Description of the Child Circumcision Procedure
There are several reasons why a child may need to be circumcised. Among other things, it can be due to medical reasons, such as Phimosis where the foreskin is sealed to the penis glans which prevents it from retracting properly. A foreskin that is not dilated is not necessarily a reason to resort to circumcision since this problem usually corrects itself over time. There are other non-medical reasons for circumcision such as cultural, religious and personal beliefs.
At the urology clinic of Dr. Carlos Marois, circumcision is preceded by an initial consultation and evaluation. During this consultation, a short questionnaire is administered, a physical examination is performed and all the different techniques are explained to the parents. The circumcision process is mostly difficult among children aged 2 to 5 years. If during the assessment we consider the child is too young or too agitated for the operation, we do not perform the circumcision under local anesthesia. If it is medically required, it is possible to have it done in a hospital under general anesthesia. If it is not medically required, then it is best to wait at least a year to re-evaluate the child to determine if he has reached the level of maturity required for circumcision under local anesthesia.
Afterwards, we schedule a second appointment for the circumcision. It is sometimes possible to have the evaluation and circumcision done in one single appointment depending on the cause of the circumcision. However, a normal test has to be performed and the child has to be mature enough to collaborate and listen to the instructions, if any. Also, the child must not have clotting disorders.
What Technique Will Be Used for Child Circumcision?
There are two techniques available using the local anesthetic: the standard technique with sutures and the Plastibell™ technique.
The Plastibell™ technique has been used for several years in Europe and especially in several circumcision clinics in the UK. This procedure is not well known in Quebec. It is currently used for newborns and infants. Plastibell™ consists of a clear plastic ring with a handle that detaches at the end of the circumcision. This very safe technique causes less bleeding and there is no need for stitches, since the glans is protected by the ring during the procedure. The ring loosens progressively 7 to 10 days after. The risk of the ring (which doesn't loosen spontaneously) getting stuck is very low, but it is higher among infants since they may experience more swelling. The patient will be required to return to the clinic for the cord to be cut and for the ring to be removed manually. This technique is especially performed on children who are more anxious and more difficult to collaborate with, since it is a quicker procedure. We use rings with larger Plastibell™ diameters in children whose penises are not yet developed. Quick and easy, this method is performed under local anesthetic. No bandage is required.
The standard technique requiring stitches takes longer and is essentially the same as for adults. There is also a bandage to be changed every day for the first week. The risk of bleeding is low, but occurs more frequently than with the Plastibell™ technique.
What Measures Should be Taken Before the Circumcision Procedure?
Firstly, Tempra should be taken by the child (according to his weight) an hour before the appointment. We also recommend a light lunch. In order to facilitate his collaboration, it is advised to speak to the child during the procedure. This way he does not worry too much about the procedure. Parents should also bring books, games or a tablet with which the child can play during the procedure. It is very important to prepare him psychologically for the treatment. The nature of the treatment must also be carefully and clearly explained to the child. The worst moment of the circumcision is the sting on penile block. The circumcision is then painless, but the patient will still feel the touch and manipulation. If ever the child becomes too agitated, the circumcision is cancelled and postponed to a later age.
What Is the Procedure?
First, one of the two parents may be present during the intervention if he or she desires. To facilitate the child’s collaboration, a narcotic syrup and a low-dose Ativan can be administered an hour before the surgery.
There are several steps to this procedure. First, we apply an anesthetic cream on the penis for about 10 minutes. We then proceed to the penile bloc 10 minutes before the circumcision by infiltrating a local anesthetic adapted to the weight of the child at the base of the penis.
The child is placed on his back.
For a Plastibell™ circumcision, the appropriate sized ring is introduced and placed on the head of the penis using the detachable handle after the incision of the foreskin and its retraction. Then, we proceed to the circumferential ligation of the foreskin with a ligature around the groove of the ring. After this, we trim the excess skin protruding beyond the ring. The ring should fall off on its own 10 to 14 days after the procedure. The residual foreskin will be white or sometimes black like the umbilical cord after birth. Schedule an appointment if the ring has not yet fallen off after 10 days.
For a standard circumcision, the skin is excised using a scalpel. Bleeding is controlled using electrocautery. The excess mucosa is also incised using a scalpel and excised using electrocautery. Finally, there is an aesthetic wound closure. It can be performed with continuous absorbable sutures. This technique leaves less scar marking than with the use of separated sutures which are often used.
A compression bandage is applied around the circumference of the penis.
We schedule an appointment for two (2) months later.
Urologist Dr. Carlos Marois is at your service to answer any questions.