Techniques for neonatal circumcision
- Brian T Caldwell, MD
Brian T Caldwell, MD
- Assistant Professor, Pediatric Urology
- University of Colorado School of Medicine
- Children's Hospital Colorado
- Section Editors
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Laurence S Baskin, MD, FAAP
Laurence S Baskin, MD, FAAP
- Section Editor — Pediatric Urology
- Frank Hinman, Jr., MD, Distinguished Professorship in Pediatric Urology
- Chief Pediatric Urology
- Professor of Urology and Pediatrics
- UCSF Benioff Children's Hospital
Circumcision is the surgical removal of all or part of the distal penile foreskin (prepuce). This topic will review the patient selection, analgesia, and techniques for neonatal circumcision, including the Gomco clamp, Plastibell device, and Mogen clamp. Discussions of the risks and benefits of neonatal circumcision, including the controversy surrounding the procedure, and management of complications are presented separately.
●(See "Complications of circumcision".)
DEVELOPMENT AND ANATOMY
The penis develops as a tri-tubed structure with bilateral corpora cavernosa (erectile bodies) and ventral midline urethra surrounded by corpus spongiosum. The penis is divided into the proximal base, pendulous middle shaft, and distal glans. The corona of the glans and immediately proximal coronal sulcus anatomically differentiate the penile shaft from the glans penis (figure 1 and figure 2).
The foreskin begins development at 12 weeks of gestation as a fold of epithelium at the base of the penis that becomes a bilaminar prepuce covering the entire glans by 18 to 20 weeks. Progression of the foreskin coincides with the development of the penis; therefore, anatomic abnormalities of the penis often result in incomplete or abnormal foreskin. An inner mucocutaneous layer of the prepuce is adherent to the epithelial layer of the glans. Circumcision removes the inner and outer layers of the prepuce as well as the intervening dartos muscle (figure 3) .
- Cold CJ, Taylor JR. The prepuce. BJU Int 1999; 83 Suppl 1:34.
- Oster J. Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child 1968; 43:200.
- American Academy of Pediatrics Task Force on Circumcision. Male circumcision. Pediatrics 2012; 130:e756.
- Horowitz M, Gershbein AB. Gomco circumcision: When is it safe? J Pediatr Surg 2001; 36:1047.
- Lehr VT, Cepeda E, Frattarelli DA, et al. Lidocaine 4% cream compared with lidocaine 2.5% and prilocaine 2.5% or dorsal penile block for circumcision. Am J Perinatol 2005; 22:231.
- Kassab M, Foster JP, Foureur M, Fowler C. Sweet-tasting solutions for needle-related procedural pain in infants one month to one year of age. Cochrane Database Syst Rev 2012; 12:CD008411.
- Brady-Fryer B, Wiebe N, Lander JA. Pain relief for neonatal circumcision. Cochrane Database Syst Rev 2004; :CD004217.
- Taddio A, Stevens B, Craig K, et al. Efficacy and safety of lidocaine-prilocaine cream for pain during circumcision. N Engl J Med 1997; 336:1197.
- Mujeeb S, Akhtar J, Ahmed S. Comparison of eutectic mixture of local anesthetics cream with dorsal penile nerve block using lignocaine for circumcision in infants. Pak J Med Sci 2013; 29:27.
- Butler-O'Hara M, LeMoine C, Guillet R. Analgesia for neonatal circumcision: a randomized controlled trial of EMLA cream versus dorsal penile nerve block. Pediatrics 1998; 101:E5.
- Holliday MA, Pinckert TL, Kiernan SC, et al. Dorsal penile nerve block vs topical placebo for circumcision in low-birth-weight neonates. Arch Pediatr Adolesc Med 1999; 153:476.
- Lander J, Brady-Fryer B, Metcalfe JB, et al. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision: a randomized controlled trial. JAMA 1997; 278:2157.
- Stolik-Dollberg OC, Dollberg S. Bupivacaine versus lidocaine analgesia for neonatal circumcision. BMC Pediatr 2005; 5:12.
- Hardwick-Smith S, Mastrobattista JM, Wallace PA, Ritchey ML. Ring block for neonatal circumcision. Obstet Gynecol 1998; 91:930.
- Stevens B, Yamada J, Ohlsson A, et al. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev 2016; 7:CD001069.
- Snodgrass WT, Khavari R. Prior circumcision does not complicate repair of hypospadias with an intact prepuce. J Urol 2006; 176:296.
- Pieretti RV, Pieretti A, Pieretti-Vanmarcke R. Circumcised hypospadias. Pediatr Surg Int 2009; 25:53.
- Chalmers D, Wiedel CA, Siparsky GL, et al. Discovery of hypospadias during newborn circumcision should not preclude completion of the procedure. J Pediatr 2014; 164:1171.
- Bowa K, Li MS, Mugisa B, et al. A controlled trial of three methods for neonatal circumcision in Lusaka, Zambia. J Acquir Immune Defic Syndr 2013; 62:e1.
- Plank RM, Ndubuka NO, Wirth KE, et al. A randomized trial of Mogen clamp versus Plastibell for neonatal male circumcision in Botswana. J Acquir Immune Defic Syndr 2013; 62:e131.
- Overview of surgical devices. In: Manual for Early Infant Male Circumcision Under Local Anesthesia, World Health Organziation (Ed), WHO Press, Geneva 2010. p.50.
- American Academy of Pediatrics Task Force on Circumcision. Circumcision policy statement. Pediatrics 2012; 130:585.
- Concodora CW, Maizels M, Dean GE, et al. Checklist assessment tool to evaluate suitability and success of neonatal clamp circumcision: A prospective study. J Pediatr Urol 2016; 12:235.e1.
- Peleg D, Steiner A. The Gomco circumcision: common problems and solutions. Am Fam Physician 1998; 58:891.
- Elder JS. Circumcision. BJU Int 2007; 99:1553.
- Mahomed A, Zaparackaite I, Adam S. Improving outcome from Plastibell circumcisions in infants. Int Braz J Urol 2009; 35:310.
- Bode CO, Ikhisemojie S, Ademuyiwa AO. Penile injuries from proximal migration of the Plastibell circumcision ring. J Pediatr Urol 2010; 6:23.
- Sinkey RG, Eschenbacher MA, Walsh PM, et al. The GoMo study: a randomized clinical trial assessing neonatal pain with Gomco vs Mogen clamp circumcision. Am J Obstet Gynecol 2015; 212:664.e1.
- Pippi Salle JL, Jesus LE, Lorenzo AJ, et al. Glans amputation during routine neonatal circumcision: mechanism of injury and strategy for prevention. J Pediatr Urol 2013; 9:763.
- Bazmamoun H, Ghorbanpour M, Mousavi-Bahar SH. Lubrication of circumcision site for prevention of meatal stenosis in children younger than 2 years old. Urol J 2008; 5:233.
- DEVELOPMENT AND ANATOMY
- TIMING OF PROCEDURE
- PAIN CONTROL
- Our approach
- Local topical anesthetics
- Penile nerve block
- - Anatomy for nerve block
- - Dorsal penile block
- - Ring block
- Non-pharmacologic adjuncts
- PRE-PROCEDURE PREPARATION
- Informed consent
- Examination of penis and scrotum
- Choice of technique
- Initial steps
- Gomco clamp
- Mogen clamp
- POST-CIRCUMCISION CARE
- COMPLICATIONS AND MANAGEMENT
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS