Yes. We are still performing circumcisions for newborns during the pandemic. Our belief is that if we delay this procedure, then the baby will require general anesthesia. We feel that that risks of general anesthesia are greater than the risk of potential exposure to COVID-19.
We will only perform the circumcision under the following conditions:
1. Both parents are permitted into the examination room while Dr. Singer is in the room.
2. No other children are permitted into the office.
3. We need 100% confidence that neither parent has any upper respiratory symptoms, including cough, sore throat, shortness of breath, loss of taste or smell, or fever.
4. We need 100% confidence that neither parent has had direct exposure to a COVID-19 patient in 2 weeks.
5. Anyone entering the office must be wearing a mask at all times.
Dr. Singer will take full precautions to protect himself as well as you and your baby. He will wear an N-95 mask, surgical hat and a surgical gown. The local anesthetic will be administered while Dr. Singer is wearing an N-95 mask. He will switch over to a fog less surgical mask just prior to the procedure. And then he will immediately switch back to an N-95 mask. He will change his gloves frequently, especially if he touches anything that could cause contamination. All surfaces in our office are sterilized with anti-viral spray.
It is strongly advisable for your baby to receive Vitamin K Prophylaxis before the circumcision to reduce the risk of bleeding.
The AAP currently recommends routine administration of Intramuscular (IM) Vitamin K to all newborns in order to prevent the development of spontaneous internal bleeding (hemorrhagic disease of the newborn). Oral Vitamin K is useful in preventing early hemorrhagic disease, but is not reliable in preventing late bleeding. Thus, IM Vitamin K is preferable over Oral Vitamin K which is preferable over receiving no Vitamin K.
Dr. Singer will still perform the circumcision if your baby has not received Vitamin K; however, parents should understand that there is a slight increased risk of bleeding from the surgical site, which could theoretically require hospital intervention. It is difficult to quantify the exact risk. To date, Dr. Singer has been able to control all post circumcision bleeding in the office and he has never needed to send a baby to the hospital for persistent bleeding.
Circumcision is a surgical procedure in which the skin (i.e. foreskin) that covers the head of the penis is completely removed, creating complete exposure of the glans.
The foreskin has an important function in the fetus. It is essential for the normal development of the penis, starting in the third month of pregnancy. As the penis begins to form primitive tissues, the skin on the shaft grows faster than the shaft itself, and folds over to form a hood. This foreskin hood completely encircles the head of the developing penis, and is responsible for the normal formation of the end of the penis, including the urinary opening (urethra).
If the foreskin is incomplete, an abnormal condition known as hypospadias develops, in which the urethra opens on the underside of the penis. Once the penis is fully developed (7th month of gestation) the foreskin no longer serves a purpose, and it ultimately becomes a liability. Contrary to popular myth and unsubstantiated anecdotes, the foreskin has no significant effect on sexual function. (Ed Schoen MD on Circumcision; RDR Books 2005)
Routine newborn circumcision is considered elective surgery and is not medically required. Therefore, parents must choose whether or not circumcision is right for their baby. Some parents prefer circumcision based on personal, religious, or cultural beliefs. Many parents choose circumcision because of ease of genital cleanliness. Others feel strongly that newborn circumcision should not be performed, and prefer to wait until the child is old enough to make his own decision.
Physicians should inform parents of the risks and benefits of newborn circumcision in an unbiased and accurate manner. Ultimately, parents should make an informed decision based on the best interest of their child.
The most recent circumcision policy statement published in 2012 by the American Academy of pediatrics states:
Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and that the procedure’s benefits justify access to this procedure for families who choose it…(However)…the health benefits are not great enough to recommend routine circumcision for all male newborns. Parents ultimately should decide whether circumcision is in the best interests of their male child.
There are at least six medically proven circumcision advantages, beginning in newborns and continuing through old age. Some of these benefits are grouped together below:
A. Reduced Risk of Urinary Tract Infection – Numerous major scientific studies have shown that an uncircumcised infant boy has 10 times the risk of developing a urinary tract infection (UTI) in the first year of life. Why would that be? The answer is that the foreskin acts as a haven for bacteria such as E. Coli, which contaminate the urine and migrate up to the kidney. UTIs in infants can be serious, causing both permanent scarring of the kidney with loss of function, as well as spread of infection to the blood and other parts of the body. Therefore, circumcision serves as a protective effect against urinary tract infection in newborns and infants.
B. Reduction of Local Penile Problems – Care of an uncircumcised penis of a young boy or adult requires proper hygiene and regular cleaning underneath the foreskin with soap and water. Poor hygiene can lead to an unpleasant infection of the foreskin and glans called balanoposthitis, in which the glans and foreskin become red, swollen, and painful with discharge. Balanposthitis requires treatment with antibiotics.
Yeast can also get trapped under the foreskin causing candida balanitis. In some instances, the foreskin can become painfully trapped below the head of the penis (paraphimosis), or it can remain tightly adherent to the glans into adulthood (phimosis), both of which may require surgical intervention, including general anesthesia.
Finally, certain genital dermatological diseases, such as lichen sclerosis and Zoon’s balanitis, are more prevalent in uncircumcised men. And, in fact, circumcision is often the treatment of choice for these diseases.
C. Reduced Acquisition of Sexually Transmitted Infections - Abrasions and microscopic tears of the foreskin create a portal of entry for sexually-transmitted organisms. Newborn circumcision has been shown to reduce the acquisition of the following sexually-transmitted diseases:
HIV (Human Immunodeficiency Virus) – There is a 40% to 60% reduction in acquisition of HIV among heterosexual males in areas of high HIV prevalence.
HPV (Human Papilloma Virus) – There is approximately 30% to 40% reduction in HPV acquisition among circumcised men. Since human papilloma virus is the primary cause of cervical cancer, there seems to be a protective effect of male circumcision against cervical cancer in female partners (3 fold reduction).
Genital Herpes (Herpes Simplex Virus) – Approximate 35% reduction in acquisition of HSV-2 in circumcised men.
There is some additional data, though less conclusive, that circumcision reduces acquisition of syphilis and bacterial vaginosis.
D. Reduced Risk of Penile Cancer – Uncircumcised men are only three times as likely to develop noninvasive squamous carcinoma of the penis (a relatively benign form of the disease). However, they are more than 20 times as likely to develop invasive (malignant) squamous cell cancer of the penis (a rarer, but more devastating disease).
The true incidence of complications after newborn circumcision is unknown, in part due to different definitions of “complication.” In experienced hands, the risks are minimal, and significant complications are quite rare. Nonetheless, all surgical procedures involved some risks, including:
Bleeding – A tiny amount of bleeding immediately after the procedure is normal. “Spotting” of blood (without active bleeding) may continue for up to 24 hours and is also normal. More serious bleeding may occur if there is a history of hemophilia or other bleeding disorders, such as a low platelet count. There may be a slight increased risk of bleeding in babies who do not receive Vitamin K.
In the usual case that bleeding occurs (1 in 500 newborns), it is typically controlled by direct pressure or application of a bandage. Sometimes bleeding requires the use of hemostatic agents, such as aluminum chloride or electrocautery. And rarely, stitches may be needed. If bleeding is uncontrollable, hospitalization and transfusion may be necessary.
In the 20 years that Dr. Singer has been performing circumcisions, he has never had a bleeding complication that he could not handle in the office.
Infection – The risk of infection with newborn circumcision is exceedingly rare (less than 1 in 1,000 newborns). Infection is rare because of the use of sterile autoclaved instruments as well as the outstanding blood flow to the area (which carries protective immune cells with it). Nonetheless, the risk of infection is still rarely possible and would require antibiotics. In the 20 years that Dr. Singer has been performing circumcisions, he has never had a baby develop an infection.
Errors in Skin Removal – This is the most common complication of newborn circumcision. The exact prevalence of this complication is unknown, and varies significantly depending upon level of experience of the practitioner. Typically, the more experienced the surgeon, the better the cosmetic result.
There is some estimation when deciding how much skin to remove, especially since there is so much anatomic variability. Those babies who have hydroceles (fluid around the testicle), torsion or rotation of the penis, shorter penises, and prematurity may present challenges in deciding how much skin to remove. Practitioners and parents do not want excessive skin removed nor do they want too little skin removed (in which cases the penis looks incompletely circumcised).
In order to be as precise as possible, Dr. Singer analyzes all of the anatomy before the procedure and uses a surgical marking pen to guide the exact amount of skin to be removed. Dr. Singer’s rate of revision is less than 1%.
Unfortunately, no guarantees can be made as to the cosmetic outcome of the procedure.
Injury to the Head of the Penis – This is an extraordinarily rare complication, and has never occurred in Dr. Singer’s hands.
