What to tell parents about circumcision
By Jane E. Anderson, MID, and Karl A. Anderson, MID

Whether to circumcise a newborn son is one of the first decisions parents must make for their child. Pediatricians can help them sort through the confusion and controversy surrounding the issue by providing accurate information and answers to their questions.

Since the American Academy of Pediatrics stated in 1971 that there are no valid medical indications for circumcision in the neonatal period, the practice has generated much controversy and confusion, both in the medical community and among families awaiting the birth of a child. The AAP modified its stand in 1989 to say, "Newborn circumcision has potential medical benefits and advantages as well as disadvantages and risks." Since then, more articles have appeared detailing the benefits and risks of circumcision as well as the benefits of giving anesthesia for the procedure.

Pediatricians need to keep abreast of the latest information so that we can answer parents' questions accurately and appropriately, especially in light of the fact that parents today have access to more medical information of varying quality than in the past. Our role in talking to parents about circumcision is similar to any other discussion we have with families. it is our responsibility to provide accurate information in words that parents can understand, answer their questions to the best of our ability, and then allow them to make the final decision for their child.

The history of circumcision

Circumcision, one of the oldest operations known, is depicted in has relief on ancient Egyptian tombs and may have been used as a mark of slavery after castration proved to have too high a mortality rate. Jewish history traces the Biblical origin to the covenant between God and Abraham in Genesis 17, at least 2,000 years before Christ. Although circumcision is not mentioned in the Koran, Moslems continue the tradition but often circumcise in later childhood.

Many aboriginal tribes of Australia and Indians of North and South America, including the Aztec priests, practiced circumcision. Columbus reportedly was met by circumcised natives. In the past, Polynesians and Indonesian cultures also practiced circumcision, apparently to facilitate coitus or as a mark of the male's ability to withstand pain.

In this century, circumcision has remained rare in Northern Europe, Central and South America, and Asia. In the United States, the prevalence has varied over time. Around 8% of males born in the US before 1870 were circumcised, compared with approximately 70% of males born between 1920 and 1950.4 The World Wars contributed to the increase in circumcision when the armed forces recommended circumcision for troops leaving for overseas to reduce the incidence of infection. 

Does circumcision have medical benefits? Circumcision has been performed from very early times in many cultures around the world (see Circumcision has been performed from very early times in many cultures around the world . The table summarizes its benefits and risks according to current data. Studies suggest that neonatal circumcision does play a role in preventing some medical conditions, including penile carcinoma and urinary tract infection, and may or may not reduce the incidence of sexually transmitted diseases and cervical cancer.

Diseases Prevented:
>7,000 cases of Aids
>10,000 cases of syphilis
>20,000 episodes of kidney infection
>1,000 cases of penile cancer
200,000 cases of phimosis (foreskin scared closed)
250,000 cases of balanoposthitis (infected forskin)

Complications:
2,000 cases of bleeding that can be stopped.
2,000 cases of infection.
300 shaft injury that needs repairing.
1 case of entire penis lost. (same result with cancer)

Penile carcinoma. Penile carcinoma. The most certain benefit of neonatal circumcision is that it prevents later development of squamous cell carcinoma of the penis. Because of the high numbers of American men who have been circumcised as infants since 1910, the incidence of squamous cell carcinoma is low, with only about 1,000 new cases identified each year. In 1980, Kochen and McCurday calculated the lifetime risk at one in every 600 uncircumcised males, compared to one in 75,000 to 8 million circumcised males. The risk for uncircumcised males is similar to the life time risk of testicular cancer, which is one in 450.

It has been suggested that good hygiene provides as effective protection against penile carcinoma as neonatal circumcision. Although hygiene is important, it does not significantly decrease the risk of cancer. Six major studies from the United States, reporting on more than 1,600 cases of penile cancer, found that no case occurred in a patient who had been circumcised as an Infant. Around 50,000 cases of penile cancer and 10,000 deaths have been reported in the US since 1930, but only 10 cases occurred in circumcised males, indicating that circumcision definitely decreases the risk of cancer.

