Circumcision
Circumcision
General Information
Male circumcision is the surgical removal of the foreskin. The foreskin is the hood of skin covering the end of the penis, which can be gently pulled back.
Circumcision may be performed for:
- Religious Reasons: Circumcision is a common practice in the Islamic and Jewish faiths. It is also practiced by many African communities as a tribal or ethnic traditions.
- Medical Reasons: Although alternative treatments are usually preferred to circumcision such as the use of topical steroids, circumcision can be carried out for medical reasons. One of the most common reasons is phimosis, a tight foreskin that will not pull back.
- Routine Circumcision: In England during the 19th century, circumcision was believed to be more hygienic and was, in fact, a common practise despite religious faith. However, male circumcision became less common as the medical community started to believe that there was no significant medical benefit to routine circumcision. Now, we know that routine circumcision can offer some protection against bacterial and viral infections. However, the risks associated with routine circumcision are far greater than these benefits. Therefore, routine circumcision has phased out of common practise.
Advantages and Disadvantages Of Circumcision
There are several potential advantages and disadvantages associated with circumcising boys. The advantages of circumcision are:
- Less risk of developing a urinary tract infection (UTI), such as a bladder infection.
- Some reduced risk of getting some types of sexually transmitted infections, such as HIV and genital herpes.
- Some reduced risk of female partners developing some types of sexually transmitted infections, such as bacterial vaginosis and trichomoniasis.
- Some reduced risk of developing cancer of the penis.
- However, there are more effective and less invasive ways of preventing these conditions. For example, practising good hygiene to prevent UTIs, or using a condom to prevent STIs.
- Most healthcare professionals would agree that the potential benefits of circumcision are not strong enough to justify routine childhood circumcision.
Disadvantages Of Circumcision Include:
- Reduced sensitivity. Circumcised men may experience less pleasure during sex.
- Potential complications of circumcision include excessive bleeding, post-operative infection and, in rare cases, injury to the urethra.
- It is also argued that routine circumcising baby boys on ethical grounds violates the principle of consent to treatment. It is said that circumcision should only be performed when a boy is old enough to make an informed decision about whether he wishes to be circumcised.
NHS Availability
The majority of clinical commissioning groups (CCGs) do not fund routine circumcision or circumcision that is carried out for religious reasons. Only a small number of CCGs fund religious or ritual circumcision based on the local population’s needs.
The NHS mostly funds circumcision which is used to treat a small number of medical conditions (see below). In such situations, circumcision is regarded as a “treatment of last resort”, when all other treatment options have failed.
In the absence of alternatives, the NHS may fund circumcision for medical reasons such as:
- Paraphimosis – a condition where the foreskin gets trapped under the tip of the penis
- Balanitis xerotica obliterans – an uncommon condition causing hardening and inflammation of the tip of the penis
- Severe cases of phimosis – a tight foreskin that can’t be retracted
- Recurrent balanitis – inflammation of the tip of the penis and foreskin
How Circumcision Is Performed
Circumcision for medical reasons is usually carried out on a day-patient basis. This means that you will not have to stay overnight in the hospital.
Older children and adults who are circumcised are usually given a general anaesthetic, where they are put to sleep. In Medstar Clinic Circumcision Centre, we perform circumcision for only religious and cultural reasons and use local anaesthetic injections, which will numb the penis and the surrounding area.
The circumcision procedure is relatively simple. The foreskin is removed with a scalpel, scissors, or a surgical clamp. Any bleeding is either cauterised (closed using heat) or the remaining edges of the skin are sutured together using dissolvable sutures.
Recovering From Circumcision
In babies who are circumcised, the foreskin usually takes about 7 to 10 days to heal. In older boys and men, the healing process can take up to four to six weeks. After circumcision, there may be some pain and swelling, and the penis will be easily irritated until it heals.
Self-Care Advice
As circumcision is a painful procedure, painkillers such as paracetamol or ibuprofen will need to be taken for at least the first three days after the operation. Children aged 16 or younger should not take aspirin. Be cautious about taking ibuprofen if you have kidney disease or stomach ulcers.
After circumcision, the penis will be red and swollen for a few days. You or your child may find it more comfortable to wear loose clothing for a while. Putting petroleum ointment directly onto the area can also reduce irritation.
