Revised:  02/06/2004

While there is some disagreement about the medical necessity of routine neonatal circumcision and the associated risks, currently a majority (61%) of newborn boys in the United States undergo this procedure. In fact, circumcision is the most commonly performed surgical procedure in this country. Certain studies indicate that uncircumcised males have an increased risk of balanitis, urinary tract infections, penile cancer, and HIV infection, and that women whose sexual partners are uncircumcised have an increased risk of cervical cancer. However, all of these studies suffer from bias and methodological flaws; therefore, these conclusions may not be valid. The most recent American Academy of Pediatrics (AAP) position is that "circumcision has potential medical advantages as well as inherent disadvantages and risks. When circumcision is being considered, the benefits and risks should be explained to the parents and informed consent should be obtained."

Some physicians are more apt to perform circumcision since improved anesthesia is now available. Methods include dorsal penile nerve block, precircumcision oral analgesics, local anesthesia of foreskin, and topical anesthesia such as viscous lidocaine. Studies have shown that infants anesthetized with either DPNB or local anesthesia demonstrate less crying, less tachycardia, less irritability, and fewer behavior changes in the 24 hours following the procedure. They also have lower postprocedure serum cortisol levels than infants circumcised without anesthesia.

INDICATIONS

 

Parental desire

CONTRAINDICATIONS

 

Hypospadias ^*

 

Unusual appearing genitalia ^*

 

Inability to determine phenotype of child ^* (ambiguous genitalia)

 

Age less than 12 hours (physiologic adaptation requires 12 to 24 hours)

 

Severe illness

 

Prematurity (until the child is ready for discharge from the hospital)

If there is a family history of bleeding problems, appropriate laboratory studies should be performed before the procedure. Undescended testicles are not necessarily a contraindication; however, they should be noted and evaluated for other reasons. Because of the risk of regurgitation, infants should be at least 1 hour postprandial. Also, document that the child has had at least one void since birth before performing the procedure.

One relative contraindication to circumcision is age greater than 6 to 8 weeks. By this age, adhesions are usually more significant, causing the procedure to be more difficult and time consuming, and frequently it requires a more experienced clinician. The foreskin may develop significant edema after lysis of these adhesion, making it difficult to use the Gomco clamp. By this age, maternal clotting factors have also been metabolized, possibly predisposing the infant to increased blood loss.