Neonatal Circumcision

Aka: Neonatal Circumcision, Newborn Circumcision, Male Circumcision, Circumcision, Gomco Clamp, Mogen Clamp, Plastibell

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II. Indications

  1. Routine procedure offered to parents in U.S.
    1. Supported by AAP as benefits outweigh risks
    2. Decision deferred to parental preference
    3. (2012) Pediatrics 130(3): 585-6 [PubMed]
  2. Jewish Tradition

III. Contraindications

  1. Abnormal appearing penis
    1. Do NOT start Circumcision if the penis appears abnormal
    2. Foreskin should be complete and penis should be straight
    3. Penile glans should be adequate size to at least fit within the Gomco 1.1 cm clamp
  2. Chordee (ventral penile curvature)
  3. Hypospadias (abnormal ventral placement of the Urethral opening)
    1. Typically repaired with foreskin
  4. Buried penis (penis retracts into fat pad)
    1. Circumcision risks entrapping glans penis with post-procedure swelling
  5. Bleeding Disorder (e.g. Hemophilia, Family History of Bleeding Disorders)
    1. Evaluate coagulation tests if parents have refused Vitamin K IM (oral is not sufficient)
  6. Age < 12 to 18 hours
    1. Perform age <28 days (<2 to 3 months for former NICU or IUGR patients)
  7. Weight >13 lbs (5.9 kg)
    1. More difficult to perform with standard Circumcision equipment
  8. Concurrent illness
    1. NICU admission
    2. Significant Neonatal Jaundice

IV. Efficacy: Benefits

  1. Circumcision is an elective procedure
  2. Potential benefits
    1. Prevention of Urinary Tract Infections
    2. Sexually Transmitted Infection Prevention
    3. Penile Cancer Prevention

V. Technique: Standard Starting Approach

  1. Precautions
    1. Before starting, confirm that the penis appears normal (do NOT start if abnormal, see above)
    2. Once started with a normal appearing penis, Circumcision should be completed
      1. Abnormalities found during cicumcision (esp. Distal Hypospadias) can be repaired without grafts later
      2. Chalmers (2014) J Pediatr 164(5):1171-4 +PMID: 24534572 [PubMed]
      3. Zamilpa (2017) Clin Pediatr 56(2):157-61 +PMID: 27162177 [PubMed]
  2. Preparation
    1. Infant placed supine in restaint that secures body, legs and arms
    2. Clean, prepare and drape the area
      1. Apply antiseptic (e.g. Hibiclens or Betadine)
  3. Anesthesia
    1. See Penile Anesthesia
    2. Oral sucrose on Pacifier
      1. Liu (2017) Medicine 96(6): e6108 [PubMed]
    3. Dorsal Penile Nerve Block
      1. Most common Circumcision Anesthesia
      2. More effective than topical Lidocaine/Prilocaine
    4. References
      1. Brady-Fryer (2004) Cochrane Database Syst Rev (4):CD004217 +PMID:15495086 [PubMed]
  4. Initial Hemostat (clamp) Use
    1. Apply two hemostats, one at 10:00 and the other at 2:00 of the distal foreskin edge (allows control)
    2. Use a third, curved hemostat (clamp) to break adhesions between foreskin and glans
      1. Hold the two hemostats already applied in the non-dominant hand
      2. Carefully insert the hemostat in the space between the foreskin and glans at 12:00
        1. Keep the curve toward the foreskin and away from the glans and Urethra
        2. Avoid creating a false passage inside the foreskin wall
      3. Gently spread the curved hemostat open and closed
        1. Rotate the hemostat position around the outside of the entire glans
        2. Avoid spreading hemostat at the ventral frenulum, 6:00 position (risk of bleeding)
  5. Circumcision Specific Methods (choose one, see techniques below)
    1. Gomco Clamp
    2. Mogen Clamp
    3. Plastibell
  6. Dressing
    1. Wash off antiseptic (especially Povidone-Iodine or Betadine)
    2. Apply petroleum jelly and gauze to the wound (prevents sticking to diaper)
    3. Reapply petroleum jelly with each diaper change
  7. Home care
    1. Baths are allowed starting on the next day
    2. Apply petrolatum (vaseline) with every diaper change for 2 weeks
    3. Retract fat pad starting on day 3 to prevent adhesions
      1. Ensure Head of penis can be seen completely, circumferentially
  8. Followup
    1. Patients may be discharged before urinating
    2. Recheck wound in 3-5 days (often coincides with weight check or home visit)
    3. Plastibell typically falls off in 5-7 days

