CHAPTER 181 Newborn Circumcision and Office Meatotomy

Newborn circumcision is the most common surgical procedure performed in the United States, yet controversy exists over the need for the procedure. Studies have shown a lower incidence of urinary tract infection (UTI), phimosis, paraphimosis, balanoposthitis, and some sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), in circumcised men. Circumcision clearly helps prevents penile cancer and may decrease the risk of cervical cancer in the sexual partner. However, some of these problems (i.e., penile cancer, UTIs, foreskin problems, and HIV infection) are rare even in uncircumcised men.

In developed countries where it is much less common for males to be circumcised, there is a low incidence of foreskin problems later in life. Behavioral factors also appear to be far more important than circumcision status in regards to the acquisition of STIs and HIV infection. Therefore, the decision to circumcise is not currently based on scientific evidence. Rather, this decision is generally made based on cultural, familial, or ethnic preference.

There is controversy in the literature regarding the cost effectiveness of newborn circumcision. Authors of a retrospective cost–benefit analysis of almost 15,000 newborn boys born in 1996 and insured by Kaiser Permanente Northern California (a large health maintenance organization) concluded that neonatal circumcision can be achieved at basically no cost. When total costs of newborn circumcision were weighed against total medical costs of not having it, the costs were basically equal. This was largely because postneonatal circumcision costs were about 10 times more than neonatal circumcision costs ($1921 per child versus $165 per newborn), and circumcision was eventually medically indicated in 9.6% of uncircumcised boys. However, other cost–benefit analysis studies have reached opposite conclusions. Also, there is controversy in the literature as to whether the percentage of newborns undergoing circumcision is increasing. If that is the case, it may start becoming more of a norm.

Clinicians performing circumcision are encouraged to remain current with guidelines and the scientific evidence. The American Academy of Pediatrics (AAP) circumcision position from March 1999, endorsed by the American College of Obstetricians and Gynecologists (ACOG) in 2001, and reaffirmed in 2005, reads as follows:

Of note, 97% of pediatric, family medicine, and obstetrics and gynecology residency programs that teach circumcision teach the administration of an anesthetic, either locally or topically. Common methods of analgesia administration include subcutaneous ring block, dorsal penile nerve block (DPNB; see Chapter 179, Subcutaneous Ring and Dorsal Penile Block for Newborn Circumcision), topical anesthesia such as lidocaine–prilocaine cream (also known as eutectic mixture of local anesthetic, or EMLA; see Chapter 10, Topical Anesthesia), and precircumcision oral analgesics. Although studies have shown lidocaine–prilocaine cream to be helpful, injected blocks appear to be more effective, and the ring block is more effective than a DPNB. Studies have shown that infants anesthetized with a block cry less, are less likely to have tachycardia, are less irritable, and have fewer behavior changes during the 24 hours after the procedure. They also have less variability in oxygen saturation and blood pressure during, and lower serum cortisol levels after, the procedure.

Three techniques of newborn circumcision are common in the United States: Mogen, Gomco, and Plastibell. Most clinicians continue to use the technique they were taught in their training. Both Gomco and Plastibell require a dorsal slit and considerable manipulation to prepare the foreskin for excision, and result in removal of a cylindrical sleeve of tissue. Both techniques carry the risk of removing too much tissue from the ventral side. In addition, Plastibell leaves behind a foreign body that may contribute to infection. One study comparing Gomco with Plastibell indicated that there was not only a higher rate of infection with Plastibell but also a slightly higher rate of bleeding.

Most clinicians who learn to use the Mogen clamp tend to prefer this technique because it is quicker and simpler, and it follows the angle of the corona so as to avoid removing excess tissue ventrally. At least two studies (Kurtis and colleagues, 1999; Kaufman and colleagues, 2002) comparing the use of the Mogen with the Gomco technique found that the Mogen procedure took about half the time and seemed to cause less discomfort (however, discomfort may be a moot point when anesthesia is used). Contrary to popular belief, the Mogen clamp is not a guillotine. It is simply a crushing device with a narrow slot that, when used appropriately, does not allow entry of the glans into the slot.

One apparent complication of circumcision is meatal stenosis (i.e., it is very rare in uncircumcised boys). Whether circumcision or a chronic inflammatory process due to superabsorbent disposable diapers, ammonia dermatitis, or inadequate parental postprocedure care is to blame is yet to be determined. In the last edition of this text, a technique for newborn meatotomy was included; however, there are few data suggesting that such a procedure might decrease the later incidence of meatal stenosis. (And it must be very rare or it would be more common in uncircumcised men.) This scarcity of data is partially because it is difficult to define meatal stenosis in a newborn. It is usually diagnosed later in life, at the time of toilet training or even later, because of its complications (e.g., painful urination that may require straining or standing, difficulty aiming stream, blood spotting in underwear). To make the diagnosis may require observed voiding (i.e., pinpoint meatus and a dorsally deflected, very fine caliber, forceful urine stream with a long voiding distance) because the appearance of the glans may be somewhat normal and thereby misleading. However, newborn meatotomy is included again in this edition because the risk of such a procedure is minimal compared with potential benefits (e.g., repair in an older male patient can be somewhat psychologically traumatic). Also, in certain situations, newborn meatal stenosis is obvious and because the infant is already anesthetized for circumcision, it would seem prudent to repair it at that time.

After toilet training, a popular method of defining meatal stenosis is by what size feeding tube or pediatric urethral catheter can be easily inserted. Because meatal stenosis is a possible complication of newborn circumcision, it seems appropriate to also include a technique for later repair (i.e., office meatotomy) in this chapter. Although it might seem somewhat psychologically traumatic to repair meatal stenosis under mere topical anesthesia, boys having difficulty with urination may be very motivated to cooperate, especially if assured of the adequacy of topical anesthesia. Pediatric sedation may also be useful (see Chapter 7, Pediatric Sedation and Analgesia).

Circumcision

Indication

Parental desire is the only necessary indication for circumcision.

Contraindications

Absolute

• Hypospadias, epispadias, or megaurethra (the foreskin is used for later repair)

• Unusual-appearing genitalia

• Inability to determine the sexual phenotype of the child (ambiguous genitalia)

Relative

• Age younger than 12 hours (physiologic adaptation requires 12 to 24 hours)

• Age greater than 6 to 8 weeks

• Severe illness

• Prematurity (until the child is ready for discharge from the hospital)

Precautions

If there is a family history of bleeding problems, appropriate laboratory studies should be performed before the procedure. If the mother is thrombocytopenic, the infant’s platelet count should be checked.

By the age of 6 to 8 weeks, maternal clotting factors have been metabolized, possibly predisposing the infant to increased blood loss. The foreskin may also develop significant edema after defining the plane and breaking up adhesions between the glans and the foreskin, making it difficult to use the Gomco clamp or Plastibell.

Preprocedure Patient and Parent Preparation

Discuss the risks and benefits of the procedure with the parents. Informed consent is obtained and a patient teaching guide is given to the parents. (See patient education and patient consent forms available online at www.expertconsult.com.) The AAP has two brochures that may be used: (1) Circumcision: Information for Parents and (2) Care of the Uncircumcised Penis (see the Suppliers section). The parents are usually asked to leave the room during the procedure. If they desire to stay, they should be given the option to look away while the procedure is being performed because it can be disconcerting to some.

Because of the risks of regurgitation and aspiration, infants being circumcised should be at least 1 hour postprandial. Confirm that the infant has had at least one void since birth.

Equipment

Equipment Common to All Techniques

• Assistant for holding infant, infant restraint or papoose board (Circumstraint) with leg straps (e.g., Circumstraint), or circumcision chair (e.g., Stang)

• Anesthetic supplies: gloves, alcohol wipes, 1% plain lidocaine, 1-mL syringe, 30-gauge needle

• Sterile gloves

• Antiseptic solution (e.g., alcohol wipes, povidone–iodine, chlorhexidine) or swabsticks

• Sterile drape with 1-inch fenestration

• Sterile 2 × 2 or 4 × 4 gauze pads

• Three straight mosquito hemostats

• White petrolatum ointment (e.g., Vaseline)

• Disposable diaper

• Adequate light source

• Glucose water or sugar-coated pacifier (optional)

• Skin marking pen (optional)

• Flexible blunt probe (optional)

• Acetaminophen drops or solution (10 to 15 mg/kg) (optional)

Equipment for the Mogen Technique

• Mogen clamp, neonatal size (2.5-mm slot)

NOTE: The larger adult size is dangerous to use on a newborn because the glans can become trapped in the larger slot. The clinician should confirm that the neonatal size does not open more than 2.5 mm.

• No. 10 blade scalpel

Equipment for the Gomco Technique

• Straight scissors with one blunt tip

• Gomco circumcision clamps (1.1-, 1.3-, and 1.45-cm sizes)

NOTE: The most commonly used size is 1.3 cm. The 1.1-cm size is used for a very small infant, whereas the 1.45-cm clamp usually fits a large infant. Even larger sizes are available for children and adults.

• No. 10 blade scalpel

• Sterile safety pin (optional)

Equipment for the Plastibell Technique

• Straight scissors with one blunt tip

• Plastibell device (1.1-, 1.2-, 1.3-, and 1.4-cm sizes)

NOTE: Similar to the Gomco technique, 1.3 cm is the most commonly used Plastibell size.

• Iris scissors

Equipment for Bleeding Complications in All Three Techniques

• Topical epinephrine

• Topical hemostatic agent of choice (e.g., Gelfoam, Surgicel, silver nitrate; see Chapter 40, Topical Hemostatic Agents)

• 5-0 absorbable suture (chromic or catgut) on a taper-point needle

• Needle holder and suture scissors

Mogen Technique

1 Consider using a skin marker to mark the coronal edge. Inspect the penis for abnormalities and for the location of the meatus on the glans. If epispadias or hypospadias is found, terminate the procedure because the foreskin may be used for later repair by a urologist.

2 The clinician should follow universal blood and body fluid precautions. If penile anatomy is normal, anesthetize the penis with a subcutaneous ring block (see Chapter 179, Subcutaneous Ring and Dorsal Penile Block for Newborn Circumcision). Consider doing the block with the infant still in his crib to allow time for the block to take effect while the rest of the surgical preparations are made. Position the infant appropriately in a warm room. An infant may experience discomfort when you extend his legs on an infant restraint board. As a result, special circumcision chairs have been developed for exposure of the penis without extension of the legs. If such a chair is not available, an assistant can hold the infant on a pillow with the knees flexed and legs abducted for adequate exposure. Most often, though, an infant restraining board is used. Leave the infant’s arms free to minimize distress. Offer him a swallow or two of glucose water or a sugar-coated pacifier to calm him.

3 Using antiseptic solution or swabsticks, prepare the entire penis and a 1-inch area surrounding the penis. Wear sterile gloves when placing the fenestrated drape.

4 Grasp the very edge of the foreskin with hemostats at the 2 and 10 o’clock positions, taking care not to grasp the glans. (When describing the penis, use the dorsal midline as the 12 o’clock position. To identify the true dorsal midline, identify the ventral raphe at the frenulum, which is the 6 o’clock position, and consider the foreskin 180 degrees opposite it to be the 12 o’clock position [Fig. 181-1]. This orientation technique is important in case the penile shaft gets rotated.)

5 Place gentle traction on the foreskin by holding the two hemostats side by side in your nondominant hand. Gently insert the third hemostat with your dominant hand, closed and from below the grasping hemostats, at the 12 o’clock position between the foreskin and the glans. Advance to the depth of the coronal sulcus (Fig. 181-2). To ensure that the meatus is not entered, keep the foreskin tented up as this hemostat is advanced. Open this hemostat and sweep it clockwise and counterclockwise to free the foreskin off the glans. This may take a number of open–close cycles starting at different places around the corona. Do not free the area from the 5 to 7 o’clock positions (the frenulum) because it contains an artery. Do not dissect beyond the depth of the coronal sulcus. As an alternative to opening and closing a hemostat, a blunt probe may be used to free the foreskin off of the glans.

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Like this:

Like Loading...

Related

Related posts:

1. Electrical Cardioversion
2. Umbilical Vessel Catheterization
3. Earlobe Repair
4. Insertion and Removal of Implanon

Stay updated, free articles. Join our Telegram channel

Join