1. Ephraim Back, MD, MPH Ellis Hospital Schenectady, NY
Circumcision
Ephraim Back, MD, MPH
Ellis Hospital
Schenectady, NY

2. Objectives To describe medical issues relating to circumcision
To describe rationale for providing anesthesia for newborn circumcision
To describe methods of nerve block for newborn circumcision
To describe methods of circumcision using Gomco and Mogen clamps

3. World’s Oldest Account of Circumcision – Egypt 2400 BC

9. Circumcision in the U.S. 1.2 –1.8 million newborn boys (60-90%)
National Health and Social Life Survey:
Circumcision rates increased from 32% in 1932 to >80% post WWII
White (81%), Black (65%), Hispanic (54%)
Jewish (96%), Protestant (71-82%), Catholic (79%)
National Center for Health Statistics:
64.1% of male infants circumcised during 1995
Laumann et.al. JAMA :1052

10. AAP Circumcision Policy -- 1999
“Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however these data are not sufficient to recommend routine neonatal circumcision.”
To make an informed choice, parents of all male infants should be given accurate and unbiased information.”
If a decision for circumcision is made, procedural anesthesia should be provided”
Pediatrics.1999:103:686

11. Circumcision and Prevention of Penile Problems
Longitudinal study in New Zealand followed a birth cohort of 500 boys:
Uncircumcised boys had higher rate of penile inflammation (14.4% vs.7.6%) and phimosis (3.7%)
During infancy, circumcised group had a higher rate of meatitis. Older uncircumcised group had a higher rate of penile problems
Majority of problems were relatively minor
Other problems include balanitis (esp. with diabetes), paraphimosis, chronic scarring, secondary phimosis.
Fergusson et.al. Pediatrics :537

12. Circumcision Status and UTI
Relative risk of UTI in uncircumcised males <1 year old compared with circumcised males increased from 4 to 10 fold:
Uncircumcised ~ 7-14 per 1,000 ( %)
Circumcised ~ 1-2 per 1,000 ( %)
NNT to prevent one UTI =
Increased periurethral bacterial colonization.
Uropathogenic bacteria adhere to mucosal surface, but not to keratinized surface of foreskin

13. Circumcision and Cancer of Penis
Risk of developing penile cancer in uncircumcised man increased 3-fold
Annual rate in U.S cases per 1 million men
Over past 20 years, of 750 to 1,000 cases of penile cancer/year in U.S., only 3 cases in men who had been circumcised as infants
NNT ~ 50,000 to prevent 1 case of cancer
May be related to HPV, hygiene, phimosis, smegma

14. Circumcision, Cervical Cancer and STDs
Cervical cancer -- controversial:
NEJM study – circumcised men had a decreased risk of HPV (OR = 0.37)
Monogamous partners of circumcised men had a decreased risk of cervical cancer (OR = 0.42)
STDs:
Uncircumcised men may be more susceptible to STDs that disrupt epithelial surfaces, such as herpes, syphilis, condyloma, and chancroid
GC and Chlamydia conflicting data
Castellsagué et al. NEJM. 2002; 346:1105

15. Siegfried et. al.Cochrane library. Issue 3, 2003
Circumcision and HIV
Siegfried et. al.Cochrane library. Issue 3, 2003

16. Circumcision Complications
Complication rate %
Bleeding ~0.1% (rarely needing transfusion)
Infection, usually manifest by local reaction
Isolated case reports of recurrent phimosis, wound separation, concealed penis, skin bridges, urinary retention, meatal stenosis, inclusion cysts
Case reports of more serious complications, including scalded skin syndrome, necrotizing fasciitis, sepsis, urethral fistula, partial amputation, and penile necrosis

17. Factors Affecting Circumcision Decision
Parents who circumcised
Easier to keep clean
Easier to do now
Medically, its better
Same as baby’s father
My doc recommended
Same as other sons
Religious
Cosmetic
Parents who Refused
Not necessary
Painful
Baby’s father not circumcised
Hospital failed to do it
Not sure
Tiemstra JD. JABFP :16

20. Arch Pediatr Adolesc Med. 2001;155:173-180.
Consensus Statement for the Prevention and Management of Pain in the Newborn
“Compared to older children, neonates are more sensitive to pain and vulnerable …”
“If a procedure is painful in adults, it should be considered painful in newborns”
“Health care professionals have the responsibility for assessment, prevention, and management of pain in neonates”
“Clinical units providing healthcare to newborns should develop written guidelines…”
Arch Pediatr Adolesc Med. 2001;155:

21. Consensus Statement for the Prevention and Management of Pain in the Newborn
Circumcision
If deemed necessary:
Use an appropriate clamp (Mogen clamp preferred over Gomco).
Apply EMLA to the proposed site.
Place a dorsal penile nerve block, ring block, or caudal block, using plain or buffered lidocaine.
Use a pacifier* with sucrose.
Consider acetaminophen for postoperative pain.