Death – There are perhaps one or two cases reported of a baby dying from newborn circumcision. Fortunately, this is an extraordinarily rare complication, and has never occurred in Dr. Singer’s hands.
Complications of circumcision may also occur months after the procedure and include physiological adhesions, skin bridges, medical stenosis, phimosis, buried penis, and epidermal inclusion cysts. Some of these complications are easily treated in the office while others may require surgical intervention by a urologist.
Full Term Babies – The baby must be healthy and preferably under one month of age, and/or less than 12 pounds. The risk of bleeding, and the need for sutures increases beyond this age/size. The American Academy of Pediatrics recommends that all babies receive intramuscular Vitamin K prior to circumcision.
Pre-Mature Babies – These babies should be at least 5 to 6 pounds, and preferably less than 10 pounds. Some of these babies are older than a month at the time of circumcision, but if one corrects for the degree of prematurity, their “corrected” age is less than a month of age (e.g. born at 32 weeks gestation, and currently 5 weeks old, so “corrected” age is 37 weeks, which equates to a newborn).
Babies older than one month may be considered eligible for circumcision at Michigan Circumcision on a case-by-case basis.
Any baby with the following should postpone circumcision:
- Significant Prematurity
- Those with Bleeding Disorders or Significant Family History of Bleeding Disorder
- Congenital Abnormalities of the Penis, Such As Hypospadias, Chordee, Sever Torsion, or Penile Scrotal Fusion
Dr. Singer’s preference is the Mogen Clamp due to its speed and accuracy. The circumcision is performed in approximately 60 to 70 seconds with minimal distress to the baby. Care is taken to ensure complete separation of all glandular adhesions prior to the removal of the foreskin.
Most physicians use the Gomco Bell or Plastibell, both of which are good surgical instruments, but require a much longer operating time (5 to 10 minutes) along with significantly more tissue handling. This may produce more distress for the baby. Use of the Mogen Clamp requires advanced surgical training, and is not available in most hospitals.
At Michigan Circumcision, we use a pain control protocol.
Dr. Singer’s pain control protocol begins with the administration of an oral sucrose solution. Medical studies have proven that sugar raises the baby’s natural endorphins (i.e. natural painkillers). Once the baby is sucking on the sugar solution, the local anesthetic can be injected with minimal discomfort.
Dorsal penile nerve block is the standard form of local anesthesia for newborn circumcision. This method involves two injections at the base of the penis that temporarily numb the nerves that provide sensation to the penis. A third injection on the ventral aspect of the penis is also administered by Dr. Singer to maximize the effectiveness of the block. Nerve blocks are extremely safe, and complications from nerve block are extraordinarily rare. Furthermore, nerve blocks are endorsed by the American Academy of Pediatrics as the standard of care for newborn circumcision.
Dr. Singer uses a lower concentration of lidocaine (0.5% vs 1.0%) than that typically used in the hospital. The 0.5% preparation is equally effective as the higher concentration, but is safer for babies who weigh less. Dr. Singer buffers the lidocaine solution with bicarbonate. This raises the pH of the solution and reduces the burning sensation of the anesthetic. And finally, Dr. Singer has pioneered an anesthetic preparation in his office that provides a more robust and consistent nerve block. The local anesthetic lasts about 45 minutes.
Soothing music and gentle touch further relax the baby. We estimate that 90% of babies do not cry during the circumcision.
We do not use any sedation or general anesthesia for newborn circumcision.
Dr. Singer uses a number of techniques to minimize discomfort which includes soothing music, parental presence, a comfortable atmosphere, concentrated sugar solution, a nerve block, and a padded board. With all of these factors, most babies do not feel pain during the procedure. In the event that the baby does feel some discomfort, parents can rest assured that the procedure time is about 70 seconds. Approximately 45 minutes after the procedure, the local anesthetic will wear off and he will feel some discomfort, but at that point the parents can hold and swaddle the baby to comfort him.
7 to 14 days is preferred. However up to 30 days of age is acceptable.
Most of the time, the circumcision will be fully healed in 7 to 10 days. However, it may take a full month for all swelling to resolve. Those babies who are older at the time of circumcision typically take longer to heal.
Yes, he will have no problem urinating. The urination will not affect the healing of the circumcision nor cause him discomfort.
Most babies sleep for several hours after the circumcision and then wake up cranky. All babies must feed within six hours after the circumcision. Typically, most are back on their schedule within 24 hours.