2. ANATOMIC CONTRAINDICATIONS TO NEONATAL CIRCUMCISION JOHN F. REDMAN, M.D.,FACS,FAAP PROFESSOR OF UROLOGY AND ANDPEDIATRICS UNIVERSITY OF ARKANSAS COLLEGE OF MEDICINE AND ARKANSAS CHILDREN’S HOSPITAL

3. ANATOMIC CONTRAINDICATIONS TO NEONATAL CIRCUMCISION OBJECTIVES: TO ANSWER THE QUESTION: IS THERETO ANSWER THE QUESTION: IS THERE AN INDICATION FOR NEONATAL AN INDICATION FOR NEONATAL CIRCUMCISION? CIRCUMCISION? TO UNDERSTAND THE PROPER TECHNIQUES TO FACILITATE THE RECOGNITION OF ANATOMIC CONTRAINDICATIONS.TO UNDERSTAND THE PROPER TECHNIQUES TO FACILITATE THE RECOGNITION OF ANATOMIC CONTRAINDICATIONS. TO UNDERSTAND THE ANATOMIC CONTRAINDICATIONS.TO UNDERSTAND THE ANATOMIC CONTRAINDICATIONS. TO UNDERSTAND THE CONSEQUENCES OF NOT RECOGNIZING ANATOMIC CONTRAINDICATIONS.TO UNDERSTAND THE CONSEQUENCES OF NOT RECOGNIZING ANATOMIC CONTRAINDICATIONS.

4. Neonatal Circumcision: Anatomic Contraindications John F. Redman, M.D., F.A.A.P. Joseph M. Elser, M.D., F.A.A.P. Abstract: Complications from neonatal circumcision may result from inexperience or poor technique, but may also result from poor patient selection based on penile anatomy. The anatomic contraindications to neonatal circumcision are therefore presented in an effort to prevent complications. J Ark Med Soc. 94:60-2 1997 J Ark Med Soc. 94:60-2 1997

5. THE INCIDENCE OF NEONATAL CIRCUMCISION IN THE US Estimates based on the National Center for Health Statistics indicate that 61% and 65% of male infants were circumcised in the United States during 1987 and 1995.

6. A majority of boys born in the United States still undergo nonritual circumcisions. This occurs in large measure because parental decision-making is based on social or cultural expectations, rather than medical concerns. Studies from the 1980s suggested that the presentation of medical information on the potential advantages and disadvantages of circumcision had little influence on parents' decisions. This finding was recently confirmed. In another contemporary study, nearly half of those physicians performing circumcisions did not discuss the potential medical risks and benefits of elective circumcision prior to delivery of the infant son. Deferral of discussion until after birth, combined with the fact that many parents' decisions about circumcision are preconceived, contribute to the high rate of elective circumcision. Major factors in parental decision- making are the father's circumcision status, opinions of family members and friends, a desire for conformity in their son's appearance, and the belief that the circumcised penis is easier to care for with respect to local hygiene. Council on Scientific Affairs. Report 10: Neonatal circumcision. Chicago: American Medical Association, 1999.

7. QUESTION? IS THE NORMAL PREPUCE, ASSOCIATED WITH A NORMAL PENIS, AN AN ANATOMIC CONTRAINDICATION TO NEONATAL CIRCUMCISION?

8. AMERICAN ACADEMY OF PEDIATRICS Task Force on Circumcision Circumcision Policy Statement Pediatrics 103: 686, 1999

9. ABSTRACT. Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. If a decision for circumcision is made, procedural analgesia should be provided.

10. Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision.

11. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child.

12. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision.

13. A CONUNDRUM? The American Academy of Pediatrics Committee on Bioethics holds that health care providers "have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses." And "the pediatrician's responsibilities to his or her patient exist independent of parental desires or proxy consent.“ The Committee on Bioethics approved the 1999 Circumcision Policy statement of the American Academy of Pediatrics indicating parents should make such a decision based upon information about the potential benefits and risks.

14. A NEONATAL CIRCUMCISION IS FREQUENTLY NOT A TECHNICALLY EASY PROCEDURE

15. ALL NEWBORN BOY’S PENISES ARE NOT THE SAME

16. IF YOUR OPINION (ON CRITICAL EXAMINATION OF THE PENIS) IS THAT THE PENIS IS PROBABLY NORMAL, BUT THAT ITS CONFIGURATION IS SUCH THAT YOU DO NOT BELIEVE THAT YOU CAN PERFORM A PERFECT, OR NEAR PERFECT, CIRCUMCISION----- DO NOT BE PRESSURED TO PROCEED.

