Parents have often reached the decision to have their infant circumcised before I say anything. However, as with any procedure, it is prudent to discuss the associated risks and benefits beforehand; misinformation among parents abounds. I tell parents about the above-mentioned medical benefits of circumcision. You may also want to mention that several studies of sexual satisfaction among circumcised and uncircumcised men have been done; these show similar to slightly increased satisfaction among circumcised men and their partners.1
Associated risks. I also discuss the risks associated with circumcision, which consist chiefly of pain, infection, and bleeding. Much less likely—but still possible—are lidocaine(Drug information on lidocaine) toxicity; trauma to the glans or urethra; and a "degloving" injury, in which the skin of the shaft retracts proximally and needs to be stitched back into place (seen primarily with the Gomco method). Another rare complication, seen primarily with the Mogen and Plastibell techniques, is paraphimosis. Meatal stenosis is a common late complication thought to be caused by chronic diaper irritation of an unprotected meatus; however, it is rarely of clinical significance.
I again emphasize that newborn circumcision is an entirely elective procedure. In a 2005 Task Force statement, the American Academy of Pediatrics did not recommend newborn circumcision. I also discuss the risk of a poor cosmetic outcome or a result that may not look exactly like what the parents had expected. Finally, I make sure that both parents are in agreement about proceeding with the procedure.
I often invite one or both parents to watch their baby's circumcision in order to relieve any anxiety about what is being done to their child. About half of parents take me up on this offer. It is a good idea to keep a chair nearby in case someone gets light-headed.
Contraindications. Cited contraindications to circumcision include illness, premature birth, age younger than 12 hours or older than 6 weeks, known bleeding diathesis, ambiguous or unusual appearance of genitalia, urethral anomalies, and—in the case of the Gomco method—a short penile shaft (less than 1 cm).3,4 If a hypospadias is discovered on cutting open the foreskin, it is recommended that the physician suture the foreskin back up and abandon the procedure; the urologist is likely to need to use the foreskin to repair the defect.6
ANALGESIA AND ANESTHESIA
After 1 hour of nothing by mouth to minimize the risk of aspiration, I place the infant on a restraint board, preferably with a cuddly blanket wrapped around his upper torso. I give him a pacifier dipped in a solution of 25% sucrose, which helps soothe him during the procedure.
Topical anesthetics, such as lidocaine or EMLA (eutectic mixture of local anesthetics), have been shown to reduce the pain of circumcision if applied in advance. Injectable lidocaine without epinephrine is most often used. Some physicians dilute the lidocaine with 0.1 mL of 1% sodium bicarbonate(Drug information on sodium bicarbonate) to counteract the burning effect of this agent. The maximum dose of lidocaine for children is 3 to 5 mg/kg.4 Given that 1% lidocaine contains 10 mg/mL, the maximum dose for a 3-kg newborn would be about 1.5 mL. I superficially inject 0.4 mL of 1% lidocaine without epinephrine at both the 10 o'clock and 2 o'clock positions; I draw back first to avoid intravascular delivery (Figure 1). Failure to wait a full 5 minutes after injection before starting the procedure may be the biggest pitfall in pain management during circumcision.4,6