Hello, I’m Jennifer Singer. Welcome to our webinar today on pediatric circumcision. I am an associate clinical professor in the Department of Urology at UCLA, specializing in pediatric urology. I’m also a health informaticist in our health informatics department. Today, we’ll be talking about circumcisions pros/cons, complications, and more. Please write your questions down, send them to #UCLAMDChat, and we’ll answer them at the end of the discussion. So, just to start. What is a circumcision? Well, it’s the surgical procedure to remove the foreskin, and it has tended traditionally to be cultural and religious, with ceremonial background dating back to Jewish and Muslim tradition. It is generally an elective procedure, although there are medical needs and indications for it, and we can see in this depiction what an uncircumcised phallus or penis looks like with the foreskin covering the head of the penis, and over here we see what a penis looks like after it’s been circumsized with the head of the penis being exposed. Just as a cross-section, we can see that an uncircumcised penis– sorry, we’re advancing– has the foreskin over the head of the penis whereas a circumcised penis is completely uncovered. So what information do we have that has been sort of vetted about from the pediatric society about when to do circumcisions, whether or not they’re indicated well. In 1999, the American Academy of Pediatrics issued its first statement about the use of circumcision in that it stated that problems with the penis, such as irritation, can occur whether a child is circumcised or uncircumcised, that there is no difference in hygiene if the penis is properly cared for, that it is unclear if circumcision changes a man’s sexual experience, that circumcision can reduce the risks of urinary tract infections in boys under a year of age, and that circumcision can provide a protection against the risk of penis cancer in developed countries. Finally, in 2007, the American Academy of Pediatrics decided to relook at the issue of circumcision and put together a task force to review the risks and benefits of newborn circumcision. Their results were published in the 2012 Journal of American Academy of Pediatrics, where we see that the evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to the procedure for families who choose to pursue it. Specific benefits that they identified included the prevention of urinary tract infections, the prevention of penis cancer in underdeveloped countries, and a reduced transmission of some sexually transmitted diseases like HIV. Further, they noted that although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits are sufficient to justify access to the procedure for families who choose to pursue it. Ultimately, parents should decide whether circumcision is in the best interest of their child. They will need to weigh their own medical information against their own religious, ethical, and cultural beliefs. Further, they stated that the medical benefits alone may not outweigh these other considerations for individual families. So if a family decides to pursue a newborn circumcision, when should it be done? Well, in general, newborn circumcision should be done after 12 to 24 hours of life to confirm the stability of the infant, that it should also be done prior to four to six weeks of life, and when the infant is less than 12 pounds older or more heavy than this, the child’s phallus becomes more mature. There’s an increase in vascularity of the penis and increased risk of bleeding complications. Subsequently, after about 6 weeks, or 12 pounds, we generally tend to wait until the child is over 3 months of age, at which time the risks of general anesthesia decline. There are some traditions that suggest performing circumcision later in life, for example, in Filipino culture, circumcision tends to be performed at around 8 or 9 years of age, so this is very much directed by preference, family preference, and tradition. Certainly, whenever indicated clinically, we do circumcisions at any time when a child needs it for a medical indication. So what are the different methods of performing newborn and child circumcision? Well, the clamp techniques are what we use for newborn circumcisions, and the freehand technique is what we use when a child is a little bit older. The clamp techniques are generally used, again as we said, when the child is 4 to 6 weeks of age, or under 12 pounds. The freehand technique is generally performed in the operating room for small children or boys. In adults we can perform the freehand technique in the clinic under local anesthesia, but for children it requires general anesthesia. However, the freehand technique tends to be more precise and accurate, with lower complication rates, and we usually wait until about 3 months of gestational age for the early anesthetic complications to be behind us. So this is a depiction of what the freehand, or most commonly, sleeve technique looks like. This would be, again, performed in the operating room under general anesthesia. The penis is depicted here with an incision that’s marked on two levels, one here at the end of the penis and one more towards the bottom of the penis. A sleeve of foreskin is then removed, and