Neonatal Circumcision

1
Neonatal Circumcision

• To Do or Not To Do?
• Can We Minimize Pain?
• These Are the Questions?
• Josephine R Fowler, MD MSc
• Assistant Professor
• Department of Family Medicine
• School of Public Health

2
Objectives

• Epidemiology of Circumcision
• View Organizations statements on circumcision.
• Review indications for circumcisions.
• Review risks associated with circumcision.
• Review evidence for anesthesia and/or analgesia
  during procedure.
• Review most common methods.

3
Epidemiology

• Circumcision rate varies by
• geographic region
• religious affiliation
• socioeconomic classification
• Uncommon in Asia, S. America, Central America,
  Europe
• 48 circumcised in Canada
• gt80 in US
• Whites gt blacks or hispanics

4
AAFP, AAP, ACOG

• The AAFP recommends physicians discuss the
  potential harms and benefits of circumcision with
  all parents or legal guardians considering this
  procedure for their newborn son.
• AAP -Parents should determine what is in the
  best interest of the child. They should be given
  unbiased information and be provided the
  opportunity to discuss this decision.
• ACOG- Existing literature is inadequate to
  evaluate appropriately routine circumcision of
  the newborn infant.
• All agree evidence is insufficient to support
  routine circumcision.
• All agree anesthesia is warranted.

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Neonatal Circumcision

• Most common surgical procedure performed in US.
• 1 million per year in the US.
• Evidence conflicting on risk and benefits.
• Most decisions based on nonmedical reasons
  (religious, ethnic, cultural,cosmetic).

• Complication rate 0.1 to 35.
• Infection (0.2-0.4)
• bleeding (usually minor)
• Failure to remove enough foreskin
• Meatus and meatal stenosis
• Necrotizing fascitis
• Urethral fistula
• Partial penile amputation
• Penile necrosis
• Concealed penis
• Death

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Indications

• True indications rare!
• Penile cancer (cannot predict which babies will
  develop cancer)
• Recurrent balanitis
• phimosis (usually cannot be diagnosed in newborn
  period)

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Optimal timing and Contraindications

• 12-24 hours post delivery.
• Evaluate for hyperbilirubinemia, infection,
  bleeding diathesis.
• Make sure infant has voided.

• Contraindications
• hypospadias
• prematurity
• bleeding disorder
• medical problem

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Infection and Circumcision

• Among infants less than 3 months of age, male
  infants account for 75 of UTIs.
• An uncircumcised male have a 3 to 20 times risk
  of developing a UTI compared to a circumcised
  male but absolute risk increase only 1.
  (NNT 90-195)

• Studies relating association with STDs
  inconclusive.
• Studies in Africa show an association between
  contracting HIV and being uncircumcised.
• Some believe that a woman whose partner is
  uncircumcised have a higher risk of cervical
  cancer.

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Does Circumcision prevent Penile cancer?

• Possibly higher if uncircumcised.
• Overall incidence 2/100,000 per year.
• Confounders
• smoking
• genital warts
• multiple partners

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Physician Views About Pain

• Pain of injecting medication may be greater than
  procedural pain.
• Newborns do not feel or remember pain.
• Potential side effects of analgesic agent too
  harmful for neonate.

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Studies Reviewing Perception of Pain in the
Neonate During Circumcision

• Current standard of care in most sites - no
  anesthesia.
• Greater increase in HR and crying (no anesthesia
  vs. DPNB) Williamson and Williamson, 1983
• Decreased motor performance and responsiveness
  after procedure Dixon et al., 1984
• Circumcised infants have stronger pain response
  to vaccines later compared to non-circumcised
  infants Taddio et al, March 1997

• Infants exhibit physiological changes associated
  with pain.
• ? HR
• ? BP
• ?cortisol levels
• ? O2 saturation
• changes in interaction and feeding

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Methods of Pain reduction during Neonatal
Circumcision

• Technique
• Mogen lt Gomco (shorter procedure)
• Pacifier /-sucrose
• reduced crying with water moistened pacifier
• better with sucrose
• less elevation of HR but not sufficient analgesia
  for neonatal circumcision
• Tylenol
• did not significantly alter intraoperative pain
  parameters

• EMLA (2.5 lidocaine and 2.5 prilocaine applied
  60 to 90 min before procedure)
• concern about local irritation, uneven
  absorption, systemic toxicity
• apply under adhesive dressing for gt 45 minutes
• potential risk of methemoglobinemia
• Limited anesthesia during tissue lysis of
  adhesions and tightening of clamp

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Studies Reviewing Perception of Pain in the
Neonate During Circumcision (Cont.)

• Dorsal Penile Nerve Block
• requires 3-5 min wait
• multiple studies document significant reduction
  in pain and improved postoperative behaviors
• 45 to 76 less crying
• rare, mild complications (local bruising,
  hematoma)

• Subcutaneous and penile ring block
• SQ ring of 0.8cc- 1.0cc plain 0.5 lidocaine
  above corona subcutaneously and circumferentially
• equally effective at all stages of procedure
• diminished pain response
• no reported complications
• may be most effective anesthetic

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Looking at the Data
15
Comparing Agents
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Comparisons

• Padded restraints better than rigid plastic
• Sucrose EMLA more effective than no
  intervention
• DPNB better pain reduction than EMLA
• SQ local block simpler to perform and provides
  good pain reduction

• Ring block more effective than DPNB which is more
  effective than EMLA, which is better than placebo
  in reducing elevation in HR, and high pitched cry.

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Basic Steps in Circumcision

• Parental counseling and consent
• Ritual?
• Parent presence?
• Conflicts?
• Examine the glans
• Prepare clean/sterile environment
• Prevent Pain
• Take down adhesions
• Place device
• Remove foreskin
• Prevent Bleeding

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Choosing the Right Surface

• Pad board with blankets or other thick soft
  materials.
• Restraint boards in semi-reclining position have
  been shown to decrease distress.

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Swaddling

• Swaddle the upper body and legs to provide warmth
  or use a radiant warmer.
• Consider soft music before, during, and after the
  procedure.
• Provide human swaddling and comfort after the
  procedure.

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Preparation

• Use betadine to clean area where anesthesia will
  be applied if using a block, penile shaft, and
  glans.

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Anesthesia
22
Anatomy of the Penis
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Dorsal Penile Block

• 27 gauge needle or tuberculin syringe are used to
  inject 0.4 cc of 1 lidocaine at 10- and 2
  oclock positions at the base of the penis.
• Needle directed posteromedially 3 to 5mm until
  Bucks fascia is entered at base of penis.
• Allow 3 to 5 min before proceeding.
• Anesthesia lasts 1-2 hours
• Bruising is the most common complication.

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Subcutaneous and Ring Block

• 0.8 to 1.0 cc of 0.5-1.0 lidocaine without
  epinephrine.
• Inject SQ along shaft at 2,10 and ventral surface
  (very superficially).
• Alternatively inject a small ring immediately
  adjacent to the corona.

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Apply Sterile Drape

• Draping keeps area clean and provides a clean
  environment to place instruments during
  procedure.

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The Gomco clamp

• Introduced in 1935
• Quick and effective
• Very little bleeding
• Concerns
• Choosing the right size bell
• Average infant requires 1.3 size
  (1.1,1.3,1.45,1.6)
• Bell should completely cover glans without overly
  distending the foreskin
• Always check bell and plate to make sure they
  match
• Technique gives better cosmetics
• Do not perform if lt1 cm penile shaft

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Circumcision Step 1

• Lysis of adhesions
• Probably the most uncomfortable if not adequately
  anesthetized
• Usually done with clamps at 3 and 9 oclock and
  hemostat gently placed between skin and fascia in
  an open and closing motion
• Special care taken to avoid bleeding at the level
  of the frenulum

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Gomco Step 1

• Dorsal crush and slit

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Gomco Step 2

• Insertion of bell over glans
• Insert safety through both foreskin and mucosa

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Gomco Step 3

• Grasp edge of dorsal slit and insert the arm of
  the bell through the hole of the plate.
• Use a hemostat to pull foreskin through base

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Gomco Step 4

• Pull the foreskin upwards and adjust the bell and
  base plate.
• Make sure bell stays under the foreskin and over
  glans
• Apex must be visible above plate

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Gomco Step 5

• Assemble yoke of clamp to arm of the bell.
• Apply nut to connect top plate with base plate.

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Gomco Step 6

• Excise foreskin near base of plate on top surface.

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Disassembling the Gomco Plate

• Remove the nut from the plate
• (note sufficient tightening produces a suction
  after the procedure)
• Take a 2x2 and gently release suction

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Gomco Final Step

• Push remaining foreskin to just above the corona.
  
• Do not retract back too far (leads to bleeding if
  pulled back too far)

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Mogen Step 1

• Separate the glans from the preputial lining.
• Lift the prepuce upward and outward (this causes
  the glans to retract towards the scrotum).
• The open jaws of the Mogen clamp are placed
  around the prepuce (grooved side facing the
  glans) as it is lifted upwards.
• .

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Mogen Step 2

• Close clamp for 1 1½ minutes.
• Excise the prepuce distal to the clamp.
• Open the clamp slowly and remove.

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Mogen Final Steps

• Downward pressure is applied to the preputial
  skin around the corona until mucosal seal is
  broken and glans is liberated.
• Use a blunt probe to release any additional
  adhesions.
• As Infant ages dog ears become less prominent.

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What if Bleeding Occurs?

• Use a small gauze to apply pressure to the area
  that is bleeding.
• May use adrenaline on gauze.
• Sometimes may require a small interrupted suture
  with 6-0 absorbable suture.

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Indications for Discharge

• Baby is not bleeding.
• Most nurseries require that the baby has voided.

41
Summary

• No clear cut reason for routine neonatal
  circumcision.
• One of the oldest medical surgeries.
• Circumcision is a surgical procedure associated
  with pain, stress, risks and benefits.

• Provide adequate information to parents so they
  can make the best decision possible for their
  baby.
• Anesthesia can ease majority of discomfort.
• Nonpharmacological means of comfort are equally
  important.
• Either technique can be done effectively in
  skilled hands.