22. Barriers to Universal Adoption of Anesthesia for Circumcision
Physicians were not trained in the technique when they originally began to perform circumcisions.
Anesthesia takes more time.
Physicians are not convinced that newborns really feel pain. Some believe that circumcision can be performed so quickly that the pain of a local injection would actually prolong the suffering.
Concerns about the adverse effects of anesthesia.

24. The four A's of the humane approach to circumcision
Anesthesia: Ring Block, DPNB, EMLA
Ancillary measures: Positioning, pacifier use, sugar administration, human contact
Appropriate technique: Minimal instrumentation and traction on tissue, for whatever tools are used
Analgesia: Postoperative acetaminophen
Veltman L. A humane approach to neonatal circumcision. Contemporary OB Gyn. June 1988

25. “Efficacy and Safety of Lidocaine-Prilocaine Cream”
Taddio et. al. NEJM :1197

26. “Efficacy and Safety of Lidocaine-Prilocaine Cream”
“Although the use of (EMLA) was associated with an overall decrease in pain, the magnitude of the effect varied during the procedure… less effective during phases associated with extensive tissue damage, such as lysis of adhesions and tightening of the clamp”
“Alternative methods… are more effective…Both techniques are rarely used because they require skills that most physicians have not acquired.
“Moreover, the injections themselves are considered painful and are associated with the risk of systemic toxicity”
Taddio et. al. NEJM :1197

27. EMLA Cream FDA APPROVES EMLA (LIDOCAINE 2.5%
AND PRILOCAINE 2.5%) CREAM FOR USE IN FULL TERM NEONATES, SUPPORTING ITS USE IN NEWBORN CIRCUMCISIONS
(Wayne, PA - May 21, 1999) EMLA (lidocaine 2.5% and
prilocaine 2.5%) Cream is now approved by the FDA for use in pediatric patients younger than one month of age for infants that had a gestational age of 37 weeks or greater. EMLA Cream was previously approved for use in children one month of age or older. This indication allows the use of EMLA Cream for circumcision and other procedures where topical analgesia (inability to feel pain) is desirable.

28. Herschel et.al. Arch Pediatr Adolesc Med. 1998;152:279
Sucrose
Herschel et.al. Arch Pediatr Adolesc Med. 1998;152:279

29. Comparison of Ring Block, DPNB, and Topical Anesthesia
54 infants randomized to 4 groups – Gomco method
Injections completed 8 minutes before circ
EMLA cream applied 90 minutes before circ
Ring block equally effective through all stages. DPNB and EMLA not effective during foreskin separation and incision
Lander et. Al. JAMA :2157

31. Equipment for Nerve Block
1cc tuberculin syringe
1 cc 1% preservative free lidocaine (without epinephrine)
30 gauge needle

32. Contemporary Ob/Gyn, February 1999

33. Dorsal Penile Nerve Block
Veltman L. A humane approach to neonatal circumcision. Contemporary OB Gyn. June 1988

34. Safety of Dorsal Nerve Block
Retrospective review of 1,022 infants with DPNB in Minneapolis during 1989
Twelve patients (1.2%) with complications:
11 of the children had injection site ecchymoses <1 cm noted before discharge
1 child had excessive bleeding at the injection site treated with silver nitrate
Ecchymoses more common with Platibell (2.1%) than with Gomco method (0.6%)
Fontaine et. al. J. Fam Pract :243

35. Schematic representation of normal neonatal penile anatomy.
Slides from Peleg and Steiner. Amer Family Physician 9/15/98

36. The Gomco circumcision clamp

37. Dorsal crush and slit

38. Insertion of the bell over the glans.

39. Inserting the arms of the bell through the hole of the plate

40. Pulling the foreskin upwards and adjusting the bell and base plate

41. Final assembly

42. Excising the foreskin

43. Slides from Reynolds Amer Fam Physician 1996; 54:177-82.
Mogen clamp
Slides from Reynolds Amer Fam Physician 1996; 54:

44. Grasp the foreskin and lyse adhesions

45. Dorsal crush

46. Safe placement of the clamp, dorsal to ventral

47. Locking the Mogen clamp shut

48. Excising the foreskin

49. Crush line covers the glans fully

50. Immediate post-op view

51. 10 days post-op