What is Circumcision?

In boys, the process of removing the excess foreskin (prepysium) hanging from the tip of the penis so that the head of the organ is completely exposed is called ‘circumcision’.

This piece can cause blockages, obstruction of urine flow and sometimes urinary tract infections. The skin itself can even become inflamed. Therefore, it has been scientifically proven that removing this skin is medically beneficial.

What is the reason for circumcision?

Circumcision is an operation that has been practiced for thousands of years. It is known to be the custom of Prophet Abraham. It is shown in the sources that Egyptians, Jews and Babylonians were circumcised throughout history. Circumcision is still routinely practiced in Muslim and Jewish communities. It has been permanently practiced with the recommendation of Prophet Muhammad (peace be upon him) to Muslims. Today, circumcision is also practiced in western countries due to its medical benefits.

In other words, circumcision in our country is more of a religious and social request and is practiced for all boys. For the family, the circumcision ceremony is considered a joyful and proud event and a spiritual happiness. For the child, circumcision is an important social event in terms of gaining status among his friends.

When should circumcision be performed?

Circumcision is recommended to be performed between 0 and 2 years of age, or between 5-7 years of age. However, with years of experience, I think it is appropriate to perform circumcision between 3 weeks and 3 months.

What are the disadvantages of circumcision between the ages of 2-5?

This period is important for the psychological development of children. Circumcision in this period may cause some psychological damage in children. Unless there is a medical necessity recommended by your doctor, circumcision should not be performed during this period.

Is Circumcision Performed in the Newborn Period (Immediately at Birth)?

This is still a controversial issue among experts. In the past, it was believed that a newborn baby did not develop pain perception. Therefore, babies were circumcised without anesthesia and painkillers. However, it was understood that this was not true and that the baby develops a sense of pain even in the womb. For this reason, circumcision has lost its former popularity in the postpartum period.

On the other hand, the importance of giving the baby to the mother and not separating the baby from the mother in terms of the individual relationship between the baby and the mother when the baby is born is a scientifically determined fact.

I also think that it is not right to separate the baby from the mother due to some psychological and physiological (hormonal) processes experienced by the mother during and after birth.

In addition, the development of the baby's tissues and organs continues as in the womb. For example, the development of the lungs and kidneys, intestines, the respiratory center and the nervous system continues.

During this period, the problems related to jaundice are solved, and the baby's nutrition and relationship with the mother are settled. The baby's growth data, congenital anomalies such as breast milk allergy, thyroid hormone irregularities or heart diseases are more or less revealed.

Considering all these reasons, if there is no medical reason, I think it is better to perform circumcision after 2-3 weeks.

Although babies are examined after birth, it may not be known whether the baby has a disease or not. The baby should not be exposed to trauma before getting used to the new world (circumcision is a surgical procedure. Surgery is also a trauma for the individual).

When it is performed after the age of five, even if the necessary precautions are taken, it has negative psychological effects on most children and the effect continues for years.

When is the best time for circumcision?

My clinical experience over the years is that circumcision is performed between 3 weeks and 3 months after birth.

During this period, the baby is not yet mobile. His/her vision is not fully developed, he/she can only recognize objects below 1 meter until 3 months of age. For this reason, environmental perception and fear are not formed until 3 months of age, and the baby cannot distinguish strangers from his/her family until 3 months of age. In addition, he is easily distracted during the intervention and circumcision is performed comfortably.

What are the differences between early and late circumcision?

There are some advantages and undesirable situations in both periods.

When done early, the baby does not remember the psychological and physiological effects of the event. The wound heals more quickly. Family care of the baby is easier.

Late circumcision, that is, after the age of 5, the child perceives what he/she has experienced and this can be perceived as a social development stage for the child. However, if it is delayed too long, it may cause embarrassment and psychological effects due to the discussion of the subject among the child's friends. On the other hand, the child may remember these experiences negatively for a lifetime.

In conclusion, for circumcisions other than medical necessities, an individual decision should be made with the family after the baby or child is examined by a specialist physician.

What kind of health problems can be encountered when circumcision is not performed?

Many health problems can be encountered;

1. Inflammation of the foreskin, which we call balanitis
2. Closure of the tip of the penis hole, inability to urinate and urinary tract infection, which requires circumcision as soon as possible, but we should distinguish the closure we call physiological from pathological in this case. This should be decided by a specialist. Do not worry if your baby urinates by squirting.
3. Paraphimosis, which we call paraphimosis, is when the foreskin escapes back and strangles the penis head. This may require emergency circumcision.
4. The urine collected under the foreskin eventually causes infection, which can cause infection in the urinary tract and kidneys.
5. Since the sensitivity of the penis head decreases in circumcised men, the event of premature ejaculation, which we call premature ejaculation, is less.
6. Infertility has been observed in uncircumcised men in sexual situations because semen remains under the foreskin and is excreted in lesser amounts.
7. Benign and malignant penile cancers are more common in uncircumcised men. Cancers of the entrance of the uterus are more common in women married to uncircumcised men.
8. Sexually transmitted diseases such as syphilis (gonorrhea) are more common in uncircumcised men.

All these are scientifically proven facts.

Who Should Perform Circumcision?

First of all, it should be remembered that circumcision is a surgical procedure that should not be simplified. It would be more beneficial for the physician who will perform circumcision to be a pediatric surgeon or pediatric urologist who performs more pediatric surgeries and therefore can better assess the physiological and psychological status of children

Under which conditions should circumcision be performed?

Circumcision can be performed with local anesthesia (with small needles or cream to be applied to the penis area) in the first 6 months of infants. However, even if it is performed locally, it should be performed in a hospital or in a clinical environment with facilities where all kinds of emergency interventions can be performed.

Like every surgery performed on older children, circumcision should be performed under operating room conditions. The correct one is circumcision performed under general anesthesia without any pain or fear. Before the child is taken to the operating room, a sedative syrup is given. After the child is taken to the operating room comfortably, local anesthesia is applied to the penis at the beginning of the anesthesia to ensure that the anesthesia is very mild and the postoperative period is painless for a few hours.

Are there any conditions in which circumcision should not be performed?

Circumcision should never be performed if there is a congenital abnormality known as ‘half circumcision’ among the people and called ‘hypospadias’ in medical language. Because the foreskin is used in the hypospadias surgery that will have to be performed later.

In addition, in cases such as urinary tract infection, blood diseases, foreskin infection, diaper rash and respiratory diseases, circumcision should not be performed before these conditions are treated.

What kind of problems can be encountered during circumcision?

Serious, even irreversible problems can be encountered, especially when it is not performed by experts. However, when performed by experts, these risks are close to zero.

As with any surgical procedure, circumcision may also have risks. As mentioned above, infection may be the most important complication if it is performed by specialists and in inappropriate environments. One of the biggest risks of circumcision performed by unskilled hands is that the child may be psychologically traumatized. This situation occurs in the form of a show of violence with local anesthesia and this fear in the child may continue for many years. There may also be problems related to the surgical technique chosen. These include bleeding and aesthetically ugly circumcisions. There may also be patients in whom the urethra has been cut, too much tissue has been removed from the penis or, on the contrary, too little has been cut and corrective surgeries are required. When the appropriate method is not chosen and performed properly, serious temporary and permanent problems can be encountered.

What should be considered before circumcision?

First of all, the family and the child should be properly informed about the process to be experienced. In children over 5 years of age, care should be taken to inform and actions and words that frighten the family and the child should be avoided. Words such as a little bit will be cut off from the tip of the willy should not be said, and the child should be explained in an appropriate language that only the excess foreskin on the willy will be removed. Before circumcision, the baby or child should be examined and this examination should include not only the willy but also a general examination. If necessary, a few blood tests should be done and the anesthesiologist should be informed. If he/she will receive general anesthesia, he/she should be informed about fasting before circumcision.

Which method should circumcision be performed?

There are several different methods defined regarding the circumcision method. The method is planned according to the habit of the specialist performing the procedure and the anatomical structure of the penis and the surrounding area of the baby and child. However, the most reliable and best method is the classical surgical procedure.

