CIRCUMCISION

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Circumcision was once considered routine procedure for most newborn males in the United States, but as with most routine procedures, parents are beginning to question if circumcision is really necessary for their babies.

Mothers often agonize about this decision, feeling, "I'm going to great lengths to bring my baby into the world as gently as possible. Circumcision just doesn't seem to fit the scene." Fathers often feel, "I want my son to have a maintenance-free penis."

The following are the most common questions we are asked about circumcision. The answers are intended to help you make an informed choice.

Baby is placed on a restraining board, and straps secure his hands and feet. The tight adhesions between the foreskin and the glans (or head) of the penis are separated with a medical instrument. The foreskin is held in place by metal clamps while a cut is made into the foreskin to about one-third of its length. A metal or plastic bell is placed over the head of the penis to protect the glans, and the foreskin is pulled up over the bell and the circumferentially cut.

Circumcision is usually a very safe surgical procedure. There are rarely any complications. As with any surgical procedure, however, there are occasional problems such as bleeding, infection, or injury to the penis. If there is a family history of bleeding tendencies or one of your previous newborns bled a lot during circumcision, be sure to inform your doctor of this fact.

Yes, it hurts. The skin of the penis of a newborn baby has pain receptors completely sensitive to clamping and cutting. The myth that newborns do not feel pain came from the observation that newborns sometimes withdraw into a deep sleep toward the end of the operation. This does not mean that they do not feel pain. Falling into a deep sleep is a retreat mechanism, a withdrawal reaction as a consequence of overwhelming pain. Not only does circumcision cause pain in the penis, the newborns over all physiology is upset. New research shows that during unanaesthetized circumcision, stress hormones rise, the heart rate speeds, and valuable blood oxygen diminishes. Babies should never be subjected to the shock of unanaesthetized circumcision.

Yes, a local anesthetic can and should be used. Painless circumcision should be a birthright. I have used a local anesthesia in nearly a thousand babies for over twenty years. It is a safe procedure and it works. Sometimes the anesthetic will not remove all the pain, but it certainly helps. Within a few hours, after the anesthetic wears off, some babies exhibit no discomfort; others will fuss for the next twenty-four hours. The most common and effective method is called a dorsal penile nerve block, in which a few drops of Xylocaine (similar to the anesthetic your dentist uses) is injected into the nerves on each side of the penis circumferentially around the base of the penis.

Making hygiene easier is often a reason given for performing circumcision. In the adolescent and adult male, the glands of the foreskin secrete a fluid called smegma. These secretions may accumulate beneath the foreskin and occasionally irritate the penis; and sometimes the penis becomes infected. Removing the foreskin removes the secretions, makes the care of the penis easier, and lessens the risk of infection. With normal bathing, however, an intact foreskin is quite easy to care for.

Leaving the foreskin intact protects the penis from irritation and infection caused by rubbing on wet and soiled diapers. At birth it is impossible to make a judgment about how tight the foreskin will remain, since almost all boys have tight foreskins for the first year. In about 50 percent of boys, the foreskin loosens from the head of the penis and retracts completely by two years. By three years of age, 90 percent of intact boys have fully retractable foreskins. Once the foreskin retracts easily, it becomes a part of normal hygiene to pull back the foreskin and cleanse beneath it during a bath. While it is true that infections from the secretions beneath the foreskin can more often be a problem in intact males, simple hygiene can prevent this problem.

Circumcision is very rarely necessary for medical reasons, but occasionally the foreskin does not retract, becomes tight and infected, and obstructs the flow of urine. This unusual condition, called phimosis, requires circumcision. If circumcision for phimosis is necessary later on in childhood or adulthood, however, an anesthesia is given.

We dub this the "uncare" of the foreskin. Above all, do not forcibly retract the foreskin. Allow it to retract naturally over a number of years. Retracting the foreskin before it is time loosens the protective seal between the foreskin and glans and increases the chance of infection. If you choose to leave your baby's foreskin intact, follow theses suggestions for its care:

You can't predict how different your son will feel if he is left intact. Boys generally have a wider acceptance of individual differences than adults do. Locker room comparisons are a bit of a myth. It is difficult to know whether the majority of the boys will be circumcised or intact in the future. The number of circumcisions has steadily declined in recent years as more parents begin to question routine circumcision. Currently, around half of the infant males in the United States are being left intact, up considerably from 23 percent in the early 1980's.

Since little boys do sometimes compare the styles of their penis, many parents feel that sameness is important among brothers. Just as you learn a lot from your first birth and may choose a different style for the next, not every child must be circumcised. If you choose to leave your next child intact, your problem will most likely be explaining to your circumcised child why his foreskin is missing.

Circumcision does not prevent cancer of the penis, which is a very rare disease anyway and occurs more frequently in males who do not practice proper hygiene. Cervical cancer, which is not prevented by circumcision, is not more common in sexual partners of intact males who practice proper hygiene. Circumcision also does not prevent sexually transmitted diseases.

Your doctor or hospital nurse will instruct you on caring for the circumcision site. For a week, apply a protective lubricant over the site every time you change baby's diaper. For about a week, the circumcised site goes through the typical healing process. Initially, it is swollen, then a yellow scab appears. The swelling and the scab resolve by one week. Be sure your doctor informs you how to tell if the circumcision site becomes infected. Surprisingly, circumcision sites rarely become infected, but here are signs to call your doctor: The entire penis is red, warm, and swollen, and the surgical site is draining pus. A yellow, nondraining scab is normal during healing.

The decision is yours. As you can see from the previous discussion, there is no compelling reason for circumcision. If you are looking to your doctor to be your son's foreskin attorney, you may still be left undecided. Even the American Academy of Pediatrics is off and on again about the foreskin. In 1983, the AAP issued an opinion that "routine circumcision is medically unnecessary." Because of recent and controversial studies among uncircumcised males, this large and respected body of pediatricians is now reconsidering its opinion. There will be more studies, more opinions, and I would guess that years down the road the fate of the foreskin will still be uncertain.