Circumcision

Topic Overview

What is circumcision?

Male circumcision is an elective surgery to remove the foreskin (prepuce), a fold of skin that covers and protects the rounded tip of the penis (glans). This surgery is most commonly done on newborns about 24 hours old. See a picture of the penis before and after circumcision .

If a baby is born early (premature) or has certain medical conditions, he may be circumcised when he is somewhat older. Circumcision may also be done in older boys and men to treat problems with the foreskin of the penis (such as phimosis or paraphimosis) or for inflammation of the tip of the penis (balanitis).

This topic focuses on the circumcision of newborns.

In the last 30 years, an average of about 61 out of 100 male babies born in hospitals in the United States were circumcised.¹ This rate varies depending on where you live. In some parts of the U.S., about half of all males are circumcised, while other parts of the country have higher circumcision rates.

Who performs circumcisions?

Circumcisions usually are done by a pediatrician, obstetrician, family medicine doctor, surgeon, or urologist. But ritual circumcision may be done by others trained in the procedure, such as mohels of the Jewish faith.

Should I have my son circumcised?

Circumcision is not medically necessary. The American Academy of Pediatrics (AAP) does not recommend circumcision as a routine procedure for newborn males. When making this policy, the AAP considered the possible health benefits of circumcision, such as a lower risk for urinary tract infections (UTIs) in the first year of life. The AAP also considered the risks and costs of the procedure.²

When you make this decision, it may help you to think about your personal and cultural preferences. For example, you may want to consider your family and religious traditions while you weigh the benefits and risks of the surgery. It is your decision whether to have your son circumcised.

What problems can develop if my son is circumcised?

Problems from circumcision are rare. If they occur, they are usually minor. The most common circumcision problems are pain, bleeding, infection of the circumcision site and at the opening of the urethra, and irritation of the exposed tip of the penis. Long-term problems are even more rare but can include damage to the opening of the urethra, excessive bleeding that requires stitches, severe infection, or scarring and other problems from surgical error.

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What Happens During a Circumcision

Circumcision for a newborn is usually done by a health professional at a clinic, in the hospital, or at an outpatient surgery center. During the procedure:

• The newborn is placed on a firm surface, often called a papoose board. Velcro straps are wrapped around the newborn's arms and legs to keep him very still during the procedure.
• The penis is cleaned.
• The surgical area is numbed with a local anesthetic while the baby remains awake. Local anesthetics include ring block, penile nerve block (dorsal penile nerve block or DPNB), or EMLA cream. General anesthesia may be used for males older than 2 to 3 months of age. When the baby is under general anesthesia, a caudal nerve block may be applied to provide postoperative pain relief.
• A sterile circumcision clamp or device is placed over the head of the penis. The three most common types of clamps used are the Gomco clamp, the Mogen clamp, and the Plastibell device. Each clamp has advantages and disadvantages, although differences between the clamps are often minor. Most doctors use the clamp they are most comfortable with.
• The foreskin is removed using a sterile scalpel or scissors.

What to Expect After Surgery

After the circumcision, the groin, penis, and scrotum may appear reddish brown because of the solution used to clean the skin before surgery. The shaft of the penis where the skin was removed will look raw and slightly swollen. This tender appearance should gradually disappear in the next few days.

Your baby will be observed for 2 to 4 hours after the procedure. Health professionals will check his penis for excessive bleeding, and the circumcision area may be dressed with petroleum jelly and gauze. If gauze is used, it stays on for about 24 hours. Before you take off the gauze, soak it in warm water and gently loosen it.

During recovery after surgery, it is common for:

• The baby to have pain while urinating. It is often painful when healing skin comes in contact with urine and stool. This pain usually fades within 3 or 4 days but may persist for up to 2 weeks. Keep in mind that even though your baby's penis will usually start feeling better after 3 days, it may look worse. The penis will usually look like it's getting better at around 7 to 10 days after the procedure.
• The baby to be irritable. Your baby may not sleep as well and may seem fussy while the circumcision site heals.
• A thin yellow film to form over the circumcision site the day after surgery. This is part of the normal healing process and should disappear in a few days.

Stitches (sutures) are not used for infant circumcision. Sutures are used when circumcision is done on an older child or adult.

Care after circumcision

You can help make your baby feel comfortable and heal more quickly if you:

• Gently wash the penis with warm water after each diaper change. Soap is not recommended. Do not attempt to remove the film that forms on the penis. This film will go away on its own. Pat dry.
• Apply petroleum jelly (such as Vaseline) liberally to raw areas on the head and/or shaft of the penis during each diaper change. The petroleum jelly prevents the scab from sticking to the diaper.
• Make sure diapers are fastened loosely to decrease irritation of the penis.

Ask your health professional about giving your baby acetaminophen (such as Tylenol) for pain control after the procedure.

Older children and adults may resume their normal activities soon after surgery, avoiding anything irritating or painful to the penis.

When to Call a Doctor

Your son's penis will be examined during routine well-baby visits. But it is important to call your health professional if problems develop after circumcision.

