Neonatal Circumcision

1. Neonatal Circumcision Lianne Beck, MD Assistant Professor Emory Family Medicine Adapted from Josephine R Fowler, MD MSc

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. Foreskin Embryology • Development of prepuce between week 8 and 16 in utero • Prepuce mucosa and glans are contiguous • Exfoliation of underlying epithelium in a proximal direction leads to resolution of the physiological adhesions and formation of a preputial sac • Usually complete by 3 - 5 years but may continue until puberty

4. Natural History • Work by Gairdner 1949 and Oster 1968 • Less than 1% of boys require a circumcision

5. Epidemiology • Circumcision rate varies by • Geographic region ( 1 in 6 worldwide) • Religious affiliation • Socioeconomic classification • Uncommon in Asia, S. America, Central America, Europe • 48% circumcised in Canada • >80% in US in 1980 and declining • Whites > blacks or hispanics

6. 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 -Parent’s 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.

7. Recent Studies Supporting Health Benefits • In three recent RCTs involving about 10,000 HIV-negative men (age range, 18–49) in Africa, circumcision decreased male heterosexual acquisition of HIV disease by 53% to 60% compared with uncircumcised men during an average follow-up of 1.5 to 2 years . • In two trials, circumcision decreased acquisition of HSV type 2 infections by 28% to 34% and penile HPV infections by 32% to 35%. • Some evidence suggests that female benefits of male circumcision include a decrease in transmission of BV, trichomoniasis and HIV.

8. Most common surgical procedure performed in US. 1 million/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 Meatal stenosis Necrotizing fasciitis Urethral fistula Partial penile amputation Penile necrosis Concealed penis Death Neonatal Circumcision

9. Indications • True indications rare! • Penile cancer (cannot predict which babies will develop cancer) • Recurrent balanitis (esp. diabetics) • Phimosis (cannot be diagnosed in newborn period)

10. 12-24 hours post delivery. Evaluate for hyperbilirubinemia, infection, bleeding diathesis. Make sure infant has voided. Contraindications: Congenital penile abn Prematurity Bleeding disorder Medical problem Optimal Timing and Contraindications

11. Infection and Circumcision • Among infants less than 3 months of age, male infants account for 75% of UTIs. • An uncircumcised male has 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. • Evidence supporting association between circumcision status and risk of developing cervical cancer is inconclusive.

12. Does Circumcision Prevent Penile Cancer? • SCC penis is rare • Neonatal circumcision is protective whereas adult circumcision is not. • Studies estimate that 600-900 circumcisions are needed to prevent one lifetime case of penile cancer • Probably related more so to poor hygiene • Confounders (smoking, phimosis, genital warts, multiple partners)

13. Sexual Functioning • Prepuce is filled with nerve endings similar to lips or fingers (much more so than the glans) • Circumcision permanently inhibits sexual function ? • Glandular skin undergoes hyperkeritinization • An investigation of the exteroceptive and light tactile discrimination of the glans of circumcised and uncircumcised men found no difference on comparison. • No valid evidence to date, supports the notion that being circumcised affects sexual sensation or satisfaction.

14. 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”.

15. Infants exhibit physiological changes associated with pain.  HR  BP cortisol levels  O2 saturation changes in interaction and feeding 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 Studies Reviewing Perception of Pain in the Neonate During Circumcision

16. Technique: Mogen < 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 > 45 minutes potential risk of methemoglobinemia Limited anesthesia during tissue lysis of adhesions and tightening of clamp Methods of Pain Reduction During Neonatal Circumcision

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

18. Looking at the Data

19. Comparing Agents

20. 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. Comparisons

21. 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

22. 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.

23. 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.

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

25. Anesthesia

26. Anatomy of the Penis

27. Dorsal Penile Block • 27 gauge needle or TB syringe is used to inject 0.4 cc of 1% lidocaine at 10- and 2 o’clock positions at the base of the penis. • Needle directed posteromedially 3 to 5mm until Buck’s 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.

28. 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.

29. Apply Sterile Drape • Draping keeps area clean and provides a clean environment to place instruments during procedure.

30. The Gomco clamp • Introduced in 1935 • 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 <1 cm penile shaft

31. Circumcision Step 1 • Lysis of adhesions • Probably causes the most discomfort, if not adequately anesthetized • Usually done with clamps at 3 and 9 o’clock 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

32. Gomco Step 1 • Dorsal crush and slit

33. Gomco Step 2 • Insertion of bell over glans • Insert safety through both foreskin and mucosa

34. 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

35. 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

36. Gomco Step 5 • Assemble yoke of clamp to arm of the bell. • Apply nut to connect top plate with base plate.

37. Gomco Step 6 • Excise foreskin near base of plate on top surface.

38. 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

39. 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)

40. Mogen Clamp • Designed in 1954 • Most commonly used by mohels for ceremonial circumcision • Has the advantages of being rapidly performed and not leaving a foreign body at the circumcision site. • The disadvantage is that the device does not directly protect the glans during the procedure.

41. 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.

42. Mogen Step 2 • Close clamp for 1 – 1½ minutes. • Excise the prepuce distal to the clamp. • Open the clamp slowly and remove.

43. 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.

44. Plastibell Technique • Introduced in the mid 1950s • Has the advantage of continuing hemostasis after the procedure is over, as the suture remains in place for a few days. • Disadvantage is that there is a foreign body at the site, which could become dislodged or infected.

45. Online Videos • http://newborns.stanford.edu/Plastibell.html • http://newborns.stanford.edu/Gomco.html • http://newborns.stanford.edu/MogenIntro.html

46. 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.

47. Indications for Discharge • Baby is not bleeding. • Most nurseries require that the baby has voided.

48. Summary of Evidence of Benefit • Neonatal circumcision prevents UTIs in the first year of life with an absolute risk reduction of about 1% • Prevents the development of penile cancer with an absolute risk reduction of less than 0.2%. • The evidence suggests that circumcision reduces the rate of acquiring an STD, but careful sexual practices and hygiene may be as effective. • Circumcision appears to decrease the transmission of HIV in underdeveloped areas where the virus is highly prevalent.

49. 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. • Any technique can be done effectively in skilled hands.

50. References • www.aafp.org/online/en/home/clinical/clinicalrecs/circumcision.html