then at the end, we sew the edges back together, and this is the final product of a circumcised penis. This just depicts removing of that sleeve and then sewing the edges back together. But newborn circumcision is a different story. In newborn circumcision, we tend to perform these procedures either in the clinic or in the labor and delivery suite. This is a restraining board on which we place the infant, and then they get placed in these Velcro restraints so as not to move during the procedure. There are many different types of clamps that we can select. In general, the most common types of clamps are the Gomco clamp, the Plastibell clamp, the Mogen clamp, and there are some others that we use less frequently. There tends to be no difference in overall complications based on the clamp type that is used; however there is a higher bleeding risk with a Gamco clamp. The Gamco is my own personal preference. There is a risk of higher site injuries and serious complications with the Plastibell clamp, and the Mogen clamp tends to have higher injury rate to the tip of the penis, the tip of the penis that we call the glans penis. This is a depiction of what the different types of clamps look like. This is an illustration. Basically, on the left side of the screen we see the Mogen clamp, In the middle of the screen we see the Plastibell clamp, and on the far right we see the Gamco clamp, again the one that I tend to use. This is how the procedure is depicted in illustrative form, and on the top we see the Gamco clamp. The bell is placed over the foreskin. After that, the arm is inserted and placed in position, and the nut is screwed down, and we removed the foreskin as depicted here. The Mogen Clamp is a little bit more direct in that the foreskin is drawn up into the Mogen clamp. It is clamped down, and the foreskin is then excised. And with the Plastibell clamp, the little plastic bell is placed over the glans penis, and then a tie is used to essentially constrict the area of the foreskin that will eventually fall off, and we’ll show you that. So, just starting with the Gamco clamp. This is named after–it’s the company that produces it, Gold Goldstein Medical Company. The Gamco Clamp is depicted here again. This is an apparatus that is entirely put together. This is the bell of the clamp, this is the arm of the clamp, and this is the nut of the clamp, and again, an illustration over here of how the clamp procedure is performed. First, we make an incision in the foreskin, place the bell over the foreskin, engage the arm, screw the nut down to constrict the penis so that there’s no bleeding. We excise the foreskin, and then finally we have this final product of a circumcised penis. This is a live depiction of what that looks like basically, here. We see the foreskin that’s been drawn up into the clamp over the bell. The arm is being connected to the bell. It then gets screwed down. We excise the sleeve of foreskin, and the final product is the circumcised penis. The Plastibell clamp is depicted here. This is a plastic apparatus that is essentially made of the plastic arm and the bell that is inserted over the head of the penis. And then we use a suture to constrict down where the ring remains on the penis after the bell is removed. We excise the foreskin, the ring is remaining in place with the suture, and a few days after this is placed, about 3 or 4 days, this plastic ring will fall off at home, and there’s a final circumcised product and that in that capacity. Again, a live illustration. The foreskin is drawn up over the plastic bell, the ring is then engaged in position with the suture placed over the ring at the position where we want to produce the circumcision site, the foreskin is excised, and then the child would go home with a plastic ring still in position that’s sutured in place. That suture constricts the skin so there’s no bleeding, and the Plastibell and the little edge of skin will fall off later, and we have a circumcised penis. So the Mogen clamp tends to be the clamp that is used most in the Jewish tradition for breast procedures. In Hebrew, Mogen means shield, so the Mogen clamp is depicted here. Essentially after the adhesions inside the foreskin are reduced, the foreskin is drawn up into the clamp, the clamp is compressed down, and the foreskin is excised, and it is a much quicker procedure. But again, there are some increased risk with Injuries to the head of the penis, as there’s no bell that is protecting the head of the penis, or the glans penis. So now what are the pros of circumcision? Well, we do know, again, this was an AAP statement that there is a reduced urinary infection rate in boys under 1 year of age if they have been circumcised. Further, there’s a reduced urinary infection rate in boys with congenital neurologic abnormalities that predispose them to infection, things like vesicle ureteral reflux or posterior urethral valves. Some believe that it’s easier to keep the penis clean; however, this is debatable and really dependent on teaching. Proper Hygiene circumcision has been shown to reduce the risk of some sexually transmitted diseases, like HPV or HIV. In underdeveloped countries, circumcision reduces the risk of penile cancer, and certainly