Circumcision is a procedure that removes the foreskin, the tissue covering the head of a boy's penis. With a newborn, this is usually done by an obstetrician or pediatrician using local anesthesia. Normally, this type of procedure can only be done in the first six weeks of life, or until the baby weighs about 12 pounds. After that time, it must be done under general anesthesia in the operating room.
The position of the American Academy of Pediatrics is that there are potential medical benefits of newborn male circumcision, but these benefits are not sufficient for the academy to recommend routine neonatal circumcision for all boys. In cases where the circumcision is not essential to a child's health, parents should weigh potential benefits and risks to make an informed decision as to their child's best interest.
If you wanted your child circumcised at birth but he was not, it may have been because he was premature, ill or because he was thought to have a problem with his penis. When the urinary opening is in the wrong place or if the penis is partially attached to the scrotum, the doctor will usually advise that your child not be circumcised until you see a pediatric urologist.
Conditions that Require Circumcision in Older Children
Phimosis is a condition in which the foreskin is too tight to be pulled back over the head of the penis. It is normal that the foreskin will not retract in infants and toddlers, and many boys cannot fully retract the foreskin until puberty. This condition typically does not require circumcision because it is essentially normal. Circumcision should only be considered if the child has infections or pain related to the phimosis.
If the foreskin is retracted and left in place, severe and painful swelling of the head of the penis may result, a condition called paraphimosis.
In some boys, the foreskin is so tight that urine collects inside of it and balloons out whenever the boy urinates. This is sometimes called a trapped penis, and it often requires surgical correction to allow the child to urinate normally.
Other Birth Defects of the Penis
When the penis is severely bent (called chordee), when the skin of the penis is attached to the scrotum, or when the urethral opening is on the underside of the penis (hypospadias), surgery should be performed. Reconstruction will also include a circumcision.
Balanitis: Some boys may experience episodes of swelling and redness of the head of the penis. These infections are easily treated. However, if the problem occurs frequently, circumcision should be considered, especially if the child has phimosis or is developing urinary tract infections. In these cases, circumcision will usually prevent further infections.
Urinary tract infections: There is good evidence that uncircumcised boys are more likely to suffer urinary tract infections. After one year of age, however, these infections are rare and tend to be mild. Certain conditions, such as vesicoureteral reflux (the abnormal flow of urine backward, from the bladder into the ureters) make infections more likely, and circumcision should be considered.
Problems in Adulthood
Studies in Africa have shown that the transmission of HIV is less likely in circumcised men. However, only the use of condoms is truly preventative. Some studies also suggest that penile cancer is less common in circumcised men, but this is a very rare disease even in uncircumcised men.
Risks of Circumcision
Circumcision on a newborn can be done in the office with local anesthesia. In older children, the procedure is done under general anesthesia in the operating room.
Severe complications are very rare, but can include bleeding, infection, and death from anesthesia. More common complications include scars between the head of the penis and the skin, and scarring of the urethral opening, called meatal stenosis. Children do experience pain after circumcision, but this can be controlled with local anesthetics injected during surgery and oral pain medicine afterwards. In addition, some children may be very anxious before or after surgery. Toddlers and preschoolers will sometimes experience regression, resulting in bedwetting or urinary accidents.
Caring for Your Uncircumcised Son
The foreskin should be left alone until it can be pulled back easily. The head of the penis does not need to be cleaned until this occurs. Trying to pull the foreskin back too soon may result in tearing it from the head of the penis, with scarring, bleeding and phimosis. As the head of the penis begins to separate from the foreskin naturally, lumps of white material composed of dead skin cells may be seen. This is normal and not a sign of infection. The skin cells will fall off on their own or may be gently removed during bathing.
How to Determine if Circumcision is Beneficial
There are specific medical reasons to circumcise an older boy. These include difficulty urinating, infections of the head of the penis, and birth defects of the penis. When there is no medical reason to perform the circumcision, it becomes a social and cosmetic issue. Therefore, in most cases, the decision of whether or not to have a child circumcised is best left to the parents rather than the doctor.
Pediatric Urology at Cedars-Sinai
Children are affected by different urologic conditions than adults, and their smaller bodies respond differently to anesthesia and surgical incisions. For these reasons, the Cedars-Sinai Urology Academic Practice is guided by the philosophy that pediatric patients are best evaluated and treated by pediatric specialists. Andrew Freedman, MD and Barry Duel, MD, the Urology Academic Practice's pediatric urologists, devote their practice to the evaluation and treatment of children. Both are board certified in Pediatric Urology, and offer broad experience in minimally invasive laparoscopic procedures. Dr. Barry Duel is experienced in robotic procedures adapted for the needs of children. The majority of their procedures are conducted on an outpatient basis, with both outpatient and inpatient surgeries attended by specialized pediatric anesthesiologists.