17. HOW DO YOU EXAMINE THE NEONATE'S PENIS? BY SIMPLE INSPECTION DECIDE IF THE PENIS HAS A NORMAL APPEARANCE. OBSERVE WHETHER THE PENIS IS SHORT OR SMALL. COMPRESS THE PUBIC SKIN AT THE BASE OF THE PENIS AND DETERMINE IF THERE IS ADEQUATE DORSAL SHAFT SKIN OR IF THE PREPUCE APPEARS TO ARISE FROM THE PUBIC SKIN.

18. INSPECT THE VENTRUM OF THE PENIS AND DETERMINE IF THERE IS A DISTINCT SHAFT SKIN OR IF THE PREPUCE APPEARS TO BE CONTIGUOUS WITH THE SCROTUM (WEBBED PENIS). COMPRESS THE ERECTILE BODIES AT THE BASE OF THE PENIS TO PRODUCE AN ERECTILE STATE AND DETERMINE THERE IS ANY CURVATURE OF THE PENIS.

19. INSPECT FOR TORSION OF THE PENIS INSPECT THE PREPUCE TO SEE IF IT IS COMPLETE OR DOES IT APPEAR TO BE HOODED ON THE DORSUM OR DEFICIENT ON THE VENTRUM OF THE PENIS INSPECT FOR WRINKLED OR REDUNDANT SKIN ON THE DISTAL DORSUM OF THE PENIS CAREFULLY VISUALIZE THE MEATUS--- DOES IT EXIT AT THE TIP OR IS IT LOCATED MORE PROXIMAL

20. THE FINAL INSPECTION BEFORE MAKING AN INCISION USE A SKIN PENCIL TO MARK THE LEVEL OF THE CORONA. IF THE SHAFT SKIN IS DEFICIENT – ABORT THE PROCEDURE. USE A HEMOSTAT TO WIDEN THE PREPUTIAL ORIFICE IF NECESSARY TO VISUALIZE THE MEATUS. IF THE MEATUS IS HYPOSPADIAC ----ABORT THE PROCEDURE.

27. ANATOMIC CONTRAINDICATIONS TO NEONATAL CIRCUMCISION HYPOSPADIASHYPOSPADIAS HOODED PREPUCEHOODED PREPUCE PENILE CURVATUREPENILE CURVATURE PENILE TORSIONPENILE TORSION BURIED PENISBURIED PENIS SMALL PENISSMALL PENIS LARGE SCROTAL OR INQUINOSCROTAL HYDROCELESLARGE SCROTAL OR INQUINOSCROTAL HYDROCELES

28. HYPOSPADIAS

34. HOODED PREPUCE

41. PENILE CURVATURE

42. PENILE TORSION

45. BURIED PENIS

49. SMALL PENIS

54. LARGE SCROTAL OR INQUINOSCROTAL HYDROCELES

55. THE BASIC PRINCIPLE TO AVOID CIRCUMCISION IN A BOY WITH AN ANATOMIC CONTRAINDICATION IF THE PENIS IS NOT NORMAL ----- DO NOT PROCEED WITH THE CIRCUMCISION!

56. THE CONSEQUENCES OF NOT RECOGNIZING ANATOMIC CONTRAINDICATIONS DEFICIENT EPITHELIUM TO PERFORM HYPOSPADIAS SURGERYDEFICIENT EPITHELIUM TO PERFORM HYPOSPADIAS SURGERY DEFICIENT INNER LEAF OF THE PREPUCE TO FORM A FIRLIT COLLARDEFICIENT INNER LEAF OF THE PREPUCE TO FORM A FIRLIT COLLAR DEFICIENT SKIN FOR SHAFT COVERAGE IN CASES OF PENILE CURVATURE OR TORSIONDEFICIENT SKIN FOR SHAFT COVERAGE IN CASES OF PENILE CURVATURE OR TORSION DEFICIENT INNER LEAF OF PREPUCE FOR REPAIR OF BURIED PENISDEFICIENT INNER LEAF OF PREPUCE FOR REPAIR OF BURIED PENIS DISTAL CICATRIX FORMATION (CONCEALED PENIS)DISTAL CICATRIX FORMATION (CONCEALED PENIS) REDUNDANT OR IRREGULAR RESIDUAL PREPUCE NECESSITATING CIRCUMCISION REVISIONREDUNDANT OR IRREGULAR RESIDUAL PREPUCE NECESSITATING CIRCUMCISION REVISION