Further Outpatient Care
Newborn infants should only have sponge baths until the circumcision site is well healed. Older patients should begin to take baths after 24 hours of 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.
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.
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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. It should be noted that in a Cochrane Review as well as other studies, the dorsal penile nerve block is more effective in eliminating pain than EMLA cream. [18]
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A ring block that consists of the circumferential subcutaneous injection of local anesthesia (eg, 1% lidocaine without epinephrine) at the base of the penis is highly effective as is a dorsal penile nerve block.
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Dorsal penile nerve block involves injection of 1% lidocaine without epinephrine with a 27 gauge needle at the base of the penis at the 2 and 10 o'clock positions. The needle is advanced until it enters Buck's fascia. After aspiration, 0.5 cc are injected in each site.
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Oral acetaminophen provides adequate pain control after neonatal circumcision.
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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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Infant penis.
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Retracting the foreskin with a dorsal slit and marking the area to be incised. Video courtesy of Pamela I Ellsworth, MD.
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Sleeve technique with electrocautery. Video courtesy of Pamela I Ellsworth, MD.
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Suturing the mucosal collar to the penile shaft skin circumferentially. Video courtesy of Pamela I Ellsworth, MD.
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Circumcision complete. Video courtesy of Pamela I Ellsworth, MD.
