Topic Overview

What is circumcision?

Male circumcision is a surgery to remove the foreskin, a fold of skin that covers and protects the rounded tip of the penis. The foreskin provides sensation and lubrication for the penis. After the foreskin is removed, it can't be put back on again. See a picture of the penis before and after circumcision.

If circumcision is done, it's usually done soon after birth. In Canada, over the last several decades the percentage of baby boys who are circumcised has decreased. The circumcision rate varies from province to province. Worldwide, the rate of circumcision is much lower. Circumcision has both risks and benefits. The decision about whether to have a baby circumcised is often based on the personal preference of the parents.

Some older boys and men need circumcision to treat problems with the foreskin of the penis (such as phimosis or paraphimosis) or for swelling of the tip of the penis (balanitis).

This topic focuses on the circumcision of newborns.

How will you know if circumcision is right for your son?

It's up to you whether you have your baby circumcised or keep your son's penis natural. The Canadian Paediatric Society (CPS) does not recommend circumcision as a routine procedure for all newborn males, but there may be benefits for some.^{footnote 1} CPS also says that parents should be the ones to decide what is in the best interest of their child.

When you make this decision, it may help you to think about your personal and cultural preferences. For example, you may want to consider your religious and family traditions while you weigh the pros and cons of the surgery.

Circumcision is not just done in newborns. Keep in mind that your son can decide on his own later in life if he wants a circumcised penis.

What problems can occur if your son is circumcised?

Problems from circumcision are not common. If they occur, they are usually minor. The most common circumcision problems are:

• Bleeding.
• Blockage of the opening of the urethra (meatal stenosis).
• Infection of the circumcision site.
• Irritation of the exposed tip of the penis.

More serious problems are rare. They include damage to the opening of the urethra, heavy bleeding that requires stitches, severe infection, and scarring.

Who performs circumcisions?

Circumcisions usually are done by a pediatrician, obstetrician, family medicine doctor, surgeon, or urologist. Circumcisions that are performed for religious reasons are sometimes done by others trained in the procedure. For your baby's safety, it is best that the person doing the surgery is well trained, uses sterile techniques, and knows how to manage your baby's pain during and after the surgery.

What Happens During a Circumcision

Circumcision is usually done by a doctor at a clinic, in the hospital, or at an outpatient surgery centre. During the procedure:

• The baby is placed on a firm surface. Velcro straps are wrapped around the baby's arms and legs to keep him very still.
• The penis is cleaned.
• The surgical area is often numbed with a local anesthetic while the baby stays awake. If your baby is age 1 month or older, he or she may need general anesthesia. Talk with your doctor about the best way to control pain in your child.
• A sterile circumcision clamp or device is placed over the head of the penis. The three most common types of clamps used are the Gomco clamp, the Mogen clamp, and the Plastibell device. Each clamp has pros and cons, although differences between the clamps are often minor. Most doctors use the clamp they are most comfortable with.
• The foreskin is removed using a sterile scalpel or scissors.

What to Expect After Surgery

After the circumcision, the groin, penis, and scrotum may appear reddish brown because of the liquid used to clean the skin before surgery. The shaft of the penis where the skin was removed will look raw and slightly swollen.

Your baby will stay in the hospital or clinic for 2 to 4 hours after the procedure. His penis will be checked for bleeding, and the circumcision area may be covered with petroleum jelly and gauze.

You will likely take your baby home the same day he is circumcised. Some swelling around the penis is normal in the first few days after the surgery. Some slight bleeding may occur. If this happens, apply direct but gentle pressure to the area with a clean cloth or bandage for about 5 to 10 minutes.

After surgery, your baby will feel some pain. He may be fussy and have trouble sleeping.

If gauze was used, it will probably come off when your baby urinates. Follow your doctor's directions about whether to put clean gauze on your baby's penis or to leave gauze off. If you need to remove gauze from the penis, use warm water to soak the gauze and gently loosen it.

A thin yellow film will form over the circumcision site after surgery. This is part of the normal healing process and should go away in a few days. Although the penis is beginning to heal, it may look worse a few days after circumcision. The penis should look like it's getting better about a week after surgery.

Care after surgery

Here are some things you can do to help your baby feel more comfortable:

• Gently wash the penis with warm water after each diaper change. Don't use soap. Pat dry.
• Put petroleum jelly, such as Vaseline, on the circumcised area. Petroleum jelly keeps the scab from sticking to the diaper.
• Make sure diapers are fastened loosely so there is less pressure on the penis while it heals.
• Don't try to remove the film that forms on the penis. It will go away on its own.

Ask your doctor about giving your baby acetaminophen (such as Tylenol) for pain. Call your doctor anytime your baby seems to be in a lot of pain.

When to Call a Doctor

Your son's penis will be checked during routine checkups. But it is important to call your doctor if your baby has problems after circumcision.

