Comprehensive Urology

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The daVinci System

Delta Medix Patient General Information

Pediatric Circumcision / Revision of Circumcision

Definition

Removal of the prepuce (foreskin) that covers the glans penis (head of the penis).

In a baby most circumcisions are performed within the first few days of life before the newborn is discharged home. In other instances, parents make a decision to have their son circumcised later in infancy or even during childhood. Some of the reasons include:

  1. Phimosis: This means that the opening of the foreskin has scarred down and the individual or parents cannot pull it back easily, or in some cases, at all. This may result in poor hygiene, and in extreme cases, interfere with urination.
  2. Urinary Tract Infection: When a young boy gets urinary tract infections, often circumcision is recommended when there is no other determined cause of the infections.
  3. Infection: The head of the penis or the foreskin itself may become repeatedly infected. Patients who have an initial infection are more likely to have problems with recurrent infections.
  4. Elective: In these cases, parents may tell the pediatrician or urologist that they wish to undergo circumcision for cosmetic or religious reasons.

Circumcision is performed as an outpatient procedure. Children are placed under general anesthesia so they are not aware of the procedure. In addition, some surgeons use a local injection of a long-acting local anesthetic agent to minimize pain when the child awakens. The recovery time is typically short.
Occasionally a newborn is circumcised but there is a problem with the healing process. In certain instances, there may be extra skin left behind. In other situations, some of the skin may form adhesions (skin bridges or scar tissue). Both scenarios may necessitate a "revision" of the circumcision. these procedures are fairly similar to a first-time circumcision with respect to preparation, procedure, recovery, and possible complications.

Preparation

As with any procedure in which anesthesia is administered, you will be asked not to feed your child anything (including any liquids) after midnight on the evening prior to the surgery. If your child is on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if your child is on, or has recently been taking any medication that may interfere with his ability to clot his blood. The most common of these medications are aspirin-like compounds and all related pain relievers, fever reducers, or anti-inflammatory compounds(whether prescription or over-the-counter). Please refer to the attached list and tell us if he has taken any of these within the past 10 days. If his medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed any of the current medications with you during the pre-operative/pre-procedure consultation.

You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

To review the basics of what we discussed in the office: The procedure usually takes less than one hour.
There are several methods to remove the foreskin. Each surgeon is comfortable with, and typically favors a specific approach. In the end, the result is the same.

Once the excess skin is completely removed, we examine the glans penis (the head) to ensure that the meatus (hole through which one urinates at the end of the penis) is of proper caliber(wide enough) and location. We also inspect the frenulum (web-like tissue on the undersurface of the penis that bridges the glans and the shaft) to ensure that it is not pulling on the glans. If this finding is apparent, we perform a frenulotomy (simple division of the skin bridge or frenulum). We then inspect the area where the skin was removed and ensure that there is no bleeding. The skin edges are sewn together, and may be coated with an antibiotic ointment. Next, we place a loose-fitting bandage around the penis. The dressing does not block the meatus, so it does not obstruct the flow of urine.

Post Procedure

Your child will be in the recovery room for a short time before being sent home. He may have some discomfort, but typically not any severe pain due to the administration of local anesthesia during the surgery. As mentioned, there will be a small dressing directly around the penis that covers the incision. Unless otherwise instructed by your surgeon, this dressing should be removed the following morning. Often we get phone calls that afternoon or evening that the bandage fell off prior to the following morning. If there is no significant bleeding, this is not a concern and you should not worry. Do not attempt to replace the bandage. It is not uncommon to see small blood staining under the bandages. If the bandage becomes soaked, or you see active blood oozing, please contact us. Sponge baths on other areas of the body are acceptable on the first day or so. Some surgeons will ask that you keep the surgical site dry for a few days longer while others may recommend warm baths a few days after the procedure. If your child is older (walking/running age), we ask that he refrain from any strenuous activity or rough play until after his follow up. Every patient has some degree of swelling and bruising, and it is not possible to predict in whom this might be minimal or significant. For this reason, the penis may appear slightly wider and/or discolored. Some patients have almost no discomfort while others are somewhat uncomfortable for a few days; longer is rare. For discomfort, he may have a pediatric-dose over-the-counter medicine to which he is not allergic (Tylenol®, Advil® or other ibuprofen product). Upon follow up in the office, we will examine the surgical repair. The sutures we use are self-dissolving, and therefore just dissolve with time. They need not be removed.

Expectations of Outcome

Circumcisions typically heal quite well. There is usually some swelling that may make the penis appear curved or wide. This swelling will disappear over the next few weeks.

Your child will not have burning when he urinates. The only exception is if we have to perform a meatotomy (open the caliber of the hole through which he urinates). If this is the case, we will discuss this finding with you after the procedure.

The suture line may be visible for quite some time after the sutures dissolve and fall out. These markings usually fade with time as the child grows.

Possible Complications of the Procedure

ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in the consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia, it is important that parents be made aware of all possible outcomes which may include, but are not limited to:

  • Meatal Stricture or Stenosis: Following circumcision, the meatus (hole at the very end of the urethra or tip of the penis) is now exposed to the diaper or undergarments. Chronic irritation may cause it to scar tighter. The result may be a slight obstruction to the free flow of urine. Often the urine stream is deflected upward and sprays. It may require a minor revision procedure such as dilatation or tiny incision.
  • Infection: Infection is possible following any procedure. Usually, warm compresses and antibiotics are sufficient. Occasionally, an infection would require partially opening the wound to allow proper drainage.
  • Hematoma: This is when a small blood vessel continues to ooze or bleed after the procedure is over. The result is greater swelling and bruising. A drainage procedure is rarely necessary and it usually resolves over time with compresses...much like any bad bruising or swelling. If the hematoma is unusually large (cumbersome or painful) or does not show resolution in a reasonable amount of time, a procedure to evacuate the clots may be required.
  • Suture Breakdown: If the penis is accidentally traumatized after the surgery, some or all of the sutures can tear. If soon after the circumcision, and if immediate attention is sought, sutures may be replaced in the operating room. In most instances, it is just a few sutures, and there is little that we need to do. In most cases, the circumcisions will still heal nicely.
  • Injury to the Glans (Head of) Penis: This is an extremely rare complication. When recognized, we will do what is indicated to repair the injury.
  • Penile Torsion or Chordee: During the procedure, the skin edges are aligned and subsequently sewn together. Nevertheless, there may be a slight torsion (rotation or twisting) to one side. If more skin is taken from one side than another, a chordee (bend of the penis to one side) could result. In either scenario, a revision procedure may be necessary. Penile torsion and chordee are conditions that babies may be born with and are both very uncommon following circumcision.
  • Chronic Pain: As with any procedure, a patient can develop chronic pain in an area exposed to surgery. Typically, the pain disappears over time. If persistent, further evaluation would be necessary.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office.

Alternative treatments, the purpose of the procedure/surgery, and the points in this hand out have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While Delta Medix endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. Delta Medix cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

Delta Medix, P.C.