Circumcision exposes the sensitive skin of the tip of the penis (glans). In babies, nappies can rub against the glans, making it sore. Tucking down your baby’s penis before putting the nappy in place will help. You may be advised to apply an antibacterial cream for up to a week. Frequent nappy changes and good hygiene are advised.
It is advised to avoid activities such as cycling or sitting on sit-on toys until the swelling has completely gone down. We advise one week of rest before returning to school and to inform the school and the teacher of the operation.
Do not use scented products in the shower or bath. Leave the penis to dry naturally.
For adults, the surgeon will also give advice about sexual activity. Usually, sex should be avoided until the wound has healed, preventing the wound from reopening.
When To Seek Medical Advice
Speak to your GP if:
- There is an infection or bleeding from the penis
- If the penis remains swollen after two weeks
- If passing urine becomes painful a few days after the operation
Complications are rare when circumcision is performed for medical reasons, but there are some risks of circumcision that should be considered.
Risks Of Circumcision
As with all types of surgery, circumcision has some risks. However, complications from circumcisions carried out for medical reasons are rare in England. Bleeding and infection are the most common complications seen with circumcision.
Other Complications Can Include:
- A decreased sensation in the penis, particularly during sex
- Damage to the tube that carries urine inside the penis (urethra), causing it to narrow and making it hard to pass urine
- Removal of too much of the foreskin
- Accidental amputation of the head of the penis, which is very rare
- Blood infection or blood poisoning (septicaemia)
Problems with circumcisions carried out for religious or cultural reasons may go unreported.
Circumcision is contraindicated for those born with a specific birth defect of the penis that affects the opening of the urethra (urinary tube). This is because the foreskin is used to reconstruct the urethra.
FAQ
Is the service available throughout the year?
Yes. Procedures are usually carried out at the clinic every day, mostly weekends. We have prolonged opening hours during school holidays. Weekday procedures can be arranged on special request with notice in advance.
Is the procedure painful?
With correct administration of local anaesthetic, circumcision is a pain free procedure to carry out. We hear word of mouth stories of procedures done where the child has felt pain making the experience very unpleasent for both the child and the parents. At Medstar, rest assured that a circumcision will not be carried forward if the local anaesthetic was unsuccessful. Although it is good to be aware of the challenges associated with children in the age group of 1 – 5 years because they are at an age when they are aware of strangers and may not comply.
How long does the local anaesthetic last?
Local aneasthtic lasts usually around 1 – 2 hours. As the anaesthetic wear off the child may be in pain for about 15-20 minutes. Therefore, it is advisable that painkillers are given just before or soon after the procedure, so that while the anaesthetic wears off there is adequate cover with painkillers.
Can the procedure be carried out with the child asleep?
All procedures carried out at the Medstar Circumcision Centre are under local anaesthetic (LA). However, if you are looking to have it done under general anaesthesia (GA), you will have to get in touch with your local private provider. Be warned that they may quote you a price around the region of £2000. More importantly, there are no added benefits of doing a circumcision under a GA – if anything; you have the added complications that are associated with a GA.
What is the best age to get a child circumcised?
The best time is soon after birth at the age of 2-3 weeks. However, it can be carried out at any age.
What is the average time to recovery?
You are looking in the region of approximately 2 weeks. In adults, it can take up to 6 weeks.
Will someone explain the procedure and the after-care to us?
As part of taking informed consent, it is imperative on the circumcision practitioner that they explain the procedure to you in full, the likely complications and the after-care.
What level of experience does the circumcision practitioner have? Is he a GP or a Surgeon?
Our practitioner is a practising NHS Surgeon who is involved in their day to day work operating. He has a wealth of experience (25 years’ experience) and you can speak with him directly about his experiences – it is important that you have full confidence in the practitioner that will operate on your child.
Are parents allowed to be present during the procedure?
Generally, we prefer parents to be present during the surgery – as this gives a great deal of confidence to the child undergoing the procedure (in the case of the older child). However, if a parent or relative feels they do not want to be present – then this will be respected, and they can remain in the waiting room.
Can I take my child home straight away?