A. Circumcision by Surgical Procedures

1. Surgical Circumcision: After general anesthesia or regional anesthesia (local), a clamp is placed on the foreskin 5-6 mm away from the glans penis. Here, care is taken to ensure that the head of the penis does not enter between the clamp. The purpose of regional anesthesia is that the child does not feel pain during and after the procedure. Then a scalpel or scissors are used to cut just below the penis. The mouths of the bleeding vessels are found and tied one by one or cauterized. The two ends of the cut skin are sewn together with sutures. A dressing is applied if necessary.

 

2- Open Circumcision Method (Sleeve Technique): Under the same conditions, two clamps are placed on the foreskin, two below and two above the foreskin. It is cut between these clamps with a pair of scissors, leaving 5 mm to the penis head. The head of the penis is cuffed. Then the area between the clamps is also cut. The two cuts are joined. The bleeding vessels are ligated or burned and the surrounding area is sutured.

B. Clamp Methods

1. Gomko clamp: Also known as the bell method or ring method. This technique is usually applied to newborn babies. Regional anesthesia is applied to the baby. The glans (head of the penis) and foreskin are separated. A metal bell is placed on the glans head and then the skin to be cut in circumcision is passed over this bell. It is pinched with an auger over the placed bell. The auger is left for about 5-6 minutes to prevent bleeding. Then the excess skin on the clamp is cut with a scalpel or scissors. This method may not require stitches.

   

    

2. Plastibell device: It is called the ring method. The instrument consists of a plastic bell and a tether that is placed on the glans penis. It is performed under local or general anesthesia. The plastibell bell of appropriate volume is placed on the glans. The foreskin is tied with a string so that it overlaps the plastibell groove. Excess skin above the tying line is cut. The tissue above the tether line necroses and the necrotic tissue, the tether and the plastibell fall off together in 3-7 days. If it does not fall off within 3 weeks, the plastibell is cut and removed. This can be a very frustrating process for both the child and the family.

   

    

3. Mogen clamp: After separation of the adhesions, the prepucium is lifted upwards so that the glans is under the “V-shaped” clamp and the overlying skin is amputated. If the Mogen clamp is not placed in the proper position, asymmetric and inadequate excisions may occur. Typically, more skin remains on the underside of the penis.

   In addition, improper placement of the clamp may lead to amputations of the glans penis.

4. Plastic disposable clamps (Alis clamp): It is a tool consisting of 2 parts, a rope of different sizes and a clamping ring. With this disposable clamp, the foreskin to be cut is first compressed with a plastic clamp and then the upper part of the skin is cut. The plastic part is removed after 1 to 5 days depending on the age of the child. Here too, the process can be frustrating for the child and the family.

   

    

C. Cautery Method: Here, cautery is used instead of a scalpel to cut. Cautery is a tool that cuts the skin due to heat at low degrees of electric current. There is no bleeding here, even if there is, these vessels are burned with cautery.

However, the possibility of scar tissue (clumsy) formation after healing in the late period is higher than other methods. However, this rate has been reduced to very low levels in the cautery developed for special circumcision today.

D. Laser Circumcision: Laser is used as a cutter instead of cautery. Today, its use is controversial because its side effects are not fully known. It is also an expensive method. Side effects similar to the cautery method are known.

What is Sutureless Circumcision?

It is a situation where the two ends of the cut foreskin are brought closer together with clamps developed without sutures. However, these clamps remain in the baby or child's willy for a long time, during which time disturbing conditions such as pain, discharge and infection may develop in the child and family.

Is it necessary to put stitches in circumcision, are the stitches removed, and if so, when are they removed?

Stitches in circumcision accelerate wound healing and facilitate wound care. There is no need to remove the stitches. These stitches usually dissolve and disappear spontaneously in 3-4 weeks.

Is There Pain After Circumcision?

Whether circumcision is performed with local or general anesthesia, painkillers are definitely given during the procedure and if painkillers are used for 3-4 days after circumcision in line with your doctor's recommendation, there is absolutely no pain.

Is There a Need for Dressing After Circumcision?

If infection does not develop after circumcision, which is very rare, there is no need for dressing.

What should be considered after circumcision?

In circumcisions performed with local anesthesia, painkillers are given according to the doctor's recommendation, no bath is taken for 3 days, no additional care is required, and the baby is fed normally.

