Circumcision

Medical indications for circumcision include:

• Phimosis – this is a tight foreskin that will not retract. This is normal in pre-pubescent boys and resolves as the boy grows so that by puberty, most boys can retract their foreskins. If the foreskin becomes scarred and cannot retract, circumcision should be considered.

• Urinary tract infection (UTI) – Circumcision should be considered in boys who have a UTI with a fever. It decreases the rate of recurrent UTI.

• Recurrent balanitis (infection of the glans penis) or posthitis (infection fo the foreskin)

Circumcision is an age-old procedure that has been and is still practiced by many cultures and religions around the world. Most ‘ritual’ or cultural circumcisions are not for medical reasons.

The aim of the procedure is to remove the foreskin. The operation is performed under general anaesthesia and takes about 30 minutes. Your child should not have to spend the night in hospital.

Your child cannot eat for 6 hours before the procedure. In breast fed babies this time may be reduced by the anaesthetist. Your child can drink water for up to 2 hours before the operation. The Day Surgery Unit will instruct you the day before surgery to confirm fasting times. It is useful to bring your child’s favourite toy along on the day.

The anaesthetist will meet you and your child prior to the procedure. They will discuss the anaesthetic with you and take you through to the operating theatre. Your child will be anaesthetised using a face mask and then you will be taken to a waiting area. Once your child is asleep a drip is inserted often in the hand or arm, but occasionally it may need to be sited in the leg.

Once your child is asleep, the foreskin is removed. The wound is closed with absorbable stitches. No dressing is required but an antibiotic ointment is applied to prevent infection.

On completion of the operation your child will be taken to the recovery area. Children often initially appear distressed and a little confused upon waking up but will quickly settle down once you are with them and if offered a drink or something to eat. Full recovery usually takes about 2-3 hours after which you can go home.

Children’s paracetamol should be given for pain relief for 24 hours. After that use paracetamol only if needed. Some children need additional medication such as ibuprofen or celecoxib. Opiate (morphine-type) medications are not usually required. Paracetamol and ibuprofen can be given at the same time and work well together. Follow the dosages recommended on the packaging or by the anaesthetist. Never give more than has been prescribed.

Bathing is safe after the operation. Antibiotic cream (Chlorsig) should be applied 2-3 times a day or after a nappy change. In addition, applying a generous dollop of Vaseline to the inside of the nappy prevents the tip of the penis from sticking to it. The skin of the glans has to change from being soft and moist to dry skin. This takes about 2 weeks and once it has occurred, the Vaseline is no longer required.

For a few days after the operation, a small amount of bloodstaining of the nappies or underpants should be expected. The urinary stream may spray because of post-operative swelling. It will resolve as the swelling subsides.

The tip of the penis (glans) and the shaft itself may look swollen and bruised for a few weeks after surgery. This too is temporary and will resolve.

In general, your child may eat a normal diet after surgery. Vomiting is common on the day of surgery. It is temporary, and usually due to the anaesthetic and pain-relief medications that are used. If vomiting occurs, start with clear liquids and add solids slowly for the first day.

• Activity: Your child should avoid strenuous activity first 1-2 days. Sport and swimming are best avoided for 3 weeks after surgery.
• School: Your children may return to day care or school when comfortable.
• Bathing/showering: As the wound is waterproof, bathing and showering is safe after the operation.
• Wound care: No specific wound care is required. The stitches are absorbable and do not require removal. No dressing changes, creams or ointments are required.
• Stool softeners and laxatives: May be needed to help regular stooling after surgery, especially if opiates are needed for pain.

Call the doctor’s office if:

• You see any signs of infection: redness along the incision site, increased swelling, discharge
• Your child’s pain gets worse or is not relieved by pain killers
• There is bleeding from the incision
• Your child has an abnormal temperature
• Vomiting continues on the day after surgery
• If you have any other concerns

I will review your child 4-6 weeks after the surgery to ensure healing of the wound. For patients from rural areas this may be deferred to your General Practitioner or Paediatrician. Please ring soon after the operation to arrange a convenient time.

This is a common operation with a low complication rate. The vast majority of children who have this operation recover well and have no serious complications of surgery. However, complications can occur. Some of the recognised ones include:

Bleeding
This occurs in <1% of boys. Some oozing is not uncommon for a few days. If it is a steady trickle or the nappy is soaked with blood, please contact me or present to the emergency department of your local hospital. Bleeding will usually cease with pressure or a compression dressing. Rarely a return to theatre is needed to control the bleeding.

Infection
The wound and glans should look red and crusty. As the glans heals, it may also become covered with white or yellow discharge. This is normal healing and does not represent infection. It will resolve by about two weeks post circumcision. A thick yellow discharge, increasing pain, redness and fever suggest infection which, if it occurs happens between days four and seven.

Cosmesis
Rarely the cosmetic outcome is not satisfactory, and a revision may be needed.

Damage to the Penis
Though very rare, cases have been reported of damage to the glans penis or penis itself.

If you have any questions, please do not hesitate to contact us.

Ph: 02 8307 0977
Fax: 02 8088 7420
Email: info@drgideonsandler.com

Please refer to the following resources for more information:

1. Circumcision: A guide for parents [PDF]
   The Royal Australasian College of Physicians
   
2. Circumcision of Infant Males [PDF]
   The Royal Australasian College of Physicians
   
3. Male Infant Circumcision [PDF]
   The Sydney Children's Hospitals Network