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Circumcision Follow-up

  • Author: Carlos A Angel, MD; Chief Editor: Ted Rosenkrantz, MD  more...
 
Updated: Jul 01, 2016
 

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.

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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.
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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.

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Prognosis

Complete resolution is expected with appropriate treatments.

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Patient Education

See the list below:

  • 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, see eMedicineHealth's patient education articles Foreskin Problems and Circumcision.
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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, New York Academy of Sciences, Society of Critical Care Medicine, Texas Pediatric Society, Children's Oncology Group, International Pediatric Endosurgery Group, International Children's Continence Society, British Association of Paediatric Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Michael Maddox, MD Resident Physician, Department of Urology, Rhode Island Hospital, Brown University Medical School

Michael Maddox, MD is a member of the following medical societies: American Medical Student Association/Foundation, American Urological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Harry P Koo, MD Chairman of Urology Division, Director of Pediatric Urology, Professor of Surgery, Virginia Commonwealth University 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, American Urological Association

Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine

Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, Eastern Society for Pediatric Research, American Medical Association, Connecticut State Medical Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

Martin David Bomalaski, MD, FAAP Pediatric Urologist, Alaska Urology; Clinical Assistant Professor, Seattle Children's Hospital

Martin David Bomalaski, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Urological Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Santos Cantu Jr, MD, to the development and writing of this article.

Medscape Reference thanks Pamela I Ellsworth, MD, FACS, Associate Professor of Urology, The Warren Alpert Medical School of Brown University; Consulting Staff, University Urological Associates, for the video contributions to this article.

References
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Infant penis.
Retracting the foreskin with a dorsal slit and marking the area to be incised. Video courtesy of Pamela I Ellsworth, MD.
Sleeve technique with electrocautery. Video courtesy of Pamela I Ellsworth, MD.
Suturing the mucosal collar to the penile shaft skin circumferentially. Video courtesy of Pamela I Ellsworth, MD.
Circumcision complete. Video courtesy of Pamela I Ellsworth, MD.
 
 
 
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