In the vast majority of cases you can. However, if the doctor is concerned that there may be a slight chance of bleeding, then he may request that you wait for about half an hour, so he can perform interval checks to ensure that there is no bleeding. Only when he is confident that it is safe, he will tell you that you may leave.
Should I be aware of any risks associated with a circumcision?
One thing you have to bear in mind is that circumcision is a surgical procedure. All surgical procedures are associated with an element of risk. However, these risks can be minimised if the procedure is carried out by a fully trained and professional circumcision practitioner, in particular if someone has a surgical background or is a practicing surgeon.
The risks associated with circumcision are (1) bleeding (1-3%) and (2) infection (1-3%). To minimise the risk of infection, the procedure is carried out in a sterile environment using sterile equipment and techniques. Antibiotic prophylaxis is usually given, too.
Are there routine follow-up checks?
Routine checks are not necessary on the new-born infant. For the older child, it may be necessary depending on how the procedure has been performed. In all cases, if the parents wish to re-visit for whatever reason, they may do so without incurring any further costs.
Procedure
We use the ‘Freehand Technique’. This method starts with a local anaesthetic. Freehand excision of the skin is performed, after which some suturing is necessary.
Please bring with you an over the counter painkiller – either Paracetamol or Ibuprofen. Once you attend the clinic we will advise you to take the first dose just before the procedure.
How The Procedure Is Performed?
The procedure is performed under a local anaesthetic that is injected at the root of the penis. An interval of about 10 minutes is given before the actual procedure is started so that the penis is completely anaesthetised, and no pain will be felt during the procedure.
The groin is fully prepped and draped to undertake the procedure in a sterile fashion.
A surgical marker pen is used to mark the line of incision on the foreskin to guide the level of the cut. This ensures symmetrical removal of skin and achievement of best final cosmetic result.
Freehand excision of the foreskin is performed along this mark. The procedure finishes with a thin strip of non-adherent dressing along the line of the wound. This serves two purposes: (1) it protects the wound from contamination and; (2) it helps to keep the swelling down.
The length of time required in total for the procedure is approximately one hour. This is broken down into (1) consultation (20 mins); (2) local anaesthetic application and time for it to take effect (10 mins) and; (3) surgery itself (30 mins).
After The Procedure
All post-operative care instructions are given.
The child will be able to wear all his clothes as normal and walk as if he has not been circumcised. Babies can have their nappies and trousers put on immediately and also be carried out of the clinic.
The child is welcome to sit and wait for a short while in the clinic if you desire so. You can take public transport immediately after the procedure.
The pain that your child will experience depends on the individual – it is more a dull ache than a sharp pain once the feeling returns. It is advisable that the child takes painkillers for 2-3 days following the procedure. Pain of course is an individual experience, the threshold of which differs between individuals.
When Can My Child Return To School and Back To Normal Function?
It is advisable to take at least 3 days off school following the circumcision.
Why Choose Us
Deciding to have a circumcision done can be a stressful time. It is important to be well informed about the nature of the procedure, the aftercare and any complications that may be involved.
We pride ourselves on our comprehensive service. We will try our very best to give you an appointment at your convenience (including evenings and weekends). Prior to the circumcision, you can contact us and our friendly staff will be happy to answer any questions you may have. On the day of the circumcision, we will provide you with a full briefing of the procedure, the aftercare and the healing process. We will also provide you with printed information of what you need to do during the healing process.
Circumcision is something you do once in a lifetime, so it’s important to get it done professionally and competently the first time.
As mentioned above, every procedure has risks and if the circumcision is performed by someone who is inexperienced, then complications may arise. If not treated properly, it may result in scars and a re-circumcision may be needed.
By choosing Dr. Comez, our operating surgeon, you can be reassured that you are in safe hands. We assure you the procedure is pain free and the cosmetic results are excellent.
Below are important factors to take into consideration when choosing a surgeon to perform the circumcision:
- Dr. Comez is a General Surgeon with 25 years’ experience in all fields of General Surgery as well as circumcision.
- Dr. Comez is fully registered with the General Medical Council (GMC) and is licensed to work as a doctor and a surgeon in the UK.