Urinary tract infections. Urinary tract infections. Circumcision decreases the risk of urinary tract infection (UTI) tenfold in the first year of life, and the decreased risk continues for the first

five years of life. Ginsberg and McCracken first reported a relationship between circumcision and UTI in 1982. Of 62 male infants admitted to the hospital with UTI, they found that 95% were uncircumcised. Wiswell's 1985 hospital-based study reported fewer UTIs during the first year of life in circumcised males. A much larger, two-part study by Wiswell and Roscelli the following year confirmed these initial findings.

In the first part of the larger study, which included 3,924 infants born at Brooke Army Medical Center, the frequency of UTI in uncircumcised males was 1.1%, ten times the frequency found in circumcised males (0.1%). in the second part of the study, of 422,328 infants born over a 10-year period, uncircumcised males made up only 19.3% of the study population but accounted for 70.8% of the UTIs. Even more significant, as the rate of circumcision decreased over the years, the number of UTIs increased.

Data from 100,000 Swedish children confirmed Wiswell's findings, revealing a risk of 1.1% for uncircumcised males in the first year of life. More recently, several reports have demonstrated that the risk of UTI is lower for circumcised than uncircumcised males beyond the first year, at least through 5 years of age. A study published in December by To and colleagues supports the findings of decreased risk of UTI for circumcised males but notes that the protective effect of circumcision may be less than previously thought.

The physiologic basis for the decreased risk of UTI in circumcised infants appears to be lower rates of urethral colonization. Several studies, including some using electron photomicrographs, demonstrate preferential binding of uropathogens such as fimbriated Escherichia coli, Pseudomonas, and Klebsiella to the sticky mucosa of the prepuce with no attachment to the outer skin. When Wiswell followed 50 boys from birth through 12 months of age, obtaining urethral cultures at every well visit, he found that uncircumcised boys had significantly higher total colony counts of uropathogenic gram-negative organisms at all ages except 12 months."

As the uncircumcised foreskin becomes increasingly retractable during the first year of life, one would expect the differences in colonization rates between uncircumcised and circumcised boys to decrease. Other issues to consider when discussing the relationship between circumcision and UTIs with parents include the increased risk of UTIs in children with known urogenital malformations and the decreased risk associated with breastfeeding.

Sexually transmitted diseases. Sexually transmitted diseases. some studies suggest that uncircumcised men are less likely to become infected with sexually transmitted diseases such as syphilis and human papillomavirus despite exposure to the causative organism. The studies often have been contradictory and difficult to interpret, however.

The most intriguing studies concern an increased risk of human immunodeficiency virus (HIV) in

fection among uncircumcised men in Africa. Early in the AIDS epidemic, studies from Africa suggested that uncircumcised, heterosexual men were four to eight times more likely than circumcised men to contract HIV when exposed. Moses and colleagues reported in 1994 that 22 of 30 studies confirmed this association and recommended adult circumcision to decrease the spread of AIDS. 14

When Caldwell and Caldwell evaluated the factors that might contribute to the 25% infectivity rate in the "AIDS belt," the only factor they found that differed in the affected populations was lack of circumcision. There have been no similar studies from western countries, so the impact of circumcision on the incidence of AIDS among American men is not known.

Cervical cancer Cervical cancer In the 1940s, it was recognized that Jewish women had a markedly lower incidence of cervical cancer (2.2/100,000) than non-Jewish women (44/100,000). Many researchers attempted to assess whether this was because the Jewish women's partners were circumcised, but most studies yielded conflicting data. Aitken-Swan and Baird seemingly presented the definitive data in 1963 when they examined the partners of women with cervical cancer and found no relationship between cancer and circumcision status.16

New data indicating that uncircumcised men acquire the human papillornavirus more easily than circumcised men has reopened the question of a possible relationship. The issue will most likely remain unresolved, however, because women today are more likely to have other risk factors for cervical carcinoma, including lower age at first intercourse and multiple partners.

What are the benefits & risks of circumcision?

1. Benefits:

• Prevents cancer of the penis
• Decreases risk of urinary tract infection in infants and children under age 5
• Avoids later circumcision for medical indications
• Prevents paraphimosis
• Prevents recurrent balanitis
• Decreases risk of acquiring HIV (in African studies)
• May decrease risk of acquiring other STDs

2. Risks:

• Operative complications
• Bleeding
• Infection
• Poor cosmetic outcome
• Excessive skin loss
• Hidden penis syndrome
• Complications of anesthesia
• Postoperative complications Fibrous bands Phimosis if not enough foreskin removed Meatal stenosis Adhesions, cysts 

The most comprehensive study of complications from circumcision remains Gee's and Ansell's 1976 report of 5,521 males circumcised between 1963 and 1972 at the University of Washington, half with the Gomco clamp and half with the Plastibell device (described below).17 The study found complications in 2% of patients, with a significant complication in 0.2%, or I patient in 500.

Since circumcision is a surgical procedure, the most recognizable complications are bleeding and infection. The most common problem reported by Gee and Ansell was hemorrhage (1%) defined as any excessive bleeding requiring treatment. Infection occurred in 23 infants (0.4%), more commonly in those circumcised with the Plastibell (0.72% vs. 0.14%). Additional studies have confirmed the rate of local infection to be approximately 0.5%, with systemic infection occurring in perhaps one in 4,000 patients.

Among the more serious complications reported by Gee and Ansell were life-threatening hemorrhage in one patient with hemophilia, infection requiring antibiotics (four patients), circumcision performed despite hypospadias (eight patients), and complete denudation of the penile shaft (one patient). Other major complications reported in the literature include sepsis, pulmonary abscess, femoral osteomyelitis, necrotizing fasciitis, and urethrocutaneous fistulas. One 4month-old whose surgeon used an electrocautery over a Gomco clamp developed sloughing of the entire penile shaft and was eventually surgically transformed into a female.

The mortality rate from circumcision is around one death per 2 million patients. Between 1953 and 1993, three boys died from complications of circumcision. During that same period, between 9,000 and 12,000 uncircumcised men died of penile cancer. 18

Some complications of circumcision are rarely acknowledged, the most common being a poor cosmetic result. A study from Australia revealed that 9.5% of circumcisions were actually repeat procedures to correct inadequately performed initial surgery.

If too little foreskin is removed, the patient may appear to be uncircumcised and may develop phimosis caused by the scarring that occurs with healing. If too much skin is removed, the shaft of the penis may be denuded. No data concerning the eventual outcome are available, but it is theoretically possible that the scarring that occurs when the shaft is denuded may later cause pain during erections. Such complications may be reduced by using a surgical marking pen to delineate the corona of the penile shaft, which is easily visible beneath the foreskin, before surgery.

Poor surgical technique can also lead to "concealed" or "hidden penis" in which too much of the outer layer of the prepuce is removed, but little of the inner layer. This causes a tethering effect that pulls the penis in toward the fat pad while covering the glans with the foreskin.

Another common, but seldom mentioned, complication of neonatal circumcision is meatal stenosis, probably caused by ulceration of the urethral meatus with subsequent scarring. The urinary stream deviates, often prompting the mother to complain that her son "misses the bowl," so the pediatrician who observes the patient voiding can easily make the diagnosis. Once stenosis is diagnosed, obtain a urinalysis to assure that there is no ongoing irritation or infection and consider a post-void bladder ultrasound, which will demonstrate residual volume if the obstruction is significant.

