ANATOMIC ANATOMIC CONTRAINDICATIONS TO CONTRAINDICATIONS TO

NEONATAL CIRCUMCISIONNEONATAL CIRCUMCISION

JOHN F. REDMAN, M.D.,FACS,FAAPJOHN F. REDMAN, M.D.,FACS,FAAPPROFESSOR OF UROLOGYPROFESSOR OF UROLOGY

AND AND

PEDIATRICSPEDIATRICS

UNIVERSITY OF ARKANSAS COLLEGE OF MEDICINEUNIVERSITY OF ARKANSAS COLLEGE OF MEDICINE

AND AND

ARKANSAS CHILDREN’S HOSPITALARKANSAS CHILDREN’S HOSPITAL

ANATOMIC CONTRAINDICATIONS TO ANATOMIC CONTRAINDICATIONS TO NEONATAL CIRCUMCISIONNEONATAL CIRCUMCISION

OBJECTIVES:OBJECTIVES:• TO ANSWER THE QUESTION: IS THERETO ANSWER THE QUESTION: IS THERE

AN INDICATION FOR NEONATALAN INDICATION FOR NEONATAL

CIRCUMCISION?CIRCUMCISION?• TO UNDERSTAND THE PROPER TECHNIQUES TO TO UNDERSTAND THE PROPER TECHNIQUES TO

FACILITATE THE RECOGNITION OF ANATOMIC FACILITATE THE RECOGNITION OF ANATOMIC CONTRAINDICATIONS.CONTRAINDICATIONS.

• TO UNDERSTAND THE ANATOMIC TO UNDERSTAND THE ANATOMIC CONTRAINDICATIONS.CONTRAINDICATIONS.

• TO UNDERSTAND THE CONSEQUENCES OF NOT TO UNDERSTAND THE CONSEQUENCES OF NOT RECOGNIZING ANATOMIC CONTRAINDICATIONS.RECOGNIZING ANATOMIC CONTRAINDICATIONS.

Neonatal Circumcision:Neonatal Circumcision:Anatomic ContraindicationsAnatomic Contraindications

John F. Redman, M.D., F.A.A.P. Joseph M. Elser, M.D., John F. Redman, M.D., F.A.A.P. Joseph M. Elser, M.D., F.A.A.P.F.A.A.P.

Abstract:Abstract:Complications from neonatal circumcision Complications from neonatal circumcision

may result from inexperience or poor may result from inexperience or poor technique, but may also result from poor technique, but may also result from poor patient selection based on penile anatomy. patient selection based on penile anatomy. The anatomic contraindications to neonatal The anatomic contraindications to neonatal circumcision are therefore presented in an circumcision are therefore presented in an effort to prevent complications.effort to prevent complications.

J Ark Med Soc. 94:60-2 J Ark Med Soc. 94:60-2 19971997

THE INCIDENCE OF NEONATAL THE INCIDENCE OF NEONATAL CIRCUMCISION IN THE USCIRCUMCISION IN THE US

Estimates based on the National Center for Health Statistics indicate that 61% and 65% of male infants

were circumcised in the United States during 1987 and 1995.

A majority of boys born in the United States still undergo nonritual circumcisions. This occurs in large measure because parental decision-making is based on social or cultural expectations, rather than medical concerns. Studies from the 1980s suggested that the presentation of medical information on the potential advantages and disadvantages of circumcision had little influence on parents' decisions. This finding was recently confirmed. In another contemporary study, nearly half of those physicians performing circumcisions did not discuss the potential medical risks and benefits of elective circumcision prior to delivery of the infant son. Deferral of discussion until after birth, combined with the fact that many parents' decisions about circumcision are preconceived, contribute to the high rate of elective circumcision. Major factors in parental decision-making are the father's circumcision status, opinions of family members and friends, a desire for conformity in their son's appearance, and the belief that the circumcised penis is easier to care for with respect to local hygiene.

Council on Scientific Affairs. Report 10: Neonatal circumcision. Chicago: American Medical Association, 1999.

QUESTION?QUESTION?

IS THE NORMAL PREPUCE, IS THE NORMAL PREPUCE, ASSOCIATED WITH A NORMAL ASSOCIATED WITH A NORMAL

PENIS,PENIS,

AN AN

ANATOMIC CONTRAINDICATION TO ANATOMIC CONTRAINDICATION TO

NEONATAL CIRCUMCISION?NEONATAL CIRCUMCISION?

AMERICAN ACADEