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Guide for a Healthy Pregnancy

DECIDING ABOUT CIRCUMCISION

If you have a baby boy, one decision you’ll need to make is whether to have him circumcised. This information sheet has general information to help you make an informed choice. After you read it, please discuss any questions you have with your clinician.

What is circumcision?

During circumcision, the foreskin of the penis is surgically removed. The foreskin is a fold of skin that covers the glans, the rounded tip of the penis. Circumcision is usually done on newborns at the hospital by an obstetrician or pediatrician. The procedure may be deferred to the office or referred to a Pediatric Urologist if the penis appears abnormal or is especially small. Circumcision is a brief and safe procedure when done by an experienced practitioner.

Why is circumcision practiced?

Muslims and Jews practice circumcision for religious reasons. In America, circumcision wasn’t common until the late 1800s, when many doctors began to suggest it had medical, hygienic, and even mental benefits. These theories weren’t based on scientific studies.

Currently, about 60% newborn boys in the U.S. are circumcised, some for religious or cultural reasons and others because of tradition. This varies from place to place. Some parents may be concerned that a boy fit in with his peers, or may feel that if a father is circumcised, his son should be too. Circumcision is less common in other countries. Approximately 5 in 10 boys are circumcised in Canada. In Central and South America, Asia and most of Europe, circumcision is rarely practiced.

Does circumcision have medical benefits?

Circumcision is a controversial issue in the medical community. In 1999 the American Academy of Pediatrics (AAP) noted that although circumcision for newborns may have medical benefits, as well as disadvantages and risks, the potential medical benefits of circumcision are not significant enough to recommend it as a routine procedure.

• Circumcision prevents possible problems with the foreskin. In phimosis, the foreskin cannot easily slide back (retract) from the end of the penis, which blocks the flow of urine. In paraphimosis, the foreskin retracts for long periods and cannot be brought forward, which causes pain and swelling. Balanoposthitis is an infection of the foreskin and glans that usually can be avoided with good hygiene. These problems are uncommon, but may make circumcision necessary when a boy is older.
• Medical studies suggest that in the first year of life circumcised infants may have fewer urinary tract infections than uncircumcised infants. The rate of urinary tract infections during the first year is estimated at 0.1% (1 in 1,000) for circumcised infants, and about 1% (1 in 100) for uncircumcised infants.
• Cancer of the penis, a rare disease, is almost unknown among circumcised men. It is associated with poor hygiene in uncircumcised men. Cancer of the penis affects 1 in 100,000 men per year.

Some medical studies suggest that circumcised men have lower rates of sexually transmitted diseases (STDs) than uncircumcised men. Other studies suggest that women whose sexual partners were circumcised have a lower rate of cervical cancer. However, many experts question the results of these studies. Behavioral factors (e.g. condom use) continue to be far more important in determining the risk of contracting an STD than circumcision status.

Does circumcision have medical risks?

Complications may occur with any surgical procedure. Circumcision carries a 0.2 to 0.6 percent risk (about 1 to 3 cases in 500) of certain minor or serious complications. These are the most common problems:

• Infection
• Excessive bleeding, which may require stitches and, very rarely, a transfusion
• Poor cosmetic result or scarring, which may make further surgery desirable or necessary
• Damage to the shaft of the penis, which may make further surgery desirable or necessary

What are options for pain relief?

Infants do feel pain during a circumcision. There is some disagreement, however, about the best approach to pain relief. Clinicians sometimes use a local anesthetic to reduce the amount of pain experienced during the circumcision. In studies determining effectiveness of anesthesia, pain is defined by the amount of time the infant cries, increases in heart rate and other stress responses. The options for pain relief have risks and benefits as outlined below.

• No Anesthesia is an option that some parents use. Some babies do not appear to get pain relief from anesthetics. Administration of anesthetics can be painful. In addition, there are some risks. Other comfort measures are available such as talking in a smooth tone, rubbing the baby’s head and snuggling and feeding afterwards.
• Topical Application of Local Anesthetics (EMLA Cream) has been shown to reduce pain-related responses during portions of the circumcision procedure, implying a limited analgesic effect. Risks include an allergic reaction (rare).
• Injection of Local Anesthesia – Local anesthesia can be injected using various techniques. This is similar to the use of Novocain at the dentist. The infant is likely to experience pain during the injection. The most common complication is bruising, which is rare. Pain relief during the procedure is somewhat variable.

General anesthesia is not used on newborns because it adds another element of risk to the operation. If circumcision is performed after the newborn period, a general anesthetic is usually required.

Caring for an uncircumcised infant

If you choose not to have your son circumcised, good hygiene will help prevent certain health problems. Early in life, the foreskin of an uncircumcised boy is firmly attached to the glans of his penis. As a child gets older, the foreskin slowly separates from the glans until it can fully retract. This happens in about 90% of boys by age 4 and in 99% by age 17.

Skin cells from the glans and foreskin are shed throughout life. The cells beneath the foreskin help form a substance called smegma. In an infant, smegma may look like white, cheesy grains under the skin. Simple bathing usually removes smegma and helps prevent possible infection in uncircumcised males of any age.

Caring for a circumcised infant

Following circumcision, it is important to keep the area as clean as possible. Gently clean with soap and warm water — do not use diaper wipes. Your doctor may recommend putting a dab of petroleum jelly on the baby’s penis or on the front of the diaper for three to five days to alleviate any potential discomfort caused by friction against the diaper. If your son has a bandage on his incision, you might need to apply a new one whenever you change his diaper for a day or two after the procedure. (Put petroleum jelly on the bandage so it won't stick to his skin.)

It usually takes between 7 to 10 days for a penis to heal. Initially the tip may appear slightly swollen and red and you may notice a small amount of blood on the diaper. You may also notice a slight yellow discharge or crust after a couple of days. Although this is normal, certain other problems are not.

Call your doctor right away if you notice any of the following:

• Persistent bleeding or blood on diaper (more than quarter-sized)
• Increasing redness
• Fever
• Other signs of infection, such as worsening swelling or discharge, or the presence of pus-filled blisters
• Not urinating normally within 12 hours after the circumcision.

Making your decision

You need to decide if you will have your son circumcised, and if so, whether you will request that anesthesia be provided. Your clinicians can help you learn more about circumcision by answering questions about the various options and medical controversies. Ultimately, though, whether or not to have a baby circumcised is a personal decision left up to you and your partner.