If any redundant foreskin remains after circumcision, boys less than 3 years of age may develop adhesions associated with a partially or completely covered glans. Epithelial cellular debris may collect underneath the remaining foreskin and present as firm pearly nodules. Based on his findings of adhesions in circumcised boys, Van Howe recommended that parents gently pull back any skin overlying the glans until a circumcised child is 15 to 18 months of age to prevent adhesions from developing.

Anecdotal reports cite lower complication rates and improved cosmetic results with the Mogen clamp, which is used by most Jewish mohels, but no research has been published comparing outcomes with the Mogen clamp, Plastibell, and Gomco devices. Such a study is currently ongoing at San Francisco General Hospital.

Because the foreskin appears to protect the glans and urethral meatus from ammoniacal injury during the diaper period, some have advocated delaying circumcision until the child is out of diapers. The later procedure, however, would have to be performed in the operating room by a urologist, with higher costs and potentially higher morbidity. Wiswell and colleagues

evaluated 476 boys circumcised after the newborn period and found complications in eight: excessive bleeding in three patients; malignant hyperthermia in two; and aspiration pneumonia, postoperative fever, and a large hematoma in one each.

is circumcision genital mutilation? Some people argue that circumcision should not be performed because it constitutes genital mutilation. The American Academy of Pediatrics released a statement on "female genital mutilation" in July 1998, encouraging its members to "decline performing all medically unnecessary procedures to alter female genitalia." The heightened world awareness of female genital mutilation has raised the question of whether male circumcision should also be considered genital mutilation. The fact that both procedures are often performed for religious reasons lends weight to the comparison.

Female genital mutilation partially or completely excises the clitoris, thus significantly decreasing or eliminating future sexual pleasure. The subsequent scarring often makes sexual intercourse difficult and painful, if not impossible. Since male circumcision does not contribute to such significant sexual difficulties, many argue that it does not fall into the category of mutilation. In addition, unlike ritual clitorectomies, newborn circumcisions are generally performed by physicians or mohels trained in the procedure.

Opponents of circumcision emphasize that there is no medical necessity for neonatal circumcision and that removing the protective covering of the sexually sensitive glans during childhood may lead to desensitization with subsequent decrease in sexual pleasure. These factors, some argue, support the contention that male circumcision does meet the criteria for mutilation. Some urge that the surgery be postponed until the patient can make his own informed decision.

How is circumcision performed?

Circumcision can be performed using the Gomco clamp (preferred by most obstetricians), the Plastibell, or the Mogen clamp. "Three ways to perform circumcision," When using the Gomco clamp or the Plastibell-the two instruments most often used in the US-a "dorsal slit" is made to separate the foreskin from the underlying glans. The bell of the Gomco clamp or the ring of the Plastibell is then placed over the glans and the foreskin is brought up over the bell or ring. The Gomco clamp compresses the foreskin between the metal clamp and bell, allowing it to be cut and removed with minimal bleeding. The Plastibell uses a surgical ligature, which is tied in a groove around the ring. The foreskin is excised and the ring with the suture left in place until avascular necrosis causes it to fall off.

The Mogen clamp is less cumbersome than the Gomco and Plastibell devices. The foreskin is stretched, brought through the clamp, and surgically excised. The beveled underedge of the clamp protects the glans from injury.

Whether the physician is using a Gomco clamp, Plastibell device, or Mogen clamp to perform circumcision, the penis can first be anesthetized using a dorsal penal nerve block. Wait at least five minutes for the anesthetic to take affect.

To administer the block, draw 0.7 mL of 1% lidocaine without epinephrine into a tuberculin syringe with a 27G needle. When the syringe is completely filled switch to a 30G needle. With the baby lying in a crib or on a pillow with his knees flexed and thighs abducted by an assistant, give him a sugared pacifier, prep the skin with a warm alcohol swab, and insert the needle I cm distal to the base of the penis at 10 o'clock and 2 o'clock. Advance it about 1 cm toward the penile abdominal junction with the tip just under the skin as shown below. Slowly inject 0.25 to 0.35 mL of lidocaine on each side of the penis, which will cause subcutaneous swelling at the needle tip.

