Other factors that frequently play a role in deciding about circumcision include religious and cultural ones. Ritual circumcision for religious purposes is practiced by Jews and Muslims. Cultural factors include tradition and personal preferences.

  Contraindications for circumcision are congenital or acquired penile abnormalities that require the preputial skin for generative repair. The most common of these conditions is hypospadias, where the opening of the urethra does not come out in the proper place at the head of the glans, but instead opens onto the underside of the penis. In this instance circumcision should be delayed until the age of 4-5, at which time the foreskin is used to reconstruct the urethra. Circumcision should also be delayed if the baby is premature or ill.

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Circumcision Methods

  Circumcision on newborns is usually performed either before they leave the hospital or in out-patient clinics a few days after birth. It should be noted that from the age of a few months, the procedure becomes more complicated and also more expensive.

  At the time the circumcision is to be performed, the infant is taken to the operating room where sterile conditions exist. Utilizing a Y-shaped plastic frame (called a "circumstraint"), the infant is first restrained to inhibit movement during the operation. The skin of the perineum and thighs are prepared with 10% povidone-iodine solution (Betadine) and the area is draped with sterile towels.

  The operation itself is normally performed using one of three possible methods methods [2]: the Gomco clamp (the most commonly used method), the Plastibell or the Mogen clamp.

Gomco clamp

  The Gomco device [3] consists of a metal bell and a clamp with a plate and yoke. After a dorsal slit is made, and the foreskin is seperated from the glans. The bell portion of the clamp is then placed over the glans and the foreskin is pulled over the bell through the plate and yoke of the clamp. The clamp is then screwed tightly onto the bell so that it holds the foreskin in place. The Gomco clamp compresses the foreskin between the metal clamp and bell, allowing it to be cut and removed with minimal bleeding. After the foreskin is excised (usually with a scalpel), the clamp and bell are removed. A vaseline gauze dressing is then applied.

Plastibell

  As in the case of the Gomco device, a dorsal slit is made first and the foreskin is separated from the glans. The Plastibell [4] consists of grooved rings of various sizes with handles. The proper size ring corresponding to the size of the glans is then selected and placed over the glans. The foreskin is pulled over the edge of the ring so that the edge is at the coronal sulcus. A silk surgical ligature is then 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 remnant of the plastibell usually falls off in three to seven days.

Mogen clamp

  When the Mogen clamp [5] [6] is used, the first step consists of attaching a hemostat to the dorsal foreskin to indicate the portion to be removed. The prepuce is then pulled forward so that the foreskin stretches and the glans retracts slightly. The clamp is then slided across the redundant foreskin which excises the foreskin (the beveled under edge of the clamp protects the glans from injury). The skin is then retracted to free any remaining adhesions. Finally a a Vaseline gauze dressing is applied.

Other Methods

  Other methods include amongst others the "Tara Klamp" and the use of lasers. For more information on these methods, and those mentioned above, see The principal methods of male circumcision, on the ICIRC site.

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Postoperative Care

  For the Gomco circumcision, a small piece of gauze with Vaseline (petroleum jelly) in the center is wrapped around the penis after circumcision. This should fall off after a few diaper changes. Do not re-apply gauze, only apply a large amount of Vaseline for a few days to assist with healing and comfort. If gauze has not fallen off within 24-48 hours after circumcision, soak with warm water or a wash cloth and carefully remove and apply petroleum jelly for 2-4 more days. Do not forcibly remove gauze. This dressing helps prevent any irritation to the site and the diaper from sticking to the skin. The penis can be washed with warm water and should be kept clean of stool.

  For a Plastibell circumcision, no dressings are required. The plastic ring will drop off five to eight days after circumcision. A dark brown or black ring of dead tissue encircling the plastic rim is normal and will fall off with the plastic ring. The result is a clean excision. Notify your doctor immediately if you notice any unusual swelling, active bleeding (usually appearing as a spot of blood larger than a quarter on the diaper) or foul odor, or if the plastic ring has not fallen off within eight days, or if the ring has slipped onto the shaft of the penis.

  The healing process usually takes about 7-10 days. Initially the tip of the penis will be bright red. As healing occurs, the redness will fade and the penis will regain its normal skin color from tip to base. During this time, the infant should not be immersed in water, but instead be cleansed using sponge baths. Parents should always seek advice from their physician before taking their infant home to make sure that they are fully informed and understand how to take care of their infant at home

Links to More Information

1. Care of child after newborn circumcision (Cincinatti Childrenīs Hospital Medical Center).
   http://www.cincinnatichildrens.com/family/pep/pep2018.asp
2. Infant, Child and Adolescant Healt Care, Ted Humphry, MD.
   http://www.northcoast.com/~thumphry/circ.html

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References

1. Urologic Surgery, ed. J.E. Fowler, Jr. Published by Little, Brown and Company.
Operative Obstetrics, 3rd Edition, R.G. Douglas and W.B. Stromm.

2. J.R. Holman, E.L. Lewis and R.L. Ringler, Neonatal circumcision techniques, Am Fam Physician 1995; 52:511-16.

3. For more information on the Gomco Clamp, see: D. Peleg and A. Steiner, The Gomco circumcision: common problems and solutions, Am Fam Physician 1998.

4. For more information on the Plastibell, see:
A.Y. al-Samarrai et al, A review of a Plastibell device in neonatal circumcision in 2000 cases, Surg Gynecol Obstet 1988; 167(4):341-3.

5. For more information on the Mogen Clamp, see: http://www.euroband.com/mogen.htm.

6. R. Reynolds, Use of the Mogen clamp for neonatal circumcision, Am Fam Physician 1996; 54:177-82.

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