Boy Circumcision in Uroklinik
What is required?
According to the National Board of Health’s guidelines, there must be an informed consent from the parent’s holder of the authority. In the case of joint parental authority, both parties must be informed and give consent to carry out the operation.
This applies to all boys under 15 years age.
Age
There is no specific age limit for circumcision, based on our many years of experience the best age is under 4 months, and a minimum weight of 5 kg. The typically most difficult age is between 2 years and 4 years, but it can still be done without problems. Age from 5 years and up, after which we assess circumcision using the classical method (conventional cut and sew) as being the most suitable method.
Which method?
Basically, we recommend the ring method (plastibell method) for all boys under 1 year, but we also quite often use the ring method for boys between 1 year and 3 years, who still use diapers. For the rest, ie boys over 3 years, the classic method (conventional cut and sew) is recommended.
What is the difference between the ring method and the classic method?
With the ring method we remove ¾ part of the foreskin and the remaining ¼ part falls off with the ring or disappears on the ring. The operation with the ring method (plastibell) takes about 7-10 minutes.
With the classic method, we remove the entire foreskin and then we ensure that there is no bleeding using diathermy and afterwards we sew the edges of the foreskin leaves with a self-dissolving sutures. The operation takes about 20-30 minutes
On the day of surgery
We recommend that the child takes a bath before coming to the clinic, as there is less risk of infection.
Approx. 30 to 45 minutes before coming to the clinic, the child’s penis should be lubricated with a thick layer of the local anesthetic crème (either Emla or Tapin crème) on the root (base of the penis). Please see the picture.
The crème must be lubricated on the area presented by the blue circle and almost with the same thickness. The area lubricated with the crème must be covered by the transparent patches which accompany the cream in the package.
Local anesthetic cream is available in 2 types, either Emla cream or Tapin cream and you have to choose only one of them and there is no difference (No one is better than the other). This is to minimize pain when the child gets the right anesthetic in the form of penis block (as an injection on the root of the penis) in the clinic a few minutes before circumcision.
You can read more about the 2 anethetics, which have been approved by the Danish Medicines Agency:
See the video below about the anesthetic cream
Before surgery
Before surgery, the child gets a penis block, as an injection in the root (basis) of the penis. The area that will be injected is lubricated in advance with the local anesthetic cream which will cause very limited discomfort under injection itself.
Which method?
Ring-Plastibell method.
With this method, we remove approx. ¾ part of the foreskin off and the last ¼ part falls off with the ring or before.
The operation takes approx. 7-10 minutes.
As mentioned before, we use the ring method for young children, and preferably those under one year age. The best age for circumcision with this method is, in our experience, 5-7 weeks old and a weight of at least over 4 kilos. We occasionally use the procedure for the older children who are still wearing diapers. Use of diapers is a requirement for this procedure.
At the request of the parents, we also sometimes use the classic method for small children.
The classic method. (conventional cut and sew)
With this method, virtually the entire foreskin is removed, and there is control over exactly how much skin needs to be cut off. The bleeding is stopped by electrical coagulation, and finally both leaves of the foreskin are sewn with an absorbable sutur, which disappears by itself after 2-6 weeks. We use this method for the older children who no longer wear diapers.
Gomgo clamp method
Is mostly used in USA and we do it after request from the parents.
The Gomco clamp has become one of the leading instruments used in the performance of non-ritual circumcision in the United States. This device is popular because of its safety record in preventing injury and bleeding.
The Gomco clamp is a surgical instrument used to perform circumcision in all age groups, but is mainly used in newborn circumcision. It is the leading instrument for newborn circumcision in the US. The WHO describes it as having “an impeccable safety record.
After retracting the foreskin, the Gomco bell is placed over the glans at the level of the corona and the foreskin is replaced into the anatomic (natural) position. The yoke is then placed over the bell, trapping the foreskin between the bell and the yoke. The clamp is tightened, crushing the foreskin between the bell and the base plate, and left in place for 5 minutes. The crushed blood vessels provide hemostasis. The flared bottom of the bell fits tightly against the hole of the base plate, so the foreskin may be cut away with a scalpel from above the base plate with no risk of injuring the glans.