Regardless of what method is used to perform circumcision, keep in mind that the cosmetic result can be improved by marking the location of the coronal sulcus on the penile shaft with a surgical marking pen before surgery. The coronal sulcus is easily visible beneath the foreskin.

Gomco clamp

The Gomco device consists of a metal bell and a clamp with a plate and yoke. Make a dorsal slit and retract the foreskin from the glans. Place the bell portion of the clamp over the glans, pull the foreskin over the bell through the plate and yoke of the clamp, and screw the clamp tightly onto the bell so that it holds the foreskin in place, as shown below. Excise the foreskin, remove the clamp and bell, and apply a Vaseline gauze dressing.

Plastibell

Make a dorsal slit and retract the foreskin from the glans. The Plastibell consists of grooved rings of various sizes with handles. Select the proper size ring and place it over the glans. Pull the foreskin over the edge of the ring so that the edge is at the coronal sulcus. Tie a silk suture tightly around the ring in the groove. Excise the foreskin at the edge of the ring, as shown below, and leave the ring in place. It usually falls off in three to seven days.

Mogen clamp

Attach a hemostat to the dorsal foreskin to indicate the portion to be removed. Pull the prepuce forward so that the foreskin stretches and the glans retracts slightly. Slide the clamp across the redundant foreskin and excise the foreskin (the beveled under edge of the clamp protects the glans). Retract the skin to free any remaining adhesions and apply a Vaseline gauze dressing.

What about pain control?

Physicians once believed that infants through 6 weeks of age could undergo circumcison without feeling pain, but it is now clear that the fetus feels pain as early as 20 weeks gestation. Infants who have experienced pain with circumcision appear to have increased responses to pain, such as the pain associated with immunizations. Whenever a circumcision is performed, therefore, the infant should receive appropriate analgesia that does not significantly increase the risk of the procedure.

Physicians using these methods must take care with drug dosages and administration to avoid the possible complications associated with systemic lidocaine, such as cardiac arrhythmias and seizures. A dose of 0.7 mL of 1% lidocaine-without epinephrine, which can cause dangerous side effects-can be used safely for DPNB.

Sucrose solution given orally on a pacifier, for example-has been found to decrease infant pain responses to heel sticks, immunizations, and circumcisions and certainly does not add to the risk of the circumcision procedure. Additional analgesia, such as oral acetaminophen suspension (10 to 15 mg/kg every six hours as needed) should also be considered.

When is circumcision contraindicated?

Any anatomic abnormality of the penis that might require later use of the foreskin in reconstructive surgery is an absolute contraindication to circumcision. The most common abnormality is hypospadias, which occurs in at least 1:235 male births but has recently been increasing in frequency. A complete exam of the genitalia, looking carefully along the ventral surface for second, third, or fourth degree hypospadias, is essential before performing circumcision.

Since the foreskin is not retractable, first degree hypospadias may not be noted until the dorsal slit has been made. Two physical findings, however, may alert the physician to the possibility of an underlying hypospadias. First, there is often an associated malformation of the prepuce, termed a "dorsal hood," which leaves the ventral surface of the glans exposed. A chordee, a band of fibrous tissue of corpus spongiosum along the ventral surface of the shaft, causing a curvature of the penis, may also, though not always, accompany hypospadias.

Infants with ambiguous Infants with ambiguous genitalia and those who are ill or significantly premature should not undergo circumcision. Excessive oozing of blood after the heel stick is another contraindication since it may indicate a hemorrhagic diathesis that could cause severe bleeding after circumcision.

Ideally, circumcision should NOT be performed in the first 24 hours after delivery, when the infant is still adjusting to extrauterine life and neonatal illness may not yet be apparent. Obviously, it should never be done without parental consent.

