Circumcision: An expert guide

In this informative article, highly respected consultant paediatric urologist and paediatric and neonatal surgeon Miss Marie-Klaire Farrugia gives a detailed guide to circumcision in babies and children, including the most common approaches used in circumcision procedures. The leading specialist also expertly explains when circumcision is indicated in babies and children and sheds light on the risks associated with the procedure.

How is circumcision performed?

There are several methods. Surgeons would normally perform the procedure surgically at all ages, without utilising clamps or gadgets. Community circumcisions are often performed using a Plastibel, which clamps the foreskin and takes about one week to fall off. Other clamps such as the Gomco are also in common use. Clamps are not indicated in older babies and children as they are more painful and less effective.

The procedure may be performed under a local anaesthetic (known as a penile block) in babies up to six weeks of age as they easily fall asleep and are less active. Penile blocks are less reliable in older babies. Once a child is over one year of age, a general anaesthetic is recommended. Of note, many community and religious circumcisions are performed without anaesthetic.

When is circumcision required?

Circumcision is indicated in cases of phimosis (inability to pull the foreskin back) which is non-responsive to medical treatment, such as mild steroid creams, or alternative techniques, such as a preputioplasty.

It is also indicated in cases of recurrent infection (known as balanitis) and a rare chronic inflammatory condition called balanitis xerotica obliterans (BXO) which causes severe scarring and sometimes obstruction to urine flow.

Circumcision reduces the risk of urinary tract infections (UTI’s) in children with underlying urological conditions such as kidney reflux or posterior urethral valves. Of note, the foreskin is always non-retractile in babies, and begins to detach from the glans as the boy gets older. There is no set age for foreskin retraction, and it only needs assessment if any of the issues above become evident.

At what age is circumcision typically performed?

Medical circumcisions can be performed at any age when there is a reason for it. Cultural and religious circumcisions are commonly performed in babies up to six weeks of age but this is a cultural or religious choice, rather than a medical indication.

How long will my baby need to recover?

The penis appears swollen and red and may develop a yellowish crust over the glans for one to two weeks. The pain resolves quite quickly but we would normally recommend regular paracetamol and/or ibuprofen for forty-eight hours. A local anaesthetic gel may also be helpful to relieve discomfort.

Are there any associated risks?

The main risk is bleeding, which can be very serious in small babies. This is why a circumcision should always be performed in a safe environment by an experienced practitioner who is able to deal with complications if they arise.

There is also a risk of infection, especially if it is performed in a non-sterile area. Up to five per cent of circumcised boys may develop meatal stenosis, a narrowing of the urethral opening, which affects urine flow. This condition would require a urethral dilatation. In specialist centres, we commonly see complications of community circumcisions, in particular bleeding, incomplete circumcisions resulting in severe scarring and misplaced Plastibels and clamps, causing glans, penile and scrotal injuries.

If you wish to schedule a consultation with Miss Farrugia, you can do so by visiting her Top Doctors profile.