Mogen Clamp
The Mogen clamp is a surgical instrument which permits rapid circumcision. It is most often used in the newborn period, particularly for Jewish ceremonial circumcision , but is also used in older boys. The newborn version has two flat blades that open 2.5 mm. The Mogen clamp is widely used around the world.
The foreskin is first extended using several straight hemostats. The Mogen clamp is then slid over the foreskin. After confirming that the tip of the glans is free of the blades, the clamp is locked, and a scalpel is used to cut the skin from the flat (upper) side of the clamp. In newborns, no sutures are required. Outside of the newborn period, cyanoacrylate tissue adhesive can be used instead of sutures.
Pain treatment
For small children, Panodil (Panodil Junior), liquid or suppositories must be given. Dosage according to package leaflet and depending on the weight of the child. Pain treatment can be supplemented with other painkillers such as Naproxen or Bonyl.
On arrival at the clinic
Upon the family’s arrival at the clinic, the doctor explains to the parents the procedure as well as as well as how to care for the child after the procedure.
In the event that the child’s weight is unknown or uncertain, the child must be weighed on an electronic scale.
After which a local anesthetic (penis block) is performed on the child.
The penis is already lubricated with anesthetic cream – either Emla cream or Tapin cream, around the root of the penis (base). Penis should be lubricated with the above anesthetic cream approx. 30-45 minutes before arrival at the clinic. With the cream on the penis, the child will not have severe pain when he is locally anesthetized.
A few minutes later the circumcision starts. The method depends on the age of the child, but usually the ring method (plastibell) is used for all children under 1 year of age. For all other children, the classic method is used. It can also be considered to use the ring method for older boys who still wear diapers.
How to take care of the child after ring method
- The child should wear a large diaper (to avoid pressure on the penis). It is recommended to use 2 or 3 sizes larger than the one the child normally uses.
- The baby should be bathed every day until falls down. The child may only be bathed in a shower and thus not in a bathtub. In addition, it can be recommended to use only perfume-free baby shampoo.
- At each diaper change, rinse thoroughly on the penis and scrotum (whole of the genital area) with plenty of water. Then dry thoroughly and finish by applying a greasy cream on the head of the penis (glans penis) – e.g. Vaseline or Locobase can be used.
- When the child is carried, direct pressure / pressure on the penis must be avoided. The child will naturally be tender in the area and it will therefore hurt if you come to press on the penis, which is why you need to pay special attention to this.
- To avoid pressure on the area, it is therefore recommended that the child only wear only diapers in the lower part and normal clothing on the upper part of the body. If it is cold, the child can be covered with a blanket.
- The result of the circumcision will be nicer for each day after the ring has fallen off. The healing process takes some time and can take up to 5 weeks before the final result can be assessed.
Points 1-5 must be applied until the ring has fallen off. On the other hand, when the ring has fallen off, the child can be treated as before the circumcision without special reservations.
The ring will gradually fall off the penis and not just at once. It may happen that the ring comes loose on one side and subsequently on the other side. It can also happen that the ring hangs in a small thread before it finally falls off the penis. Patience is very important and you do not pull on the ring, as the ring must be allowed to fall off naturally to avoid complications as bleeding.
After the ring has fallen off, the penis head (glans penis) should be inspected. The focus should be on whether the foreskin covers the head of the penis and in this case, the foreskin should be pulled back until the head of the penis is bare.
If the foreskin is adhered to the glans, then the clinic must be contacted.
If the foreskin is not adhered to the glans penis, but covering a part of it, then it is a good idea to put baby powder on the glans while you are polling back the foreskin. This should be done every time you change the diaper and do it for a couple of weeks.
When to respond after the Ring-Plastibell method?
The clinic must be contacted in case of:
– Large portion of the penis head (glans penis) protrudes from the ring. In such case it may be necessary to remove the ring acute.
– The ring has not fallen after 10 days
-Pronounced swelling, redness, thick fluid / pus or fever (signs of infection).
– The foreskin is adhered to the head of the penis (glans penis) after the ring falls off the penis.