there are potential that circumcision decreases the risk of foreskin troubles like balanoopthisis, phimosis and paraphimosis, all different disorders of the foreskin. Further pros to the idea of circumcision include evidence that predicts that a decline in circumcision rates will actually increase health care costs in the long term due to complications in the uncircumcised patient. And another important consideration is that there are good studies that show that adult men who have been circumcised do not report worsening in their sexual function, and some even report an improvement after circumcision. So what, on the other hand, are the cons about circumcision? Well, there are certainly risks of complications of any procedure. There’s an estimated 10% of men who will go on to require circumcision as adults if they had not had them in childhood due to medical indications or personal preference. Some people believe that there is a role of the foreskin, that it is protective against glans injury, abrasion, or chronic irritation. We have some good evidence from the AAP that the rate of revision has increased 119% since 2004, although the reasons for this are not currently clear, and finally, there are plenty of discussions about the potential psychological effects of individuals who have been circumcised, with concern that a male loses his right to choose for himself what he wants to do with his own genitals. A good study that documented a meta-analysis of 16 prospective well-done studies show that the complication rates of circumcision range anywhere from 0.2% to 14%. The most common are bleeding and infection. Next most common is meatal stenosis, which we’ll show you in a few slides. The risk of metal stenosis can be up to 7%. There are fairly common concerns about unsatisfactory cosmetic outcomes, such that if too much foreskin is removed, there is a buried appearance of the phallus, and if too little foreskin is removed, the foreskin appears uncircumcised. There are rare but potential reactions to drugs for anesthesia. There is the concern, although this is not validated, about the decrease of penile sensation after circumcision. Finally, we’ve talked about glands injuries, including partial amputation, amputation, and glans necrosis, which we’ll show in a few slides, and additional concerns about urethrocutaneous fistula. These are essentially openings along the urethra that can be caused by compression from the ring of the Plastibell, and we’ll show you those as well. So what are the risk factors that increase potential for complications? Well, any infant with a bleeding disorder is at increased risk, or an infant from a family with a history of a bleeding disorder. Of course, oftentimes we can’t tell in a 2 or 3-day-old infant if they have a risk of bleeding disorder, but certainly we ask about the family history to reduce any potential risks of bleeding during the procedure. Infants whose mothers were taking blood thinners during pregnancy may have an increased risk in the early days after delivery. Infants with abnormalities of their penises like hypospadias, which is an abnormal opening of the urethral meatus on the undersurface of the penis, penile webbing, where the penis appears as a pyramid from the skin attaching to the scrotum, or significant suprapubic fat pad, where there’s a great deal of fat in the suprapubic area that can cause distortion of the foreskin. Premature infants and infants with unresolved jaundice also have an increased risk of complications. So I wanted to show you some pictures of complications from circumcision, so you have an understanding of what we’ve been talking about. These are complications that can occur from any clamp procedure. This is called meatel stenosis, where the urinary opening has narrowed and scarred down over time, that can occur in up to 7% of circumcised boys. In the middle here, we see excessive skin removal, so too much skin has been removed, and the phallus looks buried, almost as if you cannot see the phallus, and over here, we see what it looks like to have redundant foreskin, almost appearing like an uncircumcised phallus. This problem is easier for us to manage than this problem because we can do revision circumcisions fairly easily to remove the redundant foreskin. However, once you take it off, you can’t give it, so if we have excessive removal, that oftentimes requires significant plastic surgical repair. These are also common complications of circumcision from all different types. These are called penile adhesions, where the foreskin will become adherent to the glans penis. This can be avoided by proper care by pushing back on the foreskin the early time period. After the circumcision is performed, this is dependent on proper teaching of the family in the post procedure time period. Penile skin bridges are also fairly common. This is where the foreskin will form a bridge to the head of the penis this can cause some tethering and pain with erection. These are very infrequent complications of circumcision, so these are very rare but potential complications, and they’re more common with the Plastibell technique. Over here on the left, we see what can happen if the ring migrates proximally. The child can lose the entire