Paediatric Circumcision

As a paediatric surgeon, one of the most common questions I get from parents is about circumcision. Circumcisions have been practiced for centuries, and while its cultural, religious, and medical significance varies across communities, it remains a topic of interest for many families. If you’re considering circumcision for your child, I hope to provide an overview to help you make an informed decision.

What is a Circumcision?

Circumcision is the surgical removal of the foreskin, the fold of skin covering the head (glans) of the penis. This is typically a quick and straightforward procedure at any age.

Why is Circumcision Performed?

1. Cultural and Religious Reasons:
   Circumcision is deeply rooted in the traditions of some religions and cultural groups.
   
   
2. Medical Reasons:
   Circumcision isn’t always medically necessary, but it is sometimes recommended to fix or prevent specific conditions, including:
   
   • Phimosis: The foreskin (skin covering the penis) cannot be pulled back over the glans.
     ALL baby boys have natural phimosis of the foreskin, It is normal from newborn to about the age of 3 years before the foreskin can be pulled back.
     As a parent it is important to know that this is a normal condition in a very young baby.
     
   • Recurrent Infections: Little boys can have infections such as balanitis (inflammation of the foreskin or glans). If balanitis occurs, the little boys will have a swollen foreskin, with a discharge from the front of the penis. Sometimes he may complain of pain while peeing because the skin is irritated.
     
   • Urinary Tract Infections (UTI or bladder infection): Circumcision can slightly decrease the risk of UTIs, especially in babies.
     This is more relevant in boys who have other medical conditions that make them slightly more likely to have urinary tract infections. Such conditions include spina bifida (a condition that affects the spine) or anatomical changes that change the normal shape of the urinary tract.
     
     
3. Hygiene and Long-Term Health:
   Some parents choose circumcision for easier hygiene and for future health benefits.
   There have been studies that have suggested that men who have had circumcisions are less likely to get sexually transmitted infections, unfortunately, there is no evidence to support this claim. Many of the studies done have been too different to draw all-encompassing conclusions.

Having a circumcision may decrease the chance of a man developing cancer of the penis.
At the moment there is not enough proof to suggest this to be true, except in invasive penile cancer. One of the risk factors for invasive penile cancer is phimosis. A man would need a circumcision to treat phimosis as it is an uncomfortable condition to have.

When is Circumcision Performed?

Circumcision is often done in the neonatal period (within the first few weeks of life) but can also be performed later in childhood or adolescence. The procedure is a simple procedure irrespective of when it is performed, with the risks being the same if the patient is a new baby or if the boy is older.

How is Circumcision Performed?

1. For Newborns:
   
   • Preparation: The baby is swaddled (wrapped up like a burrito) to minimize movement, and local anesthesia (a numbing cream and/or injection) is applied to ensure the procedure is pain-free.
     I encourage moms to send a pacifier or binky to the operating theatre as it helps soothe the little boy as well, which makes the procedure kinder and nicer for our little patient.
     
   • Technique: Surgical excision is performed and dissolvable sutures are placed under the skin. In some countries there are special devices used, however they are not available locally in Cambodia in very small sizes. Surgical glue is applied to the wound to give it an extra layer of protection against pee and poop and to allow for easier cleaning during the healing process.
     
   • Time: The procedure typically takes about 20-25 minutes.
     
     
2. For Older Children:
   
   • Because older children are more aware and have a fear of hospitals and procedures, I strongly encourage the use of a general anesthesia or deep sedation together with injection of a local anaesthetic.
     The deeper anaesthetic ensures that the boy sleeps during the procedure and has no pain, and the added injection of local anaesthetic ensures that when the boy wakes up, he will be pain free for a few hours. The local anaesthetic is only injected after the boy is sleeping to ensure that he does not feel any pain.
     
   • The surgeon removes the foreskin and closes the incision with dissolvable stitches. Surgical glue is applied to the wound to give it an extra layer of protection against pee and poop.

Benefits of Circumcision

• Reduced Risk of Infections: Circumcised men have a slightly lower risk of UTIs during infancy and certain infections later in life.
  
• Easier Hygiene: Cleaning the penis is often simpler after circumcision.
  
• Prevention of Medical Conditions: Circumcision can prevent conditions like phimosis, paraphimosis, and balanitis.

Are There Risks?

While circumcision is generally safe, like any surgical procedure, it carries some risks, including:

• Bleeding: Minimal bleeding is common, but excessive bleeding is rare.
• Infection: Proper wound care minimizes this risk.
• Scarring: A small scar is a normal part of healing.
• Complications: Very rare issues include removal of too much or too little of the foreskin.

When a circumcision is performed by an experienced surgeon, the risk of complications is extremely low.

Post-Operative Care and Recovery

1. For Newborns:
   • The healing process takes about 7-10 days.
   • Keep the area clean and apply petroleum jelly to prevent sticking to the diaper.
     
2. For Older Children:
   • Recovery may take a bit longer, about 2-3 weeks.
   • Pain or discomfort can be managed with medicine.
   • Sports and activities should be less until the wound heals completely.

Should You Choose Circumcision for Your Child?

It is a very personal decision on whether to circumcise your son, and depends on factors such as cultural beliefs, religion, and medical considerations. It’s important to discuss your concerns and questions with a trusted doctor or healthcare provider so that you can make the right decision for you and your family.

Circumcision is not a one-size-fits-all solution. If there is no medical need to do a circumcision, it is equally valid to not do it.

Reassurance for Parents

As a paediatric surgeon, I emphasize that circumcision is a routine and low-risk procedure.
The type of anaesthesia chosen will depend on your baby’s age, but we want to make sure he is not traumatised by the procedure. If you’re considering circumcision for your child, please seek advice from a qualified healthcare provider to make you make the best choice for your family.

By Dr. Caroline Zabiegaj-Zwick, Paediatric Surgeon