Call your doctor immediately if your circumcised baby:

• Is younger than 3 months of age and has a fever.
• Develops signs of infection of the penis or around the circumcision site. Signs may include severe swelling, redness, a red streak on the shaft of the penis, or a thick, yellow discharge.
• Bleeds more than the doctor said to expect or has a bloodstained area larger than the size of a bottle cap on his diaper or on the circumcision site dressing.
• Is extremely fussy or irritable, has a high-pitched cry, or refuses to eat.
• Has not passed urine within 12 hours after the circumcision was completed.

If a Plastibell device was used for the circumcision, call your health professional if the ring has not fallen off after 10 to 12 days.

Who to See

Health professionals who usually perform circumcisions on infants include:

• Pediatricians.
• Obstetricians.
• Family doctors.
• Urologists.
• Surgeons.

A urologist or surgeon normally will do circumcisions on older infants, children, and adults.

Why It Is Done

Circumcision is performed on newborns mainly for cultural reasons. For example, parents may make the decision about circumcision based on religious and family traditions, personal preferences, or the social norms within their communities. It is also important to consider the benefits and risks of the procedure.

Should I have my son circumcised?

Circumcision is not medically necessary. There may be some slight health benefits for circumcised males. But medical experts in the United States generally agree that these health benefits alone are not significant reasons to have circumcision. A 1999 study by the American Academy of Pediatrics (AAP) Task Force on Circumcision concluded that circumcision should not be recommended as a routine procedure for newborn males. Before making this recommendation, the task force looked at the possible health benefits of circumcision, such as a lower risk for urinary tract infections (UTIs) in the first year and a lower risk for getting STDs.²

• In the first year of life, urinary tract infections (UTIs) happen less often in circumcised boys than in boys who are not circumcised.^{3, 4} But UTIs are not common. Researchers in one large study concluded that the lower risk for UTIs is not significant enough to justify circumcision when balanced against the risk of bleeding and infection from circumcision surgery.⁴ About 111 boys would need to be circumcised to prevent one UTI. About 2 out of 100 boys (2%) have bleeding or infection after circumcision.⁴ Circumcision is more clearly a health benefit if a boy has a history of UTIs or is at a higher risk for developing UTIs (such as if his urinary tract is not normal).^{3, 4}
• Some studies have shown that circumcised males are a little less likely than males who have not been circumcised to get a sexually transmitted disease (STD), including HIV.^{5, 6} But circumcision should not be done to prevent STDs or HIV. All men who have high-risk sex can get STDs or HIV, regardless of whether or not they are circumcised. It is most effective to prevent STDs by teaching people about risk factors and about the importance of practicing low-risk sexual behavior.³ Male circumcision to help prevent HIV is more likely to be considered in areas where the disease is common and safe sex is not widely practiced.^{3, 6}

In the past, circumcision was considered necessary when a newborn's foreskin could not be retracted (phimosis). But now, this condition is considered normal because the foreskin of newborns is still developing. By age 3, most boys who have not been circumcised can retract the foreskin of the penis without any problems.⁷ (In rare cases, the foreskin of the natural penis [uncircumcised] cannot be retracted after a boy has reached puberty, in which case circumcision may be recommended.)

Do not have your baby circumcised if he has a medical condition that makes him more likely to have problems from the procedure. For example, do not have your baby circumcised if he:

• Is sick or in an unstable condition (such as not eating well, having difficulty passing urine or stool, or having difficulty maintaining his body temperature).
• Has any abnormality of the penis, such as having the opening of the urethra on the side of the penis shaft instead of on the tip of his penis (hypospadias or epispadias). Your baby may need to have an intact foreskin so that this irregularity can be surgically corrected when he is older.
• Has swelling or protrusion of the spinal cord (myelomeningocele or spina bifida).
• Has an abnormal opening of the rectum (anus).
• Has a family history of bleeding difficulties. (Blood tests should be done to confirm that the baby does not have this problem.)
• Was born prematurely and is not yet able to go home.

Risks

Complications from circumcision are rare. Minor complications are usually short-term and may include:^{2, 3}

• Pain. A baby may experience obvious pain when he urinates for the first time after surgery. Pain may continue for up to 2 weeks, whenever the healing skin comes in contact with urine and stool. But usually the most noticeable pain goes away within 3 or 4 days. Keep in mind that even though your baby's penis starts feeling better after 3 days, it may look worse. About 7 to 10 days after the procedure, the penis will usually look like it's healing.
• Oozing or slight bleeding from the surgical site.
• Infection of the circumcision site or at the opening to the urethra (urinary meatitis).
• Irritation of the exposed tip of the penis (glans) as a result of contact with stool and/or urine. You may help prevent this type of discomfort by applying petroleum jelly to the head of the penis.

Long-term minor complications are also rare but can include:^{2, 3}

• Damage to the opening of the urethra, which leads from the bladder to the tip of the penis (meatal stenosis).
• Loss of sensitivity in the penis. Some men who were circumcised have reported a loss of sexual sensation in the penis.
• Scarring of the penis from infection or surgical error. For example:
  • The entire foreskin may not be removed, leaving portions of it attached to the penis (skin bridge). This may cause pain during erection.
  • Scar tissue can grow outward toward the tip of the penis from the cut edge of the foreskin. Repeat surgery on the penis may be required to improve appearance or to allow normal passage of urine if the opening from the bladder has been blocked by this scar tissue.
  • The outer skin layer (or layers) of the penis may be removed accidentally.
  • An opening that is too small for the foreskin to retract over the penis (phimosis) can occur if too little foreskin is removed.

Major complications are extremely rare but can include:^{2, 3}

• A complete removal of the skin covering the shaft of the penis, causing the penis to appear to have been completely surgically removed (concealed penis).
• Excessive bleeding. Stitches may be required to stop the bleeding.
• Serious, life-threatening bacterial infection in body tissue and the blood (sepsis).
• Partial or full removal (amputation) of the tip of the penis (extremely rare).

How Well It Works

Your baby's penis usually starts feeling better within about 3 to 4 days after being circumcised. Your newborn may be fussy and irritable, may have trouble sleeping, and may have pain when he urinates during these first few days. Also, for about 2 weeks, it can be painful whenever urine or stool touches the tip of the penis. Keep in mind that even though your baby's penis starts feeling better after 3 days, it may look worse. About 7 to 10 days after the procedure, the penis will usually look like it's healing.

You will likely take your baby home the same day he is circumcised. Some swelling around the penis is normal in the first few days after the surgery. Some slight bleeding may occur. If this happens, apply direct but gentle pressure to the area with a clean cloth or bandage for about 5 to 10 minutes.

• Gently wash the area with warm water when needed. Soap is not recommended.
• Put petroleum jelly, such as Vaseline, around the circumcised area. The petroleum jelly prevents the scab from sticking to the diaper.
• Give your baby acetaminophen for pain. Talk to your doctor about how much and how often you should give your baby this medicine. Call your doctor anytime your baby seems to be in a lot of pain.

You may notice a yellow, scabby area around the penis. This lasts about 3 to 5 days and will gradually go away as the skin heals.

What to Think About

As a parent, you will decide whether you want your infant to be circumcised. Discuss and consider this option before your baby is born. If you wait, the excitement and fatigue of the delivery can affect your ability to carefully consider the benefits and risks of having your son circumcised. For more information, see:

Should I have my son circumcised?

If you decide that you would like to have your newborn circumcised, discuss your concerns and preferences before the procedure. Make it very clear to your doctor that you want pain relief for your baby during his circumcision. Talk to your doctor about which type of anesthesia is best for your baby, such as a ring block, dorsal penile nerve block (DPNB), or EMLA cream.

Also ask your health professional about giving your baby acetaminophen (such as Tylenol) for pain control after the procedure.

Whether you have your son circumcised or not, it is important to keep the penis clean. When cleaning a natural (uncircumcised) penis, be careful not to force the foreskin to retract. As your son gets older, make sure you teach him how to wash and care for his penis.

Other Places To Get Help

Organizations

Related Information

• Caring For Your Young Son's Uncircumcised Penis
• Growth and Development, Newborn

References

Citations

1. National Center for Health Statistics (2006). Table 44. Number and percentage of male infants circumcised during hospitalization, by geographic region: United States, selected years 1980-2004. National Hospital Discharge Survey: 2004 Annual Summary With Detailed Diagnosis and Procedure Data. Available online: http://www.cdc.gov/nchs/about/major/hdasd/listpubs.htm.

2. Task Force on Circumcision, American Academy of Pediatrics (1999). Circumcision policy statement. Pediatrics, 103(3): 686-693.

3. Lerman SE, Liao JC (2001). Neonatal circumcision. Pediatric Clinics of North America, 48(6): 1539-1557.

4. Singh-Grewal D, et al. (2005). Circumcision for the prevention of urinary tract infection in boys: A systematic review of randomised trials and observational studies. Archives of Disease in Childhood, 90(8): 853-858.

5. Siegfried N, et al. (2003). Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database of Systematic Reviews (3). Oxford: Update Software.

6. Auvert B, et al. (2005). Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Medicine, 2(11): 1-22. Also available online: http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0020298.

7. Elder JS (2007). Anomalies of the penis and urethra. In RM Kliegman et al., eds., Nelson Textbook of Pediatrics, 18th ed., chap. 544, pp. 2253-2260. Philadelphia: Saunders Elsevier.

Other Works Consulted

• Castellsague X, et al. (2002). Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. New England Journal of Medicine, 346(15): 1105-1112.

• Fergusson DM, et al. (2006). Circumcision status and risk of sexually transmitted infection in young adult males: An analysis of a longitudinal birth cohort. Pediatrics, 118(5): 1971-1977. [Erratum in Pediatrics, 119(1): 227.]

• Steadman B, Ellsworth P (2006). To circ or not to circ: Indications, risks, and alternatives to circumcision in the pediatric population with phimosis. Urologic Nursing, 26(3): 181-194.

• Towers HM (2006). Circumcision. In FD Burg et al., eds. Current Pediatric Therapy, 18th ed., pp. 313-315. Philadelphia: Saunders Elsevier.

• Van Howe RS (2005). Effect of confounding in the association between circumcision status and urinary tract infection. Journal of Infection, 51(1): 59-68.

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