Call your doctor right away if after circumcision:

• Your baby has a fever.
• You see signs of infection of the penis or around the circumcision site. Signs may include severe swelling and redness; a red streak on the shaft of the penis; or a thick, yellow discharge.
• Your baby bleeds more than the doctor said to expect or has a bloodstained area larger than the size of a quarter on his diaper or on the circumcision site dressing.
• Your baby is very fussy or cranky, has a high-pitched cry, or refuses to eat.
• Your baby has not passed urine within 12 hours after the circumcision was completed.

If a Plastibell device was used for the circumcision, call your doctor if the ring has not fallen off after 10 to 12 days.

Who to see

Doctors who usually perform circumcisions on infants include:

• Pediatricians.
• Obstetricians.
• Family doctors.
• Urologists.
• Surgeons.

A urologist or surgeon normally will do circumcisions on older infants, children, and adults.

Why It May Be Done

Some parents may make the decision about circumcision based on religious and family traditions, personal preferences, or the social norms of their communities. Often these cultural reasons affect the decision more than the medical risks and benefits of circumcision.

The Canadian Paediatric Society (CPS) does not recommend circumcision as a routine procedure for all newborn males, but there may be benefits for some.^{footnote 2}

Health benefits of circumcision include being less likely to get urinary tract infections (UTIs) or sexually transmitted infections (STIs). For example, in a baby's first year of life, UTIs happen less often in circumcised boys than in boys who are not circumcised. But UTIs are not common.

There may be reasons later in life when your son may need a circumcision. A boy or man may have problems retracting the foreskin or may have swelling of the foreskin that requires circumcision.

• Circumcision: Should I Keep My Son's Penis Natural?

Risks

All surgical procedures have risks. Problems after circumcision are not common. Minor problems are short-term and may include:

• Oozing or slight bleeding from the surgical site.
• Infection of the circumcision site or at the opening to the urethra.
• Irritation of the exposed tip of the penis (glans) as a result of contact with stool or urine.

Long-term problems can include:

• Damage to the opening of the urethra, which leads from the bladder to the tip of the penis (meatal stenosis).
• Scarring of the penis from infection or surgical error. For example:
  • The entire foreskin may not be removed, leaving portions of it attached to the penis (skin bridge). This may cause pain during erection.
  • Scar tissue can grow outward toward the tip of the penis from the cut edge of the foreskin. Repeat surgery on the penis may be required to improve appearance or to allow normal passage of urine if the opening from the bladder has been blocked by this scar tissue.
  • The outer skin layer (or layers) of the penis may be removed accidentally.
  • An opening that is too small for the foreskin to retract over the penis (phimosis) can happen if too little foreskin is removed.

Major problems are very rare but can include:

• The removal of more skin from the penis than the doctor intended.
• Too much bleeding. Stitches may be needed to stop the bleeding.
• Serious, life-threatening bacterial infection.
• Partial or full removal (amputation) of the tip of the penis. (This is extremely rare.)

What to Think About

Your values

As a parent, you will decide whether you want to keep your son's penis natural or want him to be circumcised. This decision often is a personal one based on your own values and religious or cultural beliefs.

It's a good idea to think about your decision before your baby is born. If you wait, the excitement and fatigue of the delivery can affect your ability to carefully consider the benefits and risks of each choice.

• Circumcision: Should I Keep My Son's Penis Natural?

Your son's values

Circumcision is not just done in newborns. Keep in mind that your son can decide on his own later in life if he wants a circumcised penis.

Circumcision and STIs

Some studies have shown that circumcised men are a little less likely than men who have not been circumcised to get or spread a sexually transmitted infection (STI), including HIV.

Any man, especially if he has high-risk sex, can get STIs, including HIV. The best way to prevent STIs is to teach people about risk factors and the importance of avoiding high-risk sex.

Other concerns

Keeping your son's penis clean may help prevent infection and other problems. It's important to keep your son's penis clean whether he has been circumcised or not. When cleaning a natural (uncircumcised) penis, be careful not to force the foreskin to retract.

If you decide that you would like to have your baby circumcised, talk with your doctor about concerns you may have about pain and your preferences for anesthesia. Ask your doctor about giving your baby acetaminophen (such as Tylenol) for pain relief after surgery.

When is circumcision not done?

Your doctor may not do circumcision if your baby has a medical condition that makes him more likely to have problems from the surgery, such as:

• Your baby is sick or unstable (such as not eating well, having trouble passing urine or stool, or having a hard time maintaining his body temperature).
• Your baby has an abnormality of the penis, such as having the opening of the urethra on the side of the penis shaft instead of on the tip of his penis (hypospadias or epispadias). Your baby may need to have an intact foreskin so that this problem can be fixed with surgery when he is older.
• Your baby has swelling or protrusion of the spinal cord (myelomeningocele or spina bifida).
• Your baby has an abnormal opening of the rectum (anus).
• Your baby has a family history of bleeding problems.
• Your baby was born early and is not yet able to go home.