How to take care of the child after the classic method (conventional cut and sew)
- Approx. 24 hours after the circumcision, the child must be bathed. It may only be bathed in a shower and thus not in a bathtub. In addition, it is recommended to use perfume-free baby shampoo exclusively. In the bath, all patches must be removed so that there is no dressing left.
- The child should have a shower daily for 10-14 days.
- Each time the child urinates, the penis should be rinsed thoroughly with plenty of water and dried after rinsing.
- In some cases, it may be necessary to lubricate the head of the penis as well as the area with stitches with an antibiotic cream such as Fucidin (in case of signs of infection). If this is the case, the area should be lubricated 3 times a day for 7-10 days.
- The child should avoid strenuous physical activities such as cycling, swimming, football and similar activities for a minimum of 4 weeks after circumcision.
- The final result can be expected 6 weeks after the end of circumcision (expected healing time).
What should one be aware of after circumcision with the classical method?
The clinic is contacted in case of:
Pronounced swelling or oozing with pus around the head of the penis and the foreskin or between the sutures.
– Fever without obvious focus.
– If there is still 3-4 weeks after circumcision, adhesion between the foreskin and the head of the penis is observed.
It should be emphasized that it can typically take up to 6 weeks before the final result can be assessed and the healing is expected to be complete.
Possible complications after circumcision with ring method
Complications after circumcision with the ring method are fortunately rare, especially if one follows the mentioned guidelines applicable to aftercare when using the ring method. In addition, the guidelines will be thoroughly reviewed with the parents before the procedure itself. Finally, relevant documentation is handed out about the important details in aftercare, which can be used in case of doubt when you are at home.
- Swelling and redness are a common reaction and are called inflammation. Inflammation is characterized by the area around the wound becoming hot, red, swollen and painful. This is a natural reaction from the body as the wound from the circumcision causes local irritation leading to dilation of blood vessels and therefore the above symptoms.
- Bleeding can occur quite rarely after circumcision with the ring method, but minor trauma to the penis can cause bleeding. If this happens, call the emergency number. In the first instance, the best advice is to perform compression around or at the bleeding site, possibly. with a greasy tissue. In the event of a lack of effect of this measure, medical contact is necessary.
- Infection is very rare with the ring method. It is important to distinguish inflammation, which is a natural response, from infection, which involves bacteria. It typically shows up with thick liquid (pus) around the wound and possibly, affected general condition with fever in the child. In this case, medical contact is necessary so that relevant antibiotics can be started.
- It happens from time to time that you accidentally pressure on the ring, so that the head of the penis (glans) is pushed further out through the ring and swell. The clinic must be contacted in this case as removal of the ring may be necessary.
- Once the ring has fallen off, it is not abnormal for some of the foreskin to continue to cover a small part of the penis head, however, one must be aware of whether there is adhesion of the foreskin to the penis head. If there is a suspicion of adhesion of the foreskin on the head of the penis, the clinic must be contacted.
- After circumcision, the penis can sometimes be pulled into the abdominal wall (abdomen) and best seen by pressure on the abdomen around the penis. This is typically seen in obese children. The clinic must be contacted for further information and guidance.
Complications after circumcision with classical method (Removal of the foreskin and subsequent suturing of foreskin edges).
Swelling, redness and pain, also called inflammation, are a common reaction. This is the same process mentioned under point 1on complications after ring method. In addition, leakage of clear and thin liquid may occur, which is harmless.
Bleeding may occur with direct trauma / blow to the wound. Again, compression is the best measure, but if the bleeding cannot be stopped despite persistent pressure (typically demanding 3-5 minutes), then the clinic must be contacted. If the clinic is closed, you must contact the physician on duty to be forwarded to the emergency room.
- Infection is always a risk, typically with symptoms in the form of thick liquid pus (infection fluid), redness and pain around the wound, and possibly fever. Doctors’ contact is necessary so that relevant treatment can be started.
- Adhesions between the foreskin and the glans can occur, but is seen much more rarely compared to the ring method. If adhesion is suspected, the clinic must be cotacted.
