GUIDELINE
PAEDIATRICS
914
Neonatal Circumcision
Background
Circumcision of the male neonate is a common
procedure in our society, usually for religious or
cultural reasons. Male neonatal circumcision is not an
innocuous procedure. Consideration should be given to
factors which may affect the outcome. For the purposes
of this guideline, "neonatal" is defined as the first
month of life.
Contraindications
- Congenital penile abnormalities, eg. hypospadias,
chordae, prominent dorsal preputial hood with lack of
ventral foreskin, micropenis, buried penis, penis
with severe penoscrotal webbing. Neonates with such
problems should be referred to a Urological
Specialist.
- Known bleeding diathesis.
- Premature infant or an infant with medical
complications.
- Family history of gross keloid formation.
Indications
Specific medical indications for the performance of
circumcision in the neonate are rare. There may be
benefits to circumcision in the prevention of phimosis,
the prevention of urinary tract infection, reduction in
the spread of the papillovirus, and the protection of
men from infection with the Human Immunodeficiency
Virus (HIV). The degree of benefit is small, however,
and does not support a recommendation to circumcise
neonates.
The Following Conditions Are Not An Indication
For Circumcision:
- Single urinary tract infection
- Difficulty retracting the foreskin (the foreskin
is not normally retractable in the neonate)
- Prevention of balanitis
Precautions
- The neonate who has a urinary tract infection
(UTI) should be assessed by a specialist before the
circumcision is recommended. Vesicoureteric reflux
and/or urinary tract obstruction must be ruled out
before circumcision would be contemplated. The
foreskin may act as a reservoir for bacteria under
such circumstances.
- The circumcision of neonates or infants with
documented vesicoureteric reflux, in order to prevent
recurrent infections, is still a controversial
issue.
- Electro-cautery should not be used in newborn
circumcision.
Informed Consent
Parental consent must be obtained prior to the
performance of circumcision. It is recommended that
such discussions occur as part of prenatal care rather
than hastily after the birth of the baby as has been
the common practice. Complaints by parents are usually
related to their expectations not being achieved.
Timing Of Circumcision
When performed, it is preferable that circumcision
be done within the first month of life. If the
procedure is not performed within the first month, most
urologists advise that the procedure should be delayed
until well after the neonatal period, unless a specific
medical indication arises. In children above the age of
three months, a free hand circumcision is preferable to
a clamp or bell technique.
Anaesthesia/Analgesia
Infants do experience pain with neonatal
circumcision, manifested by crying, elevation of the
heart rate, and a measurable increase in serum cortisol
levels. Evidence suggests that the use of approved
topical analgesia or local infiltration (e.g. Dorsal
penile nerve block) containing adrenaline free local
anaesthetic are effective methods to block the pain of
neonatal circumcision. Studies demonstrate that these
techniques are simple and safe with little risk of
complication to the newborn provided it is performed by
a physician who is experienced in such procedures. It
is imperative to ensure that injection is not
intravascular or intracorporeal.
Training Standards
In order to be granted privileges in neonatal
circumcision, the Physician must:
- Be registered and a licensed member of the College
of Physicians and Surgeons of Manitoba.
- Demonstrate competence in the performance of 10
procedures proctored by a physician who has neonatal
circumcision privileges and who agrees to provide
documentation attesting to the competency of the
other physician.
References
- American Academy of Family Physicians. Fact Sheet
For Physicians Regarding Neonatal Circumcision.
American Family Physician 1995;52(2):523-6.
- Anand KJS, Hickey MD. Pain And Its Effects In
The Human Neonate And Fetus. The New England J Of
Medicine 1987;317(21):1321-29.
- Chessare JB. Circumcision:
Is The Risk Of Urinary Tract Infection Really The
Pivotal Issue? Clinical Pediatrics
1992;Feb:100-4.
- Fetus And Newborn Committee, Canadian Paediatric
Society. Neonatal Circumcision Revisited.
Canadian Medical Association J
1996;154(6):769-80.
- Fletcher AB. Pain In The
Neonate. The New England J of Medicine
1987;317(21):1347-48.
- Ganiats TG, Humphrey JBC et al. Routine Neonatal
Circumcision: A Cost-Utility Analysis. Medical
Decision Making 1991;11(4):282-293.
- Lawler FH, Bisonni RS, Holtgrave DR. Circumcision: A
Decision Analysis Of Its Medical Value. Family
Medicine 1991;23(8):587-93.
- Masciello A. Anesthesia For
Neonatal Circumcision: Local Anesthesia Is Better
Than Dorsal Penile Nerve Block. Obstetrics And
Gynaecology 1990;75(5):834-38.
- Maxwell LG, Yaster M et al. Penile Nerve Block
For Newborn Circumcision. Obstetrics And
Gynaecology 1987;70(3):415-18.
- Niku SD, Stock JA, Kaplan GW. Neonatal
Circumcision. Urologic Clinics Of North
America 1995;22(1):57-65.
- Poland RL. The
Question Of Routine Neonatal Circumcision. New
England J Of Medicine 1990;322(18):1312-15.
- Schoen EJ. Sounding Board: The Status Of
Circumcision Of Newborns. The New England J Of
Medicine 1990;322(18):1308-11.
- Stang HJ, Gunnar MR et al. Local Anesthesia For
Neonatal Circumcision: Effects On Distress And
Cortisol Response. J Of American Medical
Association 1988;259(10):1507-11.
- Spach DH, Stapleton AE, Stamm WE. Lack of
Circumcision Increases The Risk Of Urinary Tract
Infection In Young Men. J Of American Medical
Association 1992;267(5):679-81.
- Task Force on Circumcision, American Academy of
Pediatrics. Report of the
Task Force on Circumcision. Pediatrics
1989;84:388-91.
- Williamson PS, Williamson ML. Physiologic Stress
Reduction by a Local Anesthetic During Newborn
Circumcision. Pediatrics
1983;71(1):36-40.
First Print PDRC/02-94
Revision PMWC/06-97
A Guideline is practice generally recommended.
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