of the penis. The symptoms are usually a deflected urinary stream; this can easily be fixed by a urologist.
  • Poor cosmetic appearance.
  • Skin bridges are when the foreskin reattaches to the glans, easily reparable by a urologist. The best way to avoid a skin bridge is by exposing the glans and applying a topical ointment.
  • Tearing of the sutures, usually due to erection.
  • Pain. A circumcision hurts. Local anesthesia can block nerve sensations during the procedure. Post-operative pain medicine will be prescribed.
  • Bleeding or infection.

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Repair of circumcision complications

Significant complications in circumcision are rare, occurring in about 1 in 500 cases, according to the American Academy of Pediatrics. Whenever parents see signs of infection or are concerned about the circumcision for any reason, they should see a urologist.

Most minor complications happen early after the circumcision and involve bleeding, infection or the removal of too much or too little tissue. Late complications are usually skin adhesions, meatal stenosis, skin bridges, phimosis and epithelial inclusion cysts.

Corrections of circumcision complications are generally very successful. The major complications of circumcision are listed below, along with the corrective action needed.

Bleeding after circumcision, beyond the initial amount of blood loss, are usually mild cases. Applying direct pressure to the site for a couple of minutes should stop the bleeding. A urologist can also add a Gelfoam wrap, a sponge that speeds clotting and stops oozing from the cut edge. Rare cases in which the frenular artery is bleeding may require us to add sutures.

Infection doesn’t occur often if proper sterile procedures are used. Sometimes parents mistake the scabs that occur on the cut edge or where adhesions have been removed from the glans as infection, but they aren’t. When infection is suspected, immediate treatment is required because infections in newborns can be a serious problem. This can involve antibiotics and surgical evaluation for removal of dead tissue.

Too much foreskin can sometimes be removed because it is attached to the glans on the inner surface and the device used for the circumcision can draw this skin up for removal in addition to the foreskin. This requires another surgical procedure to correct the problem.

Too little of the foreskin can also be removed, often called an incomplete circumcision, and it causes infection, irritation or does not have the desired appearance. We can correct that with another surgical procedure.

Adhesions are where the foreskin has become connected to the glans. These occur naturally and resolve in a few years, but if caused by incomplete circumcision they need to be removed.

A skin bridge is a section of skin connecting the edge of the circumcision back to the glans. This has space underneath it where debris can accumulate and cause infection.

An inclusion cyst can form along the cut edge after circumcision and may require surgical correction.

Phimosis, which is when the foreskin can’t retract, can occur normally but can also be caused by circumcision if the boy had penile web or buried penis. The circumcised edge can pull together like a purse-string, trapping the penis under the site of the circumcision. This may just need to be observed as it reconciles, or surgical revision may be needed.

Meatal stenosis is an uncommon complication and occurs when the urethra narrows, which can cause problems with the urinary stream. It can sometimes occur when blood supply to the glans is affected during a circumcision. Surgical correction may be required.

Chordee also can occur naturally, but when it develops as a complication from circumcision, it may require surgical correction.

Surgical circumcision revisions

Circumcision revisions are performed with the child under anesthesia. If performed to correct too little foreskin removed the first time, the urologist will remove the additional skin and adhesions, which are where the foreskin has become connected to the glans. We use small stiches to close and add local anesthetic to reduce pain afterward. The child can go home the same day.

The risks of surgical circumcision revision are the same as those for a circumcision or any surgical procedure.