circumcision 2

8/12/2019 Circumcision 2

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Objectives

Epidemiology of Circumcision

View Organizations statements on circumcision.

Review indications for circumcisions.

Review risks associated with circumcision.

Review evidence for anesthesia and/or analgesia

during procedure.

Review most common methods.


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Foreskin Embryology

Development of prepuce between week 8 and 16in utero

Prepuce mucosa and glans are contiguous Exfoliation of underlying epithelium in a proximal

direction leads to resolution of the physiologicaladhesions and formation of a preputial sac

Usually complete by 3 - 5 years but may continueuntil puberty

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Work by Gairdner

1949 and Oster 1968

Less than 1% of boys

require a circumcision

Natural History

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Epidemiology

Circumcision rate varies by Geographic region ( 1 in 6 worldwide)

Religious affiliation Socioeconomic classification

Uncommon in Asia, S. America, Central America,

Europe

48% circumcised in Canada

>80% in US in 1980 and declining

Whites > blacks or hispanics


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AAFP, AAP, ACOG

The AAFP recommends physicians discuss the potential harms andbenefits of circumcision with all parents or legal guardiansconsidering this procedure for their newborn son.

AAP -Parents should determine what is in the best interest of thechild. They should be given unbiased information and be provided theopportunity to discuss this decision.

ACOG- Existing literature is inadequate to evaluate appropriately

routine circumcision of the newborn infant.

All agree evidence is insufficient to support routine circumcision.

All agree anesthesia is warranted.


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Recent Studies Supporting Health Benefits

In three recent RCTs involving about 10,000 HIV-negativemen (age range, 1849) in Africa, circumcision decreased

male heterosexual acquisition of HIV disease by 53% to 60%

compared with uncircumcised men during an average follow-

up of 1.5 to 2 years .

In two trials, circumcision decreased acquisition of HSV type

2 infections by 28% to 34% and penile HPV infections by

32% to 35%.

Some evidence suggests that female benefits of male

circumcision include a decrease in transmission of BV,

trichomoniasis and HIV.7


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Neonatal Circumcision

Most common surgical

procedure performed in

US.

1 million/year in the US.

Evidence conflicting on

risk and benefits.

Most decisions based on

nonmedical reasons

(religious, ethnic, cultural,cosmetic).

Complication rate 0.1% to

35%.

Infection (0.2-0.4%)

Bleeding (usually minor)

Failure to remove enoughforeskin

Meatal stenosis

Necrotizing fasciitis

Urethral fistula

Partial penile amputation

Penile necrosis

Concealed penis

Death


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Optimal Timing and Contraindications

12-24 hours post

delivery.

Evaluate forhyperbilirubinemia,

infection, bleeding

diathesis.

Make sure infant hasvoided.

Contraindications:

Congenital penile abn

Prematurity Bleeding disorder

Medical problem


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Infection and Circumcision

Among infants less than 3 months of age, male infants

account for 75% of UTIs.

An uncircumcised male has a 3 to 20 times risk of

developing a UTI compared to a circumcised male but

absolute risk increase only 1%. (NNT =90-195)

Studies relating association with STDs inconclusive.

Studies in Africa show an association between contracting

HIV and being uncircumcised.

Evidence supporting association between circumcision

status and risk of developing cervical cancer is inconclusive.

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Does Circumcision Prevent Penile

Cancer? SCC penis is rare

Neonatal circumcision is protective whereas adult

circumcision is not. Studies estimate that 600-900 circumcisions are

needed to prevent one lifetime case of penilecancer

Probably related more so to poor hygiene Confounders (smoking, phimosis, genital warts,

multiple partners)


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Prepuce is filled with nerve endings similar to lips or fingers(much more so than the glans)

Circumcision permanently inhibits sexual function ?

Glandular skin undergoes hyperkeritinization An investigation of the exteroceptive and light tactile

discrimination of the glans of circumcised and uncircumcisedmen found no difference on comparison.

No valid evidence to date, supports the notion that beingcircumcised affects sexual sensation or satisfaction.

Sexual Functioning

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Physician Views About Pain

Pain of injecting medication may be

greater than procedural pain.

Newborns do not feel or remember pain.

