Circumcision is often performed in the neonatal period, infancy, or childhood for cultural or religious reasons and is also performed after the newborn period, when phimosis, paraphimosis, balanoposthitis, or sexually transmitted diseases are more prevalent. Medical benefits to the boy circumcised in infancy include reduced urinary infections in infancy (3,4), decreased incidence of sexually transmitted disease (2,5,6), and marked reduction in the incidence of penile carcinoma (7), but these benefits must also be weighed against the risks of the procedure: bleeding, infection, and poor outcome (8).

The American Academy of Pediatrics (AAP) in 1999 (9) concluded that there were benefits from neonatal circumcision, but the benefits gained did not warrant universal routine circumcision. Conversely, there are some opponents who feel that neonatal circumcision is never warranted (10). The AAP updated their review and recommendations concerning male circumcision in 2012. After an extensive 5-year review, the task force concluded that circumcision is a well-tolerated procedure with infrequent complications when performed by trained professionals under sterile conditions using appropriate pain management. Further, they found that the benefits of circumcision for preventive health outweighed risks associated with the procedure (11).

There is now fair evidence from studies in Africa that circumcision is protective against heterosexually acquired HIV infections in men. The average efficacy of reducing the risk of acquiring HIV in these studies was about 60% (3). The inner preputial skin in the uncircumcised man has more Langerhans cells than does the glans, outer preputial skin, or penile shaft skin. Langerhans cells have densely concentrated CD4 receptors used by HIV to bind to these receptors and enter the body. The retraction and telescoping of the inner preputial skin during intercourse facilitates HIV entry into the body (2,6). Male circumcision is also protective against syphilis, chancroid, and human papilloma virus (HPV) infections with a 30% to 40% reduction in risk of HPV infection in circumcised men compared to uncircumcised men (3).

Because circumcision is so common, there are a number of misguided ideas and practices that have evolved in American medical practice leading to some circumcisions being done for reasons that are not completely medically sound. At birth, the prepuce, in over 90% of infants, is fused to the glans and is not retractable. As studied by Gairdner in 1949 (12), the foreskin progressively retracts on its own with age, so that many preschool boys will have nonretractable foreskins that will spontaneously become retractable at some time before puberty. Oster et al. (13) found that only 1% of 17-year-olds will not have retractable foreskins. It is not necessary for parents or physicians to retract the prepuce as retractability occurs with penile growth, erection, and smegma formation; the smegma that forms will generally spontaneously be discharged from under the prepuce and does not need to be removed.
Balanoposthitis is not a mandatory indication for circumcision in children as the prepuce in that area of the penis after such an episode will generally be separated from the glans and, once separated, should not produce recurrences of balanoposthitis. Occasional episodes of balanoposthitis should not be confused with the pathologic condition of balanitis xerotica obliterans (BXO). Forcible retraction of the prepuce causes the child pain and can produce paraphimosis or a dense cicatrix and perhaps subsequent BXO (Fig. 106.2).

Phimosis becomes pathologic when the opening of the foreskin develops a tight cicatrix often caused by BXO. According to Shankar and Rickwood (14), BXO represents the one absolute indication for circumcision. BXO is a chronic dermatologic condition of the prepuce and glans, analogous to lichen sclerosus et atrophicus, that can also involve the meatus and the anterior urethra, especially if the glans is extensively involved (15).

Most of the series of BXO in children have found that most of the patients affected are older boys, whose ages range from 5 to 15 years old (14,15,16,17). Previously, it was thought that the incidence of BXO was relatively rare in boys (range from 0.6% to 6%) (14,17), but recent reviews have shown that the BXO occurs more frequently in boys than previously reported. One recent study found BXO in a child who was only 2.5 years old, significantly younger than most reported cases (17). Circumcision alone is thought to be curative of BXO in 96% of cases, but it is concerning that in more obese boys, especially those with prominent pubic fat, more severe disease is prevalent and recurrent (17).

Observation, intermittent medical treatment for balanoposthitis, and dorsal slit are common alternatives to circumcision. Recently, the use of topical steroid creams, typically 0.1% triamcinolone or 0.05% betamethasone cream (18,19,20), applied to the preputial opening for about 4 to 8 weeks has successfully treated phimosis and obviates the need for circumcision in 85% to 87% of boys reported to be using the steroid preparations.

Paraphimosis occurs when the prepuce with a tight preputial orifice becomes trapped behind the glans penis when retracted with resultant swelling of the glans that prevents its reduction. If untreated, paraphimosis can lead to infection, significant penile edema, pain, and, occasionally, loss of penile tissue. The edema can often be reduced by injecting hyaluronidase into the edematous tissue, thereby allowing for easier reduction of the paraphimosis. Alternatively, multiple punctures of the edematous prepuce with a hypodermic needle (after a penile block or analgesia is given) can relieve the edema, especially if manual pressure is applied after the punctures are made (21). Many health care providers are hesitant to inject anything or make multiple punctures into a swollen and painful penis, so another easy and effective treatment to reduce the paraphimotic edema is to place granulated sugar over the swollen penile tissue, producing an osmotic gradient that pulls the fluid out of the edematous prepuce (Fig. 106.3). Application of ice or application of a temporary pressure dressing can also be used to reduce swelling. Paraphimosis is then reduced by grasping the penis between the second and third fingers of both hands and pulling the shaft skin distally while simultaneously applying pressure to the glans with both thumbs. If this maneuver is unsuccessful, a dorsal slit is necessary to open the phimotic constriction ring. Circumcision can be performed after the inflammation and edema have resolved but should not be attempted at the time that the acute paraphimosis is present.

