eMedicine Specialties > Pediatrics: Surgery > Urology

Circumcision: Follow-up

Author: Carlos A Angel, MD, Associate Professor of Pediatrics, Division of Pediatric Surgery, University of Tennessee School of Medicine; Consulting Staff, East Tennessee Children's Hospital, East Tennessee Pediatric Surgery Group
Coauthor(s): Santos Cantu, Jr, MD, Department of Pediatrics, Consulting Staff, Christus Santa Rosa Children's Hospital
Contributor Information and Disclosures

Updated: Sep 14, 2006

Follow-up

Further Inpatient Care

  • Neonates who have excessive and poorly controlled pain during infancy may have pain intolerance and hyperalgesia later in life.
  • Sympathetic arousal due to pain is regularly seen in neonates and is manifested as tachycardia, increased blood pressure, sweating, elevated serum catecholamine and cortisol levels, and decreased oxygen saturation.
  • Behavioral responses include crying, flailing, and grimacing.
  • The AAP Task Force on Circumcision recommends the use of environmental, nonpharmacologic, and pharmacologic interventions to reduce pain and distress during neonatal circumcision. These interventions include the use of a sucrose pacifier, local application of a eutectic mixture of local anesthetic agents (prilocaine and lidocaine) (EMLA) cream, dorsal penile blocks, and ring blocks.
    • Although some physicians are averse to the use of EMLA cream in the neonatal period because of concern of causing methemoglobinemia, its use has been proven to be safe for circumcisions in this age group.
    • A ring block that consists of the circumferential subcutaneous injection of local anesthesia (eg, 0.5% lidocaine without epinephrine) at the base of the penis is highly effective (at least as effective as dorsal penile blocks) and easier to perform than dorsal penile blocks.
    • Oral acetaminophen provides adequate pain control after neonatal circumcision.
    • In patients who undergo formal circumcisions in the operating room, caudal blocks and dorsal penile blocks decrease the amount of pain medication required after the procedure.

Further Outpatient Care

  • Patients should begin to take baths within 24 hours after the procedure.
  • Regular application of triple antibiotic ointment (4-6 times/d or after each diaper change) is important to prevent infections, adhesions and the formation of crusts on the denuded glans in older children.
  • Patients should return for a follow-up visit within 1 week after circumcision.

Complications

  • Several complications are associated with neonatal circumcision.
    • Complications can be minimized if an experienced practitioner performs the circumcision.
    • Bleeding is the most common early complication and usually is adequately controlled with local hemostatic measures, such as pressure dressings. On occasion, the patient must be taken back to the operating room for surgical hemostasis and hematoma evacuation.
    • Infection is the second most common early postoperative complication, but usually is minor and easily managed with oral and topical antibiotics.
    • The most common long-term complication seen after circumcision is meatal stenosis.
  • Other complications described in isolated case reports include the following:
    • Recurrent phimosis
    • Wound separation
    • Penile torsion
    • Concealed penis
    • Unsatisfactory cosmesis
    • Skin bridges
    • Urinary retention
    • Meatitis
    • Skin chordee (due to removal of excessive skin)
    • Inclusion cysts
    • Retained Plastibell devices
  • Other case reports have mentioned rare events such as scalded skin syndrome, necrotizing fasciitis, sepsis, meningitis, urethral fistula, penile necrosis, and amputation of a portion of the glans penis.

Prognosis

  • Complete resolution is expected with appropriate treatments.

Patient Education

  • Instruct parents concerning the occurrence of physiologic childhood phimosis, which can last into the school-age years. Stress the danger of forcibly retracting the foreskin for hygienic purposes. Let them know that, after time, the adhesions found between the inner prepuce and the glans naturally lyse.
  • Instruct patients and parents of children with acquired phimosis regarding the importance of proper genital hygiene.
  • In addition, make them aware of the problems that may result from an acquired phimosis (eg, balanitis, paraphimosis, preputial pain).
  • Make all health care providers aware of the risk of paraphimosis associated with catheterization, and remind them to always reduce the foreskin after penile cleaning and catheterization.
  • Inform parents fully regarding the potential benefits and risks associated with neonatal circumcision so that they can determine whether circumcision is in the best interests of their child.
  • The AAP does not recommend routine neonatal circumcision; however, if circumcision is performed, the AAP recommends the use of procedural analgesia.
  • For excellent patient education resources, visit eMedicine's Men's Health Center. Also, see eMedicine's patient education articles Foreskin Problems and Circumcision.