foreskin around the penis, and this is a very significant complication, of course. This panel shows us what partial glans necrosis would appear like, so the ring was a little too tight and the tip of the penis lost its blood supply. This is what a urethrocutaneous fistula might look like if the ring was too tight and eroded through the urethra. We can see a second opening where a urine stream is flowing both here and out the tip of the penis. And then finally, full glands amputation, a serious complication of circumcision where the glans is entirely amputated. This is more common with a Mogen clamp. It also can occur with any of the procedures that we do. So what are some other considerations about circumcision? Well, insurance carriers vary significantly on the coverage for the procedure. Most carriers will cover all inpatient hospital costs, including circumcision. However, since many infants are released from the hospital stay within 1 or 2 days post delivery, oftentimes they miss their opportunity of being circumsized in the hospital, and then the insurance provider may elect not to cover it. If that’s the case, most circumcision cost around $200-$300. Interestingly, many parents don’t want their children to look different from their fathers or brothers or even from their peers at school, so what we know is that 9 out of 10 male infants of circumcised fathers are circumcised and that about 75% of male infants of fathers who are uncircumcised are also uncircumcised. So, who should perform the procedure? This is a question of significant debate today. Traditionally, neonatal circumcisions have been performed by obstetricians, gynecologists, pediatricians, family practitioners, pediatric urologists, and pediatric surgeons. However, more recently, training programs in obstetrics and gynecology, pediatrics, family practice have de-emphasized training in this procedure. As such, there tends to be less comfort with the procedure by the graduating trainees and overall fewer and fewer obstetricians, gynecologists, pediatricians, and family practitioners that are performing these procedures today We know that the rate of revision of circumcision, as we talked about before, is so high that in some locations some physicians are seeing greater than 100% increase in the rate of revision circumcisions and a significant inflow of patients being evaluated for redo or revision circumcisions and their practices. Obviously, the more frequently a provider performs a procedure, the lower the complication rate, so as these procedures are de-emphasized in training programs, there’s less and less comfort with those procedures. So what are our take-home messages today? Well, we know that newborn circumcision should be performed between–excuse me, before 4 to 6 weeks of age and when the infant is under 12 pounds. If we wait longer than that, we generally wait till about 3 months of age, and we perform this in the operating room under general anesthesia. We do know that clamp circumcisions are generally safe, but that there are risks, and that ultimately the family must make a decision based on informed consent. The type of clamp that is used is generally determined by the physician performing the procedure. My personal favorite is the Gamco clamp. Rates of revision circumcision are on the rise, likely as a result of de-emphasizing this procedure in training programs. And finally, unless there’s a medical indication for circumcision, parents should decide whether circumcision is in the best interest of their child, weighing medical information in the context of their own religious, ethical, and cultural beliefs and practices. Finally, if you’d like to ask any questions today, please send your questions to #UCLAMDChat, and I’m going to start answering some of these questions right now. So the first question is a great one, “What kind of medicine or anesthesia is used?” So this is also physician dependent. I tend to use a local penile block with 1% lidocaine with no epinephrine. I do a lidocaine block at the base of the penis, and generally this tends to get very good pain control. Many people choose different types of anesthesia, but for the most part most physicians now are using dorsal penile blocks. “How do I care for my son after circumcision?” Great question, so what I tell my families is that for the first couple of weeks after circumcision, all I ask you to do is place bacitracin ointment in a gauze and essentially place that gauze over the penis like a sandwich, and put this in the diaper with every diaper change. Then after I see the child back and follow up, I will separate some of the adhesions that may have formed. I will teach the family how to push back on the foreskin to make sure those adhesions don’t form. So even in a circumcised phallus, we do need to care for it by pushing back on the foreskin so the raw edges don’t adhere to the glans penis. So once we start pushing back, we apply a vaseline or an antibiotic cream on that raw surface, and over several weeks to months the likelihood of those adhesions forming are less. I generally tell families that they don’t need to worry too much about the poopy diapers in the sense that the phallus rarely gets infected. There is a significant vascular