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:
Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. If a decision for circumcision is made, procedural analgesia should be provided.
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.
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.
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).
Anatomy
The neonatal foreskin is composed of three layers: skin, loose subcutaneous tissue, and mucosa. At birth, the foreskin mucosa is adherent to the glans penis, with just a small distal opening to allow for urination. The ventral side of the mucosal surface has the highest density of nerve endings. A band of tissue called the frenulum attaches the foreskin along the ventral side of the penis and ends distally near the urethral meatus. The frenulum contains a small artery.
Circumcision
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.
Equipment
Equipment Common to All Techniques
Equipment for the Mogen Technique
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.
Equipment for the Gomco Technique
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.
Equipment for the Plastibell Technique
NOTE: Similar to the Gomco technique, 1.3 cm is the most commonly used Plastibell size.
Mogen Technique
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