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Circumcision Treatment & Management

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

Medical Care

Daily cleaning, without forceful retraction of the foreskin, is the only treatment necessary for phimosis in patients without urinary obstruction, hematuria, or preputial pain.

Treatment with topical corticosteroids is effective in separating the loose adhesions found between the glans and the foreskin.

In 2001, French researchers Berdeu et al used data from form published reports and from claims by private hospitals for children younger than 13 years. They found that topical application of clobetasol or 0.05% betamethasone cream 2 times/day to the foreskin and glans for 4-8 weeks was effective in allowing full retraction of the foreskin in 85% (range, 70-100%) of the patients who had a mean age of 5 years at inclusion. The 15% failure rate was attributed to verifiable cases of lichen scleroticas et atrophicus or nonspecific chronic inflammatory processes. Success was achieved at approximately 10% of the cost of operative circumcision; this result showed a considerable cost-effectiveness with this approach.[13]

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Surgical Care

Although several techniques are used in neonatal circumcision, all of the methods involve the following common elements:

  • Estimation of the amount of foreskin to be removed
  • Dilation of the preputial orifice to determine the presence of a normal glans and penis without any evidence of hypospadias, epispadias, chordee, or other anomalies
  • Blunt separation of the inner preputial epithelium from the glans
  • Placement of a device designed to ensure hemostasis
  • Removal of the foreskin

The 3 most common devices used to date are the Gomco clamp (67%), the Plastibell device (19%), and the Mogen clamp (10%). Both the Gomco clamp and the Mogen clamp are excellent instruments for infants but should not be used in toddlers who weigh more than 5 kg because of an increased risk of bleeding. Cosmetic results are excellent with any of these devices if they are used correctly.

In the authors' experience, the Plastibell technique can be used safely for office circumcisions in children up to 10 kg under local anesthesia because this technique induces tissue necrosis by means of suture compression of the foreskin over a plastic ring that protects the glans. Thus, adequate hemostasis is ensured in the older child. The skin sloughs off in 5-7 days, and the ring separates.

The videos below depict circumcision technique in an older child.

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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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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  9. 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].

  10. 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].

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

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

  13. 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. 2001 Feb. 87(3):239-44. [Medline].

  14. Alexander SE, Storm DW, Cooper CS. Teasing in School Locker Rooms Regarding Penile Appearance. J Urol. 2014 Oct 1. [Medline].

  15. Auvert B, Sobngwi-Tambekou J, Cutler E, Nieuwoudt M, Lissouba P, Puren A, et al. Effect of male circumcision on the prevalence of high-risk human papillomavirus in young men: results of a randomized controlled trial conducted in Orange Farm, South Africa. J Infect Dis. 2009 Jan 1. 199(1):14-9. [Medline]. [Full Text].

  16. Cantu S Jr. Phimosis and paraphimosis. Medscape Reference Journal [serial online]. 2001. Available at: http://emedicine.medscape.com/article/777539-overview. [Full Text].

  17. Doyle SM, Kahn JG, Hosang N, Carroll PR. The impact of male circumcision on HIV transmission. J Urol. 2010 Jan. 183(1):21-6. [Medline].

  18. Hart-Cooper GD, Tao G, Stock JA, Hoover KW. Circumcision of privately insured males aged 0 to 18 years in the United States. Pediatrics. 2014 Nov. 134(5):950-6. [Medline].

  19. Mehta SD, Moses S, Agot K, Parker C, Ndinya-Achola JO, Maclean I, et al. Adult male circumcision does not reduce the risk of incident Neisseria gonorrhoeae, Chlamydia trachomatis, or Trichomonas vaginalis infection: results from a randomized, controlled trial in Kenya. J Infect Dis. 2009 Aug 1. 200(3):370-8. [Medline].

  20. Moses S. Male circumcision: a new approach to reducing HIV transmission. CMAJ. 2009 Oct 13. 181(8):E134-5. [Medline]. [Full Text].

  21. Prais D, Shoov-Furman R, Amir J. Is ritual circumcision a risk factor for neonatal urinary tract infections?. Arch Dis Child. 2009 Mar. 94(3):191-4. [Medline].

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

  23. Tobian AA, Serwadda D, Quinn TC, Kigozi G, Gravitt PE, Laeyendecker O, et al. Male circumcision for the prevention of HSV-2 and HPV infections and syphilis. N Engl J Med. 2009 Mar 26. 360(13):1298-309. [Medline]. [Full Text].

 
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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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