Potential side effects of analgesic agent too

harmful for neonate.


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Studies Reviewing Perception of Pain in the

Neonate During Circumcision Infants exhibit

physiological changes

associated with pain. HR

BP

cortisol levels

O2 saturation

changes in interaction

and feeding

Current standard of care in mostsites - no anesthesia.

Greater increase in HR andcrying (no anesthesia vs.DPNB) Williamson andWilliamson, 1983

Decreased motor performanceand responsiveness after

procedureDixon et al., 1984

Circumcised infants havestronger pain response tovaccines later compared to non-circumcised infants Taddio et al,March 1997


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Methods of Pain Reduction During Neonatal

Circumcision Technique: Mogen < Gomco (shorter

procedure)

Pacifier +/-sucrose

reduced crying with watermoistened pacifier

better with sucrose

less elevation of HR but notsufficient analgesia for

neonatal circumcision Tylenol

did not significantly alterintraoperative pain

parameters

EMLA (2.5% lidocaine and2.5% prilocaine applied 60 to

90 min before procedure)

concern about local

irritation, unevenabsorption, systemic

toxicity

apply under adhesive

dressing for > 45 minutes

potential risk of

methemoglobinemia

Limited anesthesia during

tissue lysis of adhesions

and tightening of clamp


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Studies Reviewing Perception of Pain in the

Neonate During Circumcision (Cont.) Dorsal Penile Nerve

Block

requires 3-5 min wait

multiple studies document

significant reduction in pain

and improved postoperative

behaviors

45% to 76% less crying

rare, mild complications

(local bruising, hematoma)

Subcutaneous and penile

ring block

SQ ring of 0.8cc- 1.0cc plain

0.5% lidocaine above coronasubcutaneously and

circumferentially

equally effective at all stages

of procedure

diminished pain response

no reported complications

may be most effective

anesthetic


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Looking at the Data


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Comparing Agents


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Comparisons

Padded restraintsbetter

than rigid plastic

Sucrose + EMLAmore

effective than no

intervention

DPNBbetter pain

reduction than EMLA

SQ localblock simpler to

perform and provides

good pain reduction

Ring blockmore effective

than DPNB which is more

effective than EMLA,

which is better thanplacebo in reducing

elevation in HR, and high

pitched cry.


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Basic Steps in Circumcision

Parental counseling and consent Ritual?

Parent presence?

Conflicts? Examine the glans

Prepare clean/sterile environment

Prevent Pain

Take down adhesions Place device

Remove foreskin

Prevent Bleeding


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Choosing the Right Surface

Pad board with blankets or

other thick soft materials.

Restraint boards in semi-

reclining position have

been shown to decrease

distress.


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Swaddling

Swaddle the upper bodyand legs to providewarmth or use a radiant

warmer. Consider soft music

before, during, and afterthe procedure.

Provide human swaddlingand comfort after the

procedure.


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Preparation

Use betadine to clean

area where anesthesia

will be applied if usinga block, penile shaft,

and glans.


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Anesthesia


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Anatomy of the Penis


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Dorsal Penile Block

27 gauge needle or TB syringe is

used to inject 0.4 cc of 1%

lidocaine at 10- and 2 oclock

positions at the base of the penis.

Needle directed posteromedially 3

to 5mm until Bucks fascia is

entered at base of penis.

Allow 3 to 5 min before

proceeding. Anesthesia lasts 1-2 hours

Bruising is the most common

complication.


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Subcutaneous and Ring Block

0.8 to 1.0 cc of 0.5-1.0%

lidocaine without

epinephrine.

Inject SQ along shaft at2,10 and ventral surface

(very superficially).

Alternatively inject a

small ring immediatelyadjacent to the corona.


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Apply Sterile Drape

Draping keeps area clean

and provides a clean

environment to place

instruments duringprocedure.


