US Pharm. 2012;37(3):HS-2-HS-5.
Male circumcision is a common surgical procedure performed in
neonates, generally for religious or cultural reasons. The 1999
Circumcision Policy Statement of the American Academy of Pediatrics
(AAP) does not recommend routine neonatal circumcision because of
insufficient evidence regarding possible medical benefits. Controversy
concerning the suggested medical benefits of circumcision has led to
debate in recent decades.1-3 Over the past few decades, the
circumcision rate in the United States has dropped. Even given this
decline, circumcision is one of the most commonly performed medical
procedures in the U.S. There are several different devices available for
performing circumcision, and all circumcision procedures require
effective local anesthesia and pain management. Complications from the
procedure, such as bleeding and infection, are rare.
In the U.S., the overall incidence of neonatal circumcision from 1999
to 2010 was approximately 55% to 59%, which is a slight decline from
the previous decade (FIGURE 1); however, the actual incidence is
likely higher, since these estimates do not include circumcisions
performed in the community.4 The reduced incidence could be
due to several factors, including—but not limited to—the AAP policy
statement, population shifts, and changes in Medicaid coverage. AAP’s
stance against routine circumcision may discourage some parents from
circumcising their sons. As immigration changes the makeup of the U.S.
population, circumcision rates could fluctuate, since circumcision is
primarily a religious or cultural decision. As of 2009, neonatal
circumcision is covered by Medicaid in 33 states (two additional states
provide coverage depending upon the enrollment plan).4 Therefore, circumcision rates could continue to decline if more states elect not to provide coverage for the procedure.
Circumcision is most commonly performed among Jews and Muslims based
on religious tradition, and whether or not the child’s father was
circumcised is frequently a determining factor for culturally based
decisions.1,5,6 In the U.S., an estimated 75% of males aged
15 years and older have been circumcised for nonreligious reasons. The
prevalence of males circumcised for nonreligious reasons varies
substantially among countries, as shown in TABLE 1.6
Some advocates of circumcision encourage the procedure for its
potential medical benefits. There is evidence that uncircumcised infants
are more prone to urinary tract infections (UTIs), which may be
attributed to higher bacterial colonization on the glans of the penis.7,8 Schoen et al reported a 9.1-fold reduction in UTI incidence in circumcised males during the first year of life.8
Additionally, circumcision may offer protective benefits against
sexually transmitted diseases (STDs) such as gonorrhea, syphilis, and
HIV, as infectious bacteria that cause STDs are thought to colonize the
area underneath the foreskin.2,5,9-11 HIV binds to CD4 and
CCR5 receptors on Langerhans cells found on the inner surface of the
foreskin, which can lead to an increased risk of HIV transmission during
sexual intercourse.9 Research is ongoing regarding the
potential medical benefits of circumcision, with the possible reduction
of HIV transmission being of great interest worldwide. Furthermore,
circumcision may offer protective benefits against penile cancer. Maden
et al found that the risk of penile cancer was 3.2 times greater in
uncircumcised men than in those who were circumcised; however, the
authors also emphasized the importance of considering sexual history and
other medical conditions when assessing penile cancer risk.12
The Gomco clamp, the Mogen clamp, and the PlastiBell device are the
most commonly used circumcision instruments in the U.S. The Gomco and
Mogen clamps protect the glans of the penis while the foreskin is
removed by means of a crush injury.5,13,14 In randomized
trials, the Gomco clamp was determined to be more painful and took 2.5
times longer to complete the procedure compared with the Mogen clamp;
the Mogen clamp was almost twice as fast as the PlastiBell device, with
no significant differences in pain scores throughout the procedure.14,15 While the Mogen clamp enables the shortest procedure time, it is thought to remove the least amount of foreskin.5,14,15
The PlastiBell device involves the placement of a plastic protective
shield over the glans and under the foreskin. A suture is then placed
over the foreskin, compressing it and resulting in tissue necrosis. The
foreskin and the plastic shield usually fall off within a week.5,14
The instrument used to perform a circumcision depends primarily upon
the provider’s education, training, and overall preference.3,5
Circumcision is contraindicated in premature neonates, those with
bleeding disorders or a family history of bleeding disorders, and those
with penile abnormalities for which the foreskin may be needed for
Anesthesia and Analgesia
The AAP recommends that adequate analgesia be provided during circumcision, since the procedure is known to be painful.1,3,5
In addition to crying, facial grimacing, and behavioral changes,
neonates manifest pain through physiologic markers such as increased
heart rate and blood pressure and reduced oxygen saturation.16
No single agent has been proven to provide complete pain relief for all
neonates undergoing circumcision; therefore, combination therapy is
likely the most effective option.17,18 See TABLE 2 for selected anesthetic and analgesic agents.