supply to the area, which tends to reduce the risks of infection quite significantly. So in general, what we say is keep the the baby out of poopy diapers as much as you can. You can use a wipe or a washcloth and then even sponge bathe them after a day or two after the procedure. I usually ask you to wait about 48 hours to really submerge them in the bath, and many of these Children will actually come to the clinic still with their belly button intact because they’re coming before the belly button has fallen off. There is no bathing until the belly button falls off anyway, so in that case you’ll just use warm water or soapy water with a washcloth or a wet wipe. “What is the recovery time after circumcision?” Well, generally the child actually recovers quite quickly, usually for the 1st hour or so, they’re uncomfortable. We give instructions about the use of tylenol for pain after the anesthesia has worn off, but within a day or two they’re back to themselves again. Essentially, the circumcision site will heal in about a week. It will look very bruised. It can look swollen. There can be some hematoma formation, which is a little blood collection under the foreskin, and that might take up to a week to resolve, but by a week, it really does look like a well-healed circumcision site. A question, “Do adult males get circumcised? If so, how often how does adult circumcision differ technically from neonatal circumcision?” Generally, in this country we don’t do many adult circumcision with clamps, so we generally do them in a freehand technique like we showed before, where we essentially remove a sleeve of the foreskin. I can go back to that depiction. Oops, let’s see from the beginning. So this is actually a depiction of how we do circumcisions, whether in the adult stage or in the pediatric stage. When we take them to the operating room, we can do this in the clinic under local anesthesia in an adult male, who we can obviously discuss the procedure with. There can be variables in anesthesia or numbing of the penis with just the local block, so adult men can have this done in clinic, but we remove a sleeve of the foreskin freehand and then sew the edges back together, and this is generally how we do most adult male circumcision. In other countries, they do use clamps or concision x for adult males as well, but we tend not to do that so much in this country. “What is the post-operative care of adult circumcisions, and are there any limitations after surgery?” Yes, so after adult circumcision that care is generally the same, so I usually recommend the bacitracin ointment is applied along the suture line for a good 3 to 4 weeks after the procedure and then conversion to a vaseline until all the stitches dissolve. We use absorbable sutures, and so we say to keep it moist and apply of azulene until all the stitches dissolve, and then once they dissolve, there’s no more care that needs to be done directly other than normal. The restrictions are essentially, for adult males, no intercourse, no masturbation for at least 4 weeks after the procedure and just a couple of days of light activity just to keep the risk of bleeding down, but generally back to regular activity shortly thereafter. “How should I prepare my patient or my child for circumcision in general coming in for a circumcision?” We just ask you to limit their fluid intake for a few hours before the procedure, so we say for 3 hours before the procedure, no formula feeds, no intake of any sort, because that increases the risk of vomiting during the procedure. Other than that, there really is no preparation for the procedure necessary. “How should I bathe my baby after circumcision?” So I think we discussed that briefly, but just I’ll review that. In the first couple of days after the circumcision, wet wipes or a washcloth with soapy water or just regular water is fine. Try to keep your baby out of dirty diapers as much as possible, but don’t get too concerned if they’re sitting in dirty diapers. The risks of infection are fairly low. Every surgeon will instruct you differently about how to manage the local site, but I generally say nothing to do with the local site but putting a bacitracin gauze over it with every diaper change, and then when you come back in clinic, we show you how you had to push back on the adhesions and clean the foreskin more aggressively. “What are the risks of adult male circumcision?” They’re essentially the same as the risk of pediatric circumcision, so risks of bleeding and infection. There are always risks of meatal stenosis at any age and on which we perform these procedures. There are certainly risks that are less likely, like risks of injury to the tip of the penis, to the urethra. Those are unlikely, and nerve risks are very unlikely, but they’re essentially the same risks as to pediatric population. And “the recovery time of the adult,” I think we addressed that one before. Again, 4 to 6 weeks, essentially 4 weeks out of intercourse or masturbation. So we’ve gone through the first panel of questions. Is that it? Okay. We’re going to complete the webinar today. I appreciate very much you logging in. If there are any further questions, we’re going to have this posted on our website. Thank you very much.