Is circumcision ever medically necessary? Is circumcision ever medically necessary? There are no medical indications for neonatal circumcision. As a child matures, however, he may develop phimosis, requiring surgical correction to relieve the obstruction. Paraphimosis, the persistent retraction of the foreskin along the shaft of the penis, causes lymphatic and venous obstruction, which can lead to arterial compromise. Surgical relief may be provided by a dorsal slit in the foreskin, so the patient can choose to have a circumcision or to have the dorsal slit sutured after the swelling has resolved.

Recurrent episodes of balanitis (inflammation of the glans) would be an indication for circumcision, but balanitis is rarely seen except in tropical countries or older patients with diabetes.

More common in the US is posthitis, inflammation of the outer layer of the foreskin, which is often caused by gram-negative bacteria and Candida albicans. Since the prepuce is composed of two layers, inflammation of the outer layer does not injure the underlying glans, which is protected by the inner layer. Thus, circumcision may not be indicated for patients who have recurring episodes of posthitis.

What care do uncircumcised boys need?

Parents of uncircumcised infants should be instructed NOT to attempt to retract the foreskin or use cotton swabs to clean underneath it. As Gairdner demonstrated in 1949, the clefts in the stratified squamous epithelium between the glans and foreskin develop gradually and very few newborns have retractable foreskins. By I year of age, 50% of boys have partially retractable foreskins. The foreskin is completely retractable in 80% of 3-year-old boys and 99% of 17-year-olds.

Normal bathing maintains cleanliness until the foreskin becomes easily retractable. Once it does, the parent, and later the child, can gently pull it back, wash the glans, and replace the foreskin over the glans.

In light of the natural development of the foreskin, the historic pediatric in-office procedure of "freeing adhesions" by passing a probe between glans and foreskin is medically unfounded. Moreover, it can cause pain, bleeding, and adhesions.

Phimosis has been inaccurately diagnosed in newborns simply because the foreskin is unretractable. The diagnosis should be reserved for boys whose preputial ring (the opening of the foreskin) has become stenosed by scarring. This obstructs voiding and can easily be recognized (often by a parent) by observing whether the foreskin "balloons" when the child urinates. "He puffs out when he pees" has been listed as a chief complaint by several of our patients' mothers.

True phimosis cannot develop until after the foreskin has separated from the glans, and thus cannot be present at birth. Oster's data on 1,968 uncircumcised Danish boys between 6 and 17 years of age who were examined annually for up to eight years demonstrated that uncircumcised boys have a small incidence of preputial adhesions and true phimosis, which appears to decrease normally with age.

An interesting recent observation is that 5- and 6-year-old boys who were circumcised for phimosis were noted to have lichen sclerosis et atrophicus on pathological review. Lichen sclerosis in prepubertal girls responds well to topical corticosteroid treatment. In 1995, Wright published a prospective study of ill boys referred for surgical treatment of phimosis who were instead treated with topical betamethasone cream for one month. Treatment was successful and circumcision was avoided in 80%. A more recent evaluation of the costs associated with treating phimosis showed topical steroid therapy using betamethasone 0.05% cream for four to six weeks to be so effective that the author recommends trying treatment with the cream before considering circumcision.

Is circumcision cost-effective?

Several authors have attempted to calculate the cost-benefit ratio of circumcision, but most have used inaccurate or old data. In 1987, approximately 1.95 million infant boys were born, and if they had all been circumcised at $100 per procedure, the total cost would have been $195 million. Based on these figures, Ross and Elder calculated the cost of preventing one urinary tract infection by circumcision at $2,000 to $8,000 and the cost of preventing one case of penile cancer at around $45,000.

A report from Ontario, Canada, estimated that the cost of universal neonatal circumcision would be twice the cost of medically indicated circumcisions performed in adult men. When the figures were adjusted for days lost from work and cost of hospitalization, however, neonatal circumcision was the more economical approach.

What role for the doctor?