Miscellaneous

Medicolegal Pitfalls

  • The most relevant ethical questions regarding circumcision refer to the decision by parents to allow or request an operation that only has marginal proven health benefits and results in permanent physical alteration of the child at a time when the child has no input in the decision-making process.
  • Another relevant question involves the decision to provide anesthesia or analgesia in cases in which their use is not the tradition in certain cultures for ritual circumcisions. Some countries (eg, Sweden) legally enforce the use of analgesia, even if this contradicts the customs and traditions of certain groups.
  • Although the issue of informed consent is at the forefront of any debate on the medical-ethical issues surrounding circumcision, parents undoubtedly make countless health-related decisions on behalf of their children until they are legal adults. Therefore, the obligation of providers is to have a frank and thorough discussion of the true benefits and risks of the procedure with any parent contemplating circumcision for their child in order to allow them to make an informed decision that is in the best interest of their son, leaving biases by the wayside, without trying to influence this decision.
 


More on Circumcision

Overview: Circumcision
Differential Diagnoses & Workup: Circumcision
Treatment & Medication: Circumcision
Follow-up: Circumcision
References

References

  1. Alanis MC, Lucidi RS. Neonatal circumcision: a review of the world's oldest and most controversial operation. Obstet Gynecol Surv. May 2004;59(5):379-95. [Medline].

  2. Bailey RC, Neema S, Othieno R. Sexual behaviors and other HIV risk factors in circumcised and uncircumcised men in Uganda. J Acquir Immune Defic Syndr. 1999;Nov 1;22(3):294-301. [Medline].

  3. Berdeu D, Sauze L, Ha-Vinh P, Blum-Boisgard C. Cost-effectiveness analysis of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect. BJU Int. Feb 2001;87(3):239-44. [Medline].

  4. Cantu S Jr. Phimosis and paraphimosis. eMedicine Journal [serial online]. 2001. Available at: http://www.emedicine.com/emerg/topic423.htm. [Full Text].

  5. Lannon CM, Bailey AGB, Fleischman AR. Circumcision policy statement. American Academy of Pediatrics. Task Force on Circumcision. Pediatrics. Mar 1999;103(3):686-93. [Medline].

  6. Roth DR, Gonzales ET Jr. Disorders of renal development and anomalies of the collecting system, bladder, penis, and scrotum. In: Oski FA, eds. Oski's Essential Pediatrics. 2nd ed. Wolters Kluwer;1994: 1763-5.

  7. Schoen EJ. Ignoring evidence of circumcision benefits. Pediatrics. 2006;118(1):385-7. [Medline].

  8. Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis. AIDS. 2000;14(15):2361-70. [Medline].

  9. Wiswell TE, Hachey WE. Urinary tract infections and the uncircumcised state: an update. Clin Pediatr (Phila). Mar 1993;32(3):130-4. [Medline].

  10. Wolbars AL. Circumcision and penile cancer. Lancet. 1932;1:150-3.

Further Reading

Keywords

circumcision, prepuce, foreskin, peritectomy, prepuce excision

Contributor Information and Disclosures

Author

Carlos A Angel, MD, Associate Professor of Pediatrics, Division of Pediatric Surgery, University of Tennessee School of Medicine; Consulting Staff, East Tennessee Children's Hospital, East Tennessee Pediatric Surgery Group
Carlos A Angel, MD is a member of the following medical societies: American College of Surgeons, American Pediatric Surgical Association, British Association of Paediatric Surgeons, Children's Oncology Group, International Children's Continence Society, International Pediatric Endosurgery Group, New York Academy of Sciences, Society for Surgery of the Alimentary Tract, Society of Critical Care Medicine, and Texas Pediatric Society
Disclosure: Nothing to disclose.

Coauthor(s)

Santos Cantu, Jr, MD, Department of Pediatrics, Consulting Staff, Christus Santa Rosa Children's Hospital
Disclosure: Nothing to disclose.

Medical Editor

M David Bomalaski, MD, FAAP, Chief of Medical Staff, 3rd Medical Group, Elmendorf Air Force Base
M David Bomalaski, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics and American Urological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Nothing to disclose.

Managing Editor

Harry P Koo, MD, Chairman of Urology Division and Director of Pediatric Urology, Virginia Commonwealth University; Professor of Surgery, VCU School of Medicine, Medical College of Virginia; Director of Urology, Children's Hospital of Richmond
Harry P Koo, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, and American Urological Association
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Nothing to disclose.

Chief Editor

William J Cromie, MD, MBA, President and Chief Executive Officer, Health Care, Capital District Physicians' Health Plan
William J Cromie, MD, MBA is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Urological Association, Medical Society of the State of New York, Société Internationale d'Urologie (International Society of Urology), Society for Pediatric Urology, Society of University Urologists, and Society of Uroradiology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.