- He has the knowledge and clinical skills that are needed to carry out a safe circumcision according to the GMC regulations.
- Dr. Comez has had long experience in administering local anaesthetic as most of his work requires this skill. Mr Comez will ensure that no pain is felt before starting the procedure, making sure your child feels no pain during the circumcision.
After the Procedure
Your child felt no pain during the circumcision because local anesthesia was used. He may have cried due to the psychological effects and perceived sensation of contact with skin. The effects of local anesthesia will wear off after 2 hours and your child may start to feel pain. Feeling pain in the first 24 hours is absolutely normal. Therefore, your child should take the prescribed painkiller syrup immediately after the circumcision. You need to give the painkiller for at least three days at 6-hour intervals, even if there is no pain.
The first night after a circumcision can be sleepless; this is expected. The child becomes very sensitive and may show crying behaviours to attract attention. Painkillers used during this period will be sufficient. Pain will regress 50-75% at most after 24 hours and will be nearly completely alleviated at 48 hours.
Your child can eat and drink right after the circumcision.
Children mostly urinate before a circumcision, but some may urinate during the procedure as well. Pain that develops after the circumcision may cause involuntary spasm in the regional muscles. Therefore, your child may have his first urination after a circumcision a little bit late; this is expected. The first couple of trials to urinate may be unsuccessful due to excessive spasm. Warm compression can be applied to the region of the urinary bladder in such cases.
Interruptions or sensation of burning may occur during the first urination. This is entirely normal. However, if your child does not urinate for a long time (24 hours), if pain aggravates gradually and excessively, or if blood is noticed along with or in the urine, you should contact our clinic.
The dressing (circumcision bandage) can be removed at home after the first 24 hours under normal circumstances. This period can sometimes be extended to 48-72 hours. You can remove the dressing by having your child sit in warm water or while washing him, or you can remove it directly by soaking it. Do not be afraid to remove the dressing. It is extremely beneficial to perform daily warm water dressing and bathing routines. Do not feel worried or concerned while performing this procedure, it is completely painless. A few drops of blood can be seen while the dressing is removed, which is normal, too.
Once the dressing is removed, use a very thin layer of the antibiotic cream that is given to you at the location of the sutures; continue to do so two to three times a day for a week.
Small blood stains on the dressing are not important; however, you need to present to our clinic in the event of leakage-like bleeding.
The first 24 hours after circumcision are critical and your child needs to rest as much as possible. It is very important that the first 6 hours are spent lying down. If there is no risk of bleeding or infection, your child may move and go out after 24 hours.
Some swelling and bruising after the circumcision is normal secondary to local anesthesia. There will not be a need to worry. There may be long-standing bruising on the penis head in children with adhesions on the penis skin (phimosis) before circumcision, do not worry.
Since excess pubic fat accumulation is observed in overweight children, the penis may appear embedded in the skin and the wound dressing may come off earlier after the circumcision; do not be concerned.
After circumcision, if the penis embeds in the skin, the penis head should be taken out by gently pulling the foreskin back daily, until the wound heals. If not, a second procedure may be required.
After circumcision, in children with pubic fat accumulation, the embedded penis may appear as if not enough skin has been removed. Since the penis protracts during adolescence, the foreskin will also gain the normal position.
It is extremely important to act normally with children after the circumcision. It is better to give encouraging and relaxing advice such as “You can walk”, “You can go to the toilet”, “You can take a shower, but remember to be careful”rather than worrying and passing your anxiety onto your child with advice such as “It will hurt, it will bleed, do not walk, do not go to the toilet, eat less, do not wear anything”.
You may need to contact our clinic:
- If the dressing is totally covered with blood or if there is visible bleeding.
- If there is excessive darkness in the penis head especially 6 hours after the circumcision. Bruising can normally be seen at the penis head and location of local anesthesia and this can persist for several weeks.
- If there is no urine production 24 hours after circumcision.
- If pain aggravates despite the medicines.
- If there is blood in the urine.
- If there is excessive nausea, vomiting or fever.
As Medstar Clinic, we are pleased to offer you all the opportunities of modern medicine.
Please contact us for further information or if you have any concerns or encounter any issues after your procedure.
Dr. Turhan COMEZ
General Surgeon