Topical Anesthetics: Some providers may prefer
topical anesthetics since they are relatively noninvasive and are proven
to be safe, with minimal risk of methemoglobinemia or systemic
toxicities. Mild erythema, usually occurring within 24 hours, has been
reported in some neonates.19-22 Topical lidocaine-prilocaine
cream (lidocaine 2.5% and prilocaine 2.5%) is a commonly used eutectic
mixture of local anesthetics (EMLA). Through randomized,
placebo-controlled trials, lidocaine-prilocaine cream (0.5-2 g under an
occlusive dressing) has been shown to be significantly more effective
than placebo for reducing pain during circumcision, as measured by
behavioral and physiologic changes.19-21,23
Lidocaine-prilocaine cream (1 g) applied to the penis for 60 to 80
minutes prior to circumcision was found to be safe and effective for
neonates. Neonates who received lidocaine-prilocaine cream spent less
time crying, displayed less facial activity, and experienced smaller
increases in heart rate and blood pressure compared with those receiving
placebo. However, pain relief was diminished during circumcision phases
involving substantial tissue damage.20 Benini et al found
similar efficacy using lidocaine-prilocaine 0.5 g cream applied under an
occlusive dressing for 45 to 60 minutes prior to circumcision.19
Compared with lidocaine 30% cream (1 g), lidocaine-prilocaine cream
(1 g) more effectively reduced crying time and suppressed heart rate and
blood pressure increases in neonates undergoing circumcision.21
Topical lidocaine 30% cream (0.5 g) applied to the penis 20 minutes
before circumcision did not have an overwhelmingly significant advantage
over placebo in terms of physiologic changes; newborns in the placebo
group, however, experienced more crying (and at a higher intensity) and
leg and arm flailing than the lidocaine group. Lidocaine cream was
concluded to be a safe option in newborns since no significant systemic
absorption of lidocaine was reported.24
Dorsal Penile Nerve Block (DPNB): Although more
invasive than lidocaine-prilocaine cream, DPNB is a more effective
method of providing local anesthesia to infants undergoing circumcision.22,25-27
DPNB is administered by injecting lidocaine 1% (0.2-0.5 mL) in two
dorsolateral sites (the 2 o’clock and 10 o’clock positions at the base
of the penis) 3 to 8 minutes prior to circumcision.14,22,25,26,28
Epinephrine should never be added to the lidocaine because of its
vasoconstrictive properties and the risk of ischemia and necrosis.17 To minimize the risk of adverse reactions such as bruising or hematoma formation, proper administration is essential.22
Compared with lidocaine-prilocaine cream, DPNB results in better pain
reduction in terms of behavioral changes, pain scale scores, and/or
physiologic alterations.22,24,26 Two studies that used
Neonatal Infant Pain Scale (NIPS) scores as endpoints concluded that
NIPS scores were significantly lower in neonates receiving DPNB versus
lidocaine-prilocaine, indicating greater pain reduction.22,26
Additionally, Butler-O’Hara et al reported that infants receiving
lidocaine-prilocaine cream (0.5 g applied 60 minutes prior) experienced
an escalation in heart rate more than fivefold greater than in infants
Subcutaneous Ring Block: As with DPNB, ring
block is more invasive than lidocaine-prilocaine cream and should be
administered by a trained clinician; however, the pain of injection is
less than that of circumcision. Ring block was determined to be superior
to DPNB (0.4 mL of lidocaine 1% at two dorsolateral injection sites),
lidocaine-prilocaine cream (2 g applied 90 minutes prior), and placebo
in newborns undergoing circumcision. The ring block was administered by
injecting 0.8 mL of lidocaine 1% in a “ring” around the penis (halfway
along the shaft) approximately 8 minutes prior to the procedure. Ring
block more effectively reduced pain during foreskin separation and
incision, as evidenced by less crying and lower heart rate. DPNB was the
second most effective anesthetic, followed by lidocaine-prilocaine
cream. About one-half of newborns in the ring block and DPNB groups
experienced minor bruising following the procedure. As with DPNB,
epinephrine should not be added to the lidocaine.23
Acetaminophen: Acetaminophen is commonly used to
relieve discomfort or pain in infants, but it is not recommended as the
sole analgesic to reduce circumcision-related pain. In a double-blind,
placebo-controlled trial, infants were randomized to receive either
placebo or acetaminophen 15 mg/kg every 6 hours for 24 hours, beginning 2
hours before the procedure. Crying time and physiologic changes (heart
and respiratory rates) were monitored throughout the procedure, and a
standardized comfort score was used to determine postoperative pain. No
significant differences were apparent between the two groups during the
intraoperative period and the immediate postoperative period. Infants
receiving acetaminophen showed statistically significant improvements in
comfort scores 6 hours postoperatively, which implies that
acetaminophen may be beneficial after the initial postoperative period.27
Sucrose: The use of sucrose-dipped pacifiers in
neonates has been shown to be superior to the use of water-dipped
pacifiers for reducing crying during painful procedures (circumcision
and heel sticks).18,29,30 Sucrose is less effective than
lidocaine-prilocaine cream or DPNB for reducing pain, as determined by
changes in heart rate, oxygen saturation, and blood pressure.18,31
However, the combination of sucrose and lidocaine-prilocaine cream has
been shown to be more effective than either agent alone for relieving
neonatal pain associated with circumcision.18
The complication rate for circumcision reported in the literature
varies, but is generally between 2% and 5%. The most common complication
is bleeding, with a reported incidence of around 1%. Direct pressure to
the site is sufficient to control bleeding in most patients.32
Occasionally, the use of thrombin, epinephrine, or sutures may be
required. Infection may occur, but with less frequency than bleeding,
and can be successfully treated with oral antibiotics and local wound
care. The most serious long-term complication is the inability to
retract the remaining foreskin, which results in phimosis. This may be
treated with topical steroids; however, surgical revision is usually
required. Less common complications include skin bridges, inclusion
cysts, fistulas, glans injury, and penile-sensation deficits.33
Ultimately, the decision regarding neonatal circumcision is to be
made by the child’s parents. The benefits and risks of the procedure
should be explained to the parents in an unbiased fashion, thereby
allowing them the opportunity to make the best decision for their child.
If circumcision is performed, combination analgesic therapy should be
provided for the most effective pain relief. Ring block and DPNB are
superior to lidocaine-prilocaine cream and lidocaine cream for reducing
pain during the procedure. In addition to an anesthetic, a
sucrose-dipped pacifier can help soothe the neonate during circumcision,
and acetaminophen has shown benefit for relieving postoperative pain.
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2. Lerman SE, Liao JC. Neonatal circumcision. Pediatr Clin North Am. 2001;48:1539-1557.
3. Howard CR, Howard FM, Garfunkel LC, et al. Neonatal circumcision and pain relief: current training practices. Pediatrics. 1998;101:423-428.
4. CDC. Trends in in-hospital newborn male circumcision—United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2011;60:1167-1168.
5. Alanis MC, Lucidi RS. Neonatal circumcision: a review of the world’s oldest and most controversial operation. Obstet Gynecol Surv. 2004;59:379-395.
6. World Health Organization (WHO) and Joint United Nations Programme on HIV/AIDS. Male Circumcision: Global Trends and Determinants of Prevalence, Safety and Acceptability. Geneva, Switzerland: WHO; 2007.
7. Ginsburg CM, McCracken GH Jr. Urinary tract infections in young infants. Pediatrics. 1982;69:409-412.
8. Schoen EJ, Colby CJ, Ray GT. Newborn circumcision decreases
incidence and costs of urinary tract infections during the first year of
life. Pediatrics. 2000;105:789-793.
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10. Moses S, Plummer FA, Bradley JE, et al. The association between
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11. Cook LS, Koutsky LA, Holmes KK. Circumcision and sexually transmitted diseases. Am J Public Health. 1994;84:197-201.
12. Maden C, Sherman KJ, Beckmann AM, et al. History of circumcision,
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13. Wan J. GOMCO circumcision clamp: an enduring and unexpected success. Urology. 2002;59:790-794.
14. Kurtis PS, DeSilva HN, Bernstein BA, et al. A comparison of the
Mogen and Gomco clamps in combination with dorsal penile nerve block in
minimizing the pain of neonatal circumcision. Pediatrics. 1999;103:e23.
15. Taeusch HW, Martinez AM, Partridge JC, et al. Pain during Mogen or PlastiBell circumcision. J Perinatol. 2002;22:214-218.
16. American Academy of Pediatrics, Canadian Paediatric Society. Prevention and management of pain and stress in the neonate. Pediatrics. 2000;105:454-461.
17. Taddio A. Pain management for neonatal circumcision. Paediatr Drugs. 2001;3:101-111.
18. Mohan CG, Risucci DA, Casimir M, et al. Comparison of analgesics in ameliorating the pain of circumcision. J Perinatol. 1998;18:13-19.
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20. Taddio A, Stevens B, Craig K, et al. Efficacy and safety of lidocaine-prilocaine cream for pain during circumcision. N Engl J Med. 1997;336:1197-1201.
21. Woodman PJ. Topical lidocaine-prilocaine versus lidocaine for neonatal circumcision: a randomized controlled trial. Obstet Gynecol. 1999;93:775-779.
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penile nerve block. Pediatrics. 1998;101:e5.
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block, dorsal penile nerve block, and topical anesthesia for neonatal
circumcision: a randomized controlled trial. JAMA. 1997;278:2157-2162.
24. Weatherstone KB, Rasmussen LB, Erenberg A, et al. Safety and efficacy of a topical anesthetic for neonatal circumcision. Pediatrics. 1993;92:710-714.
25. Williamson PS, Williamson ML. Physiologic stress reduction by a local anesthetic during newborn circumcision. Pediatrics. 1983;71:36-40.
26. Garry DJ, Swoboda E, Elimian A, Figueroa R. A video study of pain relief during newborn male circumcision. J Perinatol. 2006;26:106-110.
27. Howard CR, Howard FM, Weitzman ML. Acetaminophen analgesia in neonatal circumcision: the effect on pain. Pediatrics. 1994;93:641-646.
28. Kirya C, Werthmann MW Jr. Neonatal circumcision and penile dorsal nerve block—a painless procedure. J Pediatr. 1978;92:998-1000.
29. Blass EM, Hoffmeyer LB. Sucrose as an analgesic for newborn infants. Pediatrics. 1991;87:215-218.
30. Kaufman GE, Cimo S, Miller LW, Blass EM. An evaluation of the
effects of sucrose on neonatal pain with 2 commonly used circumcision
methods. Am J Obstet Gynecol. 2002;186:564-568.
31. Herschel M, Khoshnood, Ellman C, et al. Neonatal circumcision. Randomized trial of a sucrose pacifier for pain control. Arch Pediatr Adolesc Med. 1998;152:279-284.
32. Weiss HA, Larke N, Halperin D, Schenker I. Complications of
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33. Malone P, Steinbrecher H. Medical aspects of male circumcision. BMJ. 2007;335:1206-1209.
34. Lehr VT, Cepeda E, Frattarelli DA, et al. Lidocaine 4% cream
compared with lidocaine 2.5% and prilocaine 2.5% or dorsal penile block
for circumcision. Am J Perinatol. 2005;22:231-237.
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