VI. Technique: Gomco Clamp

  1. Follow initial measures above (including lysis of adhesions)
  2. Crush a section of foreskin at 12:00 to prevent bleeding when cut
    1. Apply straight hemostat to foreskin 12:00 position
    2. Crush line one third to one half of the length of the foreskin
  3. Cut the foreskin along the crush line (dorsal slit)
    1. Insert the blunt end of scissors within the foreskin along the crush line
  4. Retract the foreskin
    1. Break any remaining adhesions between the foreskin and glans
  5. Select, apply and secure a bell over the glans penis
    1. Bells are 1.1 to 1.6 cm (1.3 cm is by far most common, 1.6 cm is rare)
    2. Apply over the glans, so the bell rests between the foreskin and glans
    3. Secure the foreskin around the bell with safety pin (or hemostat)
  6. Secure bell to base plate
    1. Remove the hemostats at 10:00 and 2:00
    2. Pull the safety pin, foreskin and top of the bell through the base plate hole
    3. Gently pull the foreskin up through through the hole, over the bell, so it is taught
    4. The end of the dorsal slit should be visible on the foreskin that has been pulled through the base hole
    5. Slide the bell top into the forked holder attached to the base plate
    6. Palpate the sides of the bell to confirm the glans is completely enclosed by the bell
    7. Tighten the base plate screw while ensuring the bell remains aligned in the base plate hole
  7. Cut the foreskin
    1. Using a scalpel (e.g. #15 blade), cut the foreskin by applying the blade against the bell
    2. Make the cut at the position where the bell and foreskin meet the hole in the base plate
    3. Leave the clamp in place for at least 5 minutes (decreases risk of bleeding)
  8. Remove the Gomco Clamp
    1. Unscrew the base clamp enough to free the bell
    2. Remove the bell from within the base plate hole
    3. Using moistened gauze, gently separate the clamp from the glans
  9. Instructional Video
    1. https://vimeo.com/74547358

VII. Technique: Mogen Clamp

  1. Follow initial measures above (including lysis of adhesions)
  2. Precautions
    1. Mogen Clamp is at increased risk of glans amputation or Laceration (Exercise caution!)
  3. Apply the Mogen Clamp
    1. Push the glans down within the foreskin
    2. Reapply the two hemostats, one now at 9:00 and the other at 3:00 of the distal foreskin edge
    3. Pull the foreskin through a narrowly opened (3 mm) Mogen Clamp with concave side downward
  4. Close the Mogen Clamp
    1. First, it is critical to ensure that the top of the penis (glans) is not caught in the clamp
    2. Unlike other techniques, Mogen Clamp does NOT use a Bell to protect the glans penis
    3. Close and tighten the clamp, when certain only the foreskin is within the Mogen Clamp
  5. Cut the foreskin
    1. Using a scalpel (e.g. #15 blade), cut the foreskin by applying the blade against the floor of the clamp
    2. Leave the clamp in place for at least 90 seconds; consider up to 5 minutes (decreases risk of bleeding)
  6. Remove the clamp
    1. Remove the clamp
    2. Gently use a small probe along the inner foreskin edge to separate it from the glans
    3. Exercise caution to prevent entering the Urethra with the probe
  7. Instructional Video (Stanford)
    1. https://med.stanford.edu/newborns/professional-education/circumcision/mogen-clamp-technique.html

VIII. Technique: Plastibell

  1. Follow initial measures above (including lysis of adhesions)
  2. Crush a section of foreskin at 12:00 to prevent bleeding when cut
    1. Apply straight hemostat to foreskin 12:00 position
    2. Crush line one third to one half the length of the foreskin
  3. Cut the foreskin along the crush line (dorsal slit)
    1. Insert the blunt end of scissors within the foreskin along the crush line
  4. Retract the foreskin
    1. Break any remaining adhesions between the foreskin and glans
  5. Select, apply and secure a bell over the glans penis
    1. Bells are 1.1 to 1.7 cm (1.3 cm is most common)
    2. Apply over the glans, so the bell rests between the foreskin and glans
    3. Secure the foreskin around the bell with hemostat
  6. Pull the foreskin over the bell
    1. Gently pull the foreskin up over the bell, so it is taught
    2. The end of the dorsal slit should be visible on the foreskin that has been pulled over the bell
    3. Palpate the sides of the bell to confirm the glans is completely enclosed by the bell
    4. Secure the foreskin position by applying a transverse clamp across the top of the bell
  7. Tie string against bell
    1. Palpate the groove on the bell and position a tie over the top of this groove
    2. Carefully close the string loop and ensure that it is completely within the groove (critical)
    3. Tie the enclosed string very tightly against the bell
  8. Cut the foreskin
    1. Using a scissors, cut the excess foreskin, distal to the tie, exposing the top of the bell
    2. Confirm no bleeding from the cut edges
      1. Observe for 60-90 seconds before breaking the handle in the next step
  9. Break off the plastic handle
    1. Plastic ring remains in place, secured by string tie within groove
  10. Instructional Video
    1. https://vimeopro.com/hpmi/plastibell-circumcision/video/27771734

IX. Complications: Miscellaneous

  1. Overall Complication Rates
    1. Complications uncommon when performed in the first few days of life (4 per 1000 procedures)
    2. Complication rates increase 10-20 fold for older boys and men
  2. Granulation tissue
    1. May appear as yellow adherent scab
    2. Common, normal healing response following Circumcision
  3. Pseudo-redundant foreskin
    1. Infant gains weight and becomes a chubby, including the fat pad at the base of the penis
    2. Fat pad displaces skin distally
    3. Prepare parents, and reassure that this resolves as the child grows and penis grows
    4. Pediatric urologists rarely see teens who need revision at Puberty
  4. Redundant foreskin (too little foreskin removed or asymmetric removal)
    1. Differentiate from pseudo-redundant foreskin (as above)
    2. Risk of Phimosis or poor cosmetic result
    3. Asymmetric skin removal may result in penile curvature
    4. Skin Tags may result from a slipped Plastibell
  5. Skin separation (esp. vental surface)
    1. Apply frequent petrolatum (vaseline) until heals
  6. Excessive foreskin removed
    1. Presents as denuded area of the distal penile shaft below the glans penis
    2. Typically heals spontaneously by epithelialization without complication
    3. Ensure Hemostasis (see below)
    4. Apply Antibiotic ointment with every diaper change until heals
  7. Epidermal Cyst
    1. Clear cyst of involuted skin often on the dorsum
    2. Surgically repaired by pediatric urology (recurrs if cyst ruptures)
  8. Penile adhesions
    1. Nonvascularized adhesions
      1. Typically mild and resolve spontaneously
      2. Gently retract shaft skin with diaper changes
      3. Apply ointment to raw regions
      4. Avoid forceful breaking of adhesions
      5. Refer to pediatric urology for refractory adhesions
        1. Typical non-surgical, office-based lysis under Topical Anesthetic)
    2. Vascularized adhesions
      1. Do not resolve spontaneously
      2. Refer to pediatric urology
        1. Most (75%) repaired in office-based lysis under Topical Anesthetic)
  9. Infection (uncommon)
  10. Glans Injury (uncommon)
    1. Increased risk with mogan clamp
  11. Urethral meatal stenosis
    1. Reapply petroleum jelly with each diaper change after Circumcision to prevent meatal stenosis

X. Complications: Bleeding

  1. Management: Venous (dark blood, slow ooze, areas of skin separation)
    1. Hold constant pressure for >5 minutes with moist gauze (or wet wipe)
    2. Apply 1:1000 Epinephrine topically
        1. Apply Gelfoam wrap (speeds coagulation)
  2. Management: Arterial (bright red, pumpers)
    1. Clamp Vessel (if visualized) with hemostat
    2. Cautery pen for focal coagulation
  3. Management: Refractory bleeding
    1. Consult Urology
    2. Suture bleeding site
      1. Place superficial figure of eight Suture
      2. Exercise caution (especially on ventral surface) to avoid Urethral Trauma
        1. Suturing too deep can result in a urethrocutaneous fistula
    3. Consider blood dyscrasia
      1. Observe for Petechiae, Hematuria or Bright Red Blood Per Rectum
      2. Significant life-threatening bleeding may occur with conditions such as Hemophilia
        1. Circumcision related bleeding may be the initial presentation of Hemophilia
  4. Prevention of bleeding
    1. See Contraindications as above regarding Bleeding Disorders and other risks
    2. Avoid excessive manipulation of the penile frenulum (volar band at base of glans)
    3. Leave foreskin clamp (e.g. Gomco Clamp) on for 5 minutes during Circumcision
    4. Apply copious vaseline to Vaseline Gauze and leave applied to cut foreskin edge for 24 hours

XI. Resources

  1. Stanford Newborn Nursery
    1. http://newborns.stanford.edu/CircComplications.html

XII. References

  1. Granberg (2024) Mayo Clinic Pediatric Days, lecture attended 1/18/2024
  2. Omole (2020) Am Fam Physician 101(11):680-5 [PubMed]

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