Approximately 2 hours after circumcision performed with general anesthesia, feeding is started in accordance with the recommendations of the doctor and nurse. Again, painkillers are given according to the doctor's recommendations. There is no need for dressing, the existing dressing is opened after 24-48 hours. For 15 days, the child does not use bicycle and walker. Other than that, there are no restrictions in the child's life. Circumcision panties can be worn. In diapered babies, diapers are changed frequently to prevent poop contamination.

Is it useful to put a circumcision diaper or a cut cardboard cup on the willy after circumcision?

In small babies, it is enough to apply a cream recommended by your doctor into the diaper so that the diaper does not stick to the willy. There is no need for any other medicine or dressing.

In older children, a single dressing for 1 -2 days is sufficient, circumcision rug can be used in these children. However, these children may not want to wear their normal clothes afterwards, they think that the clothes will cause pain when they touch the willy. In these children, the physician and family should decide according to the condition of the child. My general approach is not to use it.

What are the Most Common Complications After Circumcision?

The rates of circumcision complications have been reported between 0.2-10% in the literature. The main complications are

1. Bleeding after circumcision. Bleeding after circumcision is usually mild and can be controlled by applying pressure. Excessive bleeding is seen in 0.6% of cases and can only be stopped surgically. Children with bleeding disorders such as hemophilia may have severe bleeding after circumcision.
2. The frequency of infection after circumcision is between 0.2-0.4%. It is more common after circumcisions performed with the Plastibel device. It responds well to antibiotic treatment.
3. Removal of insufficient tissue It may be necessary to circumcise again later due to insufficient tissue removal during circumcision. The foreskin should be removed until the glans penis is completely exposed. However, it should not be too hasty to perform circumcision again because the foreskin is left too much. Generally, circumcision for the second time is recommended only for those who have an uncircumcised appearance. Otherwise, it has been observed that as the penis grows, the foreskin retracts and in cases where the foreskin seems to have been removed less, it has gained a normal circumcised appearance over the years. Therefore, one should not be hasty about circumcision for the second time. In addition, in buried penises, it is seen as if the foreskin is left too much even though it is cut normally.
4. Secondary phimosis: It is the narrowing of the foreskin remaining after circumcision. It should be corrected surgically.

 

1. Narrowing of the urinary orifice (meatal stenosis). The narrowing of the urinary orifice is thought to be caused by mechanical irritation due to frenular artery ligation or friction of the urinary orifice exposed after circumcision. In addition, in cases where the urinary orifice is congenitally narrow and not visible under the foreskin, it may be mistakenly considered as a complication of circumcision because the stenosis becomes visible after circumcision. Dilatation meatotomy or meatotoplasty can be performed for urinary orifice narrowing.
2. Glans amputation is another very important complication. All or part of the glans penis may be amputated. If the glans penis is completely detached, it should be wrapped in moist gauze and placed in ice water in a plastic bag. It should not be placed directly into the ice. It should be implanted as soon as possible on the properly cut wound edges after the necessary local debridement.

 

1. Skin bridge: It is more common in cases of bitits where the foreskin is not well separated from the glans penis. It is corrected surgically by cutting.
2. Methemoglobinemia (blue baby): Methemoglobinemia should be considered in a patient who presents with cyanosis (bruising in the hands, feet and lips) after circumcision but whose circulatory and respiratory system findings are normal. In methemoglobinemia, there is inadequate oxygen transport to tissues in the blood. In methemoglobinemia, cyanosis does not improve by giving oxygen to the baby. It is treated by giving methylene blue. It is more common in the first six months of life. Methhemoglobinemia develops more frequently in children given pyrilocaine (citanest) as local anesthesia. Pyrilocaine given at a dose higher than 2 mg/kg has been reported to cause methemoglobinemia in infants younger than six months. Local anesthesia with pupivacaine is safer in young children, especially in the first trimester.

*** If you see a deformity in your child's penis, consult a physician. Even if only the foreskin seems to be missing, do not circumcise your child without consulting a pediatric surgeon!

*** The information provided here, the content of the website is organized for the purpose of informing the visitor. No information should be considered as advice by visitors and should not lead to any decision or action. Families related to the subject should have their patient examined by a pediatric surgery specialist in mulaka and make a decision by consulting with him/her and consulting his/her one-to-one information.