Although Patel demonstrated in 1966 that physicians can influence parental decisions, newer studies reveal that parents choose circumcision for two major reasons, neither of which is affected by medical information. The strongest factor associated with neonatal circumcision was the circumcision status of the father. Another significant factor was religious beliefs. These influences notwithstanding, pediatricians should still provide families with accurate medical information to assist them in this important decision. Some of the questions a pediatrician might review with parents are discussed in the parent guide on the facing page.

The decision whether or not to circumcise a newborn son is especially important for parents, since it is usually the first decision that they must make together for another human being. When parents have a difficult time with this decision, it often indicates that they are having problems with communication in other areas, and pediatricians should be reluctant to step in with advice. It is far better to help parents recognize their communication difficulties and provide supportive resources than to promote a decision that the family may later regret.

The parent guide on circumcision may be photocopied and distributed to families in your practice without permission of the publisher.

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 Parent Handout:

If you have a boy, you will be asked if you want him circumcised. This is a matter you should think about very carefully before your baby is born. Circumcisions are usually done soon after birth. Many parents prefer to discuss their questions with the pediatrician well in advance, so that they have time to talk things over together and reach a decision both are comfortable with. Here are some of the questions parents ask:

What is circumcision?

Baby boys are born with a covering (the foreskin) over the sensitive end (glans) of the penis. A circumcision is an operation to remove this skin, leaving the end of the penis uncovered. The procedure takes about 15 minutes to perform. Newborn babies can feel pain, so most doctors use local anesthesia (medicine to decrease Pain). Ask your doctor about this. Even when local anesthesia is used, babies may feel some pain for a short time after the operation.

Why are circumcisions per-formed?

Circumcisions are done for many reasons. Moslems and Jews perform circumcisions for religious reasons. Other people choose to have their sons circumcised so that the baby will look like his father. There are many countries in the world where circumcision is almost never done.

Circumcision is not required by law and is not medically necessary. it doesn't affect future sexual enjoyment and won't prevent a man from becoming infected with most sexually transmitted diseases, although it may decrease the chances of acquiring some of these diseases.

Circumcision of newborn boys does help prevent cancer of the penis. The risk that an uncircumcised boy will develop cancer of the penis in later life is about I in 600. Careful attention to cleanliness may help decrease the risk in men who are uncircumcised. Circumcision also decreases the risk that a baby boy will develop a urinary tract infection during his first few years of life. Uncircumcised boys have a 1% risk of developing a urinary infection in the first 12 months of life; circumcised boys have a 0. 1% risk.

What are the risks of circumcision?

Because circumcision is an operation, complications may occur. One large study found that about two babies out of every 100 had a problem following surgery. The most common problems are: 0 Heavy bleeding, rarely requiring blood transfusion. Bleeding happens in I of 100 babies who are circumcised. 0 infection of the penis. This happens in I in 500 babies and, rarely, may require treating the baby with intravenous antibiotics. 0 The foreskin may be cut too short or left too long or may heal improperly. In rare cases, a second operation may be needed to correct the problem.

How do you keep the penis clean if your child is not circumcised? How do you keep the penis clean if your child is not circumcised? When you take your baby home, you do not need to do anything special. The foreskin of a newborn cannot be pulled back, and so just by bathing your baby, you are keeping the penis clean. After the baby is I year old, you can gently try to pull back the foreskin while you are bathing him. If the foreskin moves easily, wash the end of the penis and carefully place the foreskin back over the end of the penis. If you cannot pull the foreskin back, don't worry. This is perfectly normal and you can try again in a few months. As your child grows, the foreskin will gradually become retractable. just as you will teach your son to wash his hands and face, you can teach him to clean his penis.

It is your decision

Before you decide to have your son circumcised, it is important that you understand what the operation is and what the possible problems are. Please ask your nurse or doctor any questions you may have before you sign the consent form. Your nurse or doctor will show you how to care for your baby after the operation.