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The Gomco clamp

Introduced in 1935 Concerns

Choosing the right size bell

Average infant requires 1.3 size

(1.1,1.3,1.45,1.6)

Bell should completely coverglans without overly distending

the foreskin

Always check bell and plate to

make sure they match

Technique gives better cosmetics

Do not perform if


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Circumcision Step 1

Lysis of adhesions

Probably causes the most discomfort, if not

adequately anesthetized Usually done with clamps at 3 and 9 oclock

and hemostat gently placed between skin and

fascia in an open and closing motion

Special care taken to avoid bleeding at the level

of the frenulum


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Gomco Step 1

Dorsal crush and slit


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Gomco Step 2

Insertion of bell over

glans

Insert safety throughboth foreskin and

mucosa


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Gomco Step 3

Grasp edge of dorsal

slit and insert the arm

of the bell through thehole of the plate.

Use a hemostat to pull

foreskin through base


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Gomco Step 4

Pull the foreskin

upwards and adjust the

bell and base plate. Make sure bell stays underthe foreskin and over glans

Apex must be visible above

plate


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Gomco Step 5

Assemble yoke of

clamp to arm of the

bell. Apply nut to connect

top plate with base

plate.


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Gomco Step 6

Excise foreskin near

base of plate on top

surface.


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Disassembling the Gomco Plate

Remove the nut from

the plate

(note sufficienttightening produces a

suction after the

procedure)

Take a 2x2 and gently

release suction


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Gomco Final Step

Push remaining

foreskin to just above

the corona. Do not retract back too

far (leads to bleeding

if pulled back too far)


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Mogen Clamp

Designed in 1954

Most commonly used by

mohels for ceremonial

circumcision Has the advantages of being

rapidly performed and not

leaving a foreign body at the

circumcision site.

The disadvantage is that thedevice does not directly protect

the glans during the procedure.

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Mogen Step 1

Separate the glans from the

preputial lining.

Lift the prepuce upward and

outward (this causes the glansto retract towards the scrotum).

The open jaws of the Mogen

clamp are placed around the

prepuce (grooved side facing

the glans) as it is lifted

upwards.


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Mogen Step 2

Close clamp for 11

minutes.

Excise the prepuce distal to the

clamp. Open the clamp slowly and

remove.


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Mogen Final Steps

Downward pressure is applied

to the preputial skin around the

corona until mucosal seal is

broken and glans is liberated.

Use a blunt probe to release any

additional adhesions.

As infant ages dog ears become

less prominent.


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Plastibell Technique

Introduced in the mid 1950s

Has the advantage of continuing

hemostasis after the procedureis over, as the suture remains in

place for a few days.

Disadvantage is that there is a

foreign body at the site, whichcould become dislodged or

infected.

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Online Videos

http://newborns.stanford.edu/Plastibell.html

http://newborns.stanford.edu/Gomco.html

http://newborns.stanford.edu/MogenIntro.ht

ml

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http://newborns.stanford.edu/Plastibell.htmlhttp://newborns.stanford.edu/Gomco.htmlhttp://newborns.stanford.edu/MogenIntro.htmlhttp://newborns.stanford.edu/MogenIntro.htmlhttp://newborns.stanford.edu/MogenIntro.htmlhttp://newborns.stanford.edu/MogenIntro.htmlhttp://newborns.stanford.edu/Gomco.htmlhttp://newborns.stanford.edu/Plastibell.html


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What if Bleeding Occurs?

Use a small gauze to apply pressure to the

area that is bleeding.

May use adrenaline on gauze.

Sometimes may require a small interrupted

suture with 6-0 absorbable suture.


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Indications for Discharge

Baby is not bleeding.

Most nurseries require that the baby has

voided.


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Summary of Evidence of Benefit

Neonatal circumcision prevents UTIs in the first year of

life with an absolute risk reduction of about 1%

Prevents the development of penile cancer with an absolute

risk reduction of less than 0.2%.

The evidence suggests that circumcision reduces the rate of

acquiring an STD, but careful sexual practices and hygiene

may be as effective.

Circumcision appears to decrease the transmission of HIVin underdeveloped areas where the virus is highly

prevalent.

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Summary

No clear cut reason for routineneonatal circumcision.

One of the oldest medical surgeries.

Circumcision is a surgical procedure associated with pain,

stress, risks and benefits. Provide adequate information to parents so they can make

the best decision possible for their baby.

Anesthesia can ease majority of discomfort.

Nonpharmacological means of comfort are equallyimportant.

Any technique can be done effectively in skilled hands.

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