Paediatric Urology – Circumcision

C ircumcision is one of the oldest operations known: it is mentioned in the Bible (book of Genesis) and paintings depicting circumcision were found in Egyptian tombs.

1When should a circumcision be performed?

Performing circumcision purely for social / cultural / religious reasons is controversial From a medical perspective however, there are definite conditions when circumcision is needed.

These include:

  • Phimosis (This is the inability to retract the foreskin of the penis in order to expose the glans (head of the penis). Phimosis is normal in babies and boys up to the age of 5 years and in this age group the foreskin should never be forced back.
  • Paraphymosis (This is a very painful condition that develops when a tight foreskin is forcefully retracted)
  • Recurrent infection of the glans (head) of the penis or the foreskin (called balanitis or balano-posthitis). This is common in men who suffer from Diabetes.
  • Cancer of the penis
  • Warts on the penis
  • Trauma to the foreskin (usually caused by a zipper)
2When should a circumcision NOT be performed?

Circumcision should not be performed in small babies who:

  • Were born prematurely
  • Have severe illness
  • Have a bleeding tendency (eg haemophilia)
  • Were born with an abnormal looking penis:
    • Skew or rotated penis
    • Abnormally placed urethra (the urethra is the small opening usually located on the tip of the glans where urine comes out. Some baby boys are born with this opening not at the tip of the penis, but somewhere along the shaft of the penis – this condition is called hypospadias)
3Benefits of circumcision
  • It prevents the development of penis cancer:Men who had circumcision as a baby will almost never develop cancer of the penis
  • It protects against HIV:Circumcision reduces the rate of HIV transmission by 50-70%
  • It may prevent urinary tract infections in baby boys under the age of 6 months
4Methods of circumcision

There are many techniques for performing circumcision.

Excision using a surgical scalpel (also called the “double sleeve” technique) is safe and reliable, with a low complication rate and excellent cosmetic result.

Circumcision: Surgical removal of the penile foreskin

Other techniques for performing circumcision include clamps and shields, which are made of plastic or metal. Although these devices can be applied by nurses, it is preferable that a circumcision always be performed by a qualified doctor.

5Common patient concerns about circumcision

Circumcision has no effect on a man’s libido (sex drive), his sexual ability, his fertility or the quality of his erection.

There is controversy regarding the effect of circumcision on a males sexual enjoyment: some people believe that sexual enjoyment is increased after a circumcision while others are of the opinion that it is decreased.
6What preparation is needed before the day of the operation
Your doctor will discuss the procedure with you, informing you of the possible risks and complications. No routine blood tests are usually required, unless you have other medical conditions. Pubic hair should be shaved before the operation. If you are taking aspirin tablets daily, this needs to be stopped at least 5 days prior to the operation.
7What to expect on the day of the operation
A circumcision can be performed under local- or general anaesthesia. If local anaesthesia is used then the doctor will inject the anaesthetic with a small needle around the base of the penis just under the skin. This local anaesthetic will cause a burning sensation that lasts for about 5 seconds. After this, you should not feel any pain for the duration of the procedure.
The foreskin is then surgically removed and small bleeding vessels are closed off with a stitch or electric current.
Stitches are then used to close the skin incision just below the glans penis. Most doctors use absorbable stitches but tissue glue can also be used. A small bandage or other type of dressing is then applied.
Circumcision is a quick and simple procedure and you will not be required to spend a night in hospital.
8After the operation
Be sure to follow your doctor’s orders regarding care of the wound during the first few days after the operation. The stitches mostly dissolve on their own within 2-5 weeks. Mild pain is normal in the first few days after the operation but contact your doctor if the pain persists, worsens or if there is swelling, a throbbing pain or pus in the wound.
9Risks and complications

Circumcision is a minor operation with a low complication rate. Most complications are not serious and can be managed with simple measures.

Possible complications include:

  • Bleeding
  • Infection
  • Ulceration of the urethral opening
  • Skin complications (related to the surgeon removing too much skin or not enough skin)
  • Damage to the glans of the penis
  • Damage to the shaft of the penis
  • Inability to pass urine after the operation (this is uncommon and will usually resolve within a few hours)