Another alternative to a circumcision for pathologic phimosis is to perform a preputioplasty as either a triple incision procedure or a Y-V plasty on the dorsal surface of the prepuce. The triple incision involves three longitudinal incisions across the stenotic preputial ring down to the inner preputial layer with subsequent transverse closure of the three skin defects using absorbable suture which allows enlargement of the phimotic ring. The Y-V plasty can be performed by retracting the preputial skin to the corona (taking down the glanular adhesions to the prepuce), marking a “Y” incision from the inner preputial skin on the dorsum, incising the inner preputial skin on the marked “Y,” and advancing and closing the inner skin
as a “V” using absorbable sutures to enlarge the phimotic ring. Both of these methods allow the patient to remain uncircumcised, if this is preferred, but both methods may form scar bands requiring an eventual formal circumcision (21).

The goal of a circumcision is to remove an adequate amount of the prepuce such that the glans is exposed and balanoposthitis, phimosis, BXO, and paraphimosis are prevented. Too much or too little skin should not be removed, as the former can tether the penis and on occasion produce chordee, while the latter may produce continued risks of phimosis or paraphimosis.

All circumcisions should take place with an anesthetic: During the newborn period, local anesthesia with 1% lidocaine is generally used with or without topical anesthesia (EMLA 2.5% to 2.5% lidocaine-prilocaine). EMLA should be used cautiously in newborns, especially premature infants, as methemoglobinemia can occur. Other potential side effects from EMLA use include erythema, edema, or blister formation, and are more common in low birth weight infants who should probably have penile nerve blocks used instead (3). In older children and adolescents, general anesthesia is usually used. In adults and some adolescents, local anesthesia will often suffice. The penis is cleaned and draped and the foreskin retracted by taking down all the adhesions between the glans and the inner preputial skin. If a dense phimotic band prevents preputial retraction, a dorsal slit may be performed by placing one blade of a straight clamp inside the preputial opening in the dorsal midline (ensuring that the blade is not within the urethral meatus itself) and then placing the other blade on the outer skin. The clamp is closed and left in place for a few minutes, crushing the tissue and producing temporary hemostasis; the crushed area is then incised with scissors. Stretching the preputial opening gently with the hemostat clamp makes visualizing the urethral meatus easier and the dorsal slit may then be safely performed. Marking the coronal ridge (as seen through the shaft skin) in ink helps identify where to place the circumferential incision about the shaft skin. In the adult or older child, the proposed line of incision in the inner preputial sac is marked with ink about 3 to 4 mm below the coronal sulcus.

A common method of excising the prepuce, called a “sleeve technique,” is performed by incising the two previously marked lines of incision circumferentially about the penis and dividing the tissue between the layers. Hemostasis is secured generally with judicious use of either bipolar or monopolar cautery, although vessels can also be individually ligated. The skin and the inner preputial epithelium are then coapted with fine absorbable sutures (Fig. 106.4).

Alternatively, another circumcision method involves putting the prepuce on stretch after applying a hemostat to the dorsal and ventral aspects of the preputial orifice. The area of the shaft skin previously marked as overlying the coronal ridge is pulled forward beyond the tip of the glans and a straight clamp is applied, taking care to ensure that the glans is not included in the clamp. The prepuce distal to the clamp is amputated with a knife, the clamp is removed, hemostasis is secured, and the skin edges are coapted. It is especially
important in this method to take down all preputial adhesions first or excess inner preputial skin may be left behind that may cause a tightening of the excess skin on the penile shaft, similar to paraphimosis in an uncircumcised male.

With the advent of synthetic tissue adhesives such as Dermabond (2-octyl cyanoacrylate, Ethicon), circumcisions can be performed quickly and safely with good cosmetic results in most children with minimal surgical time, few if any sutures required, and minimal tissue handling, thereby decreasing postsurgical swelling and possibly postsurgical pain (22) (Fig. 106.5).

Timing of the surgical repair of urogenital anomalies with a general or local anesthetic is important with regard to feasibility of the surgery, safety of the surgery to the patient, and the psychological impact of the anomaly and surgery. Penile surgery and repair of concealed penis or scrotal conditions can be scheduled at a time that is appropriate for the infant and convenient for parents and physicians, as these conditions or anomalies do not generally cause any functional detriment to the patient, with the exception of megaprepuce that may cause infections or voiding difficulties if not corrected. Technically, from the surgeon’s point of view, outpatient surgical correction with a general anesthetic may contemplated as early as
the child’s fourth to sixth month, age adjusted for prematurity. Neonatal circumcision done with a local anesthetic may be performed in an office or nursery setting once the patient is clinically healthy, feeding well, and not known to have any bleeding or other problems that would preclude a circumcision in infancy.

Psychological aspects of surgery create a relative upper age time limit (24). The child’s anxiety concerning hospitalization, gender identity, separation from their parents and guardians, and subsequent sexual development generally increase with age as the child passes the age of 1 year. If genital surgery is performed before the child is 18 months of age, the patient will generally not remember the surgery nor associate the experience with any abnormality of his penis or scrotum. Therefore, optimal surgical timing for these patients is from generally best between 6 and 18 months. Parents need to determine what time during this window is best for their child and them. Most of these surgical repairs can usually be performed on an outpatient basis. Rarely will an overnight hospitalization be required. It is also easier for parents to care postoperatively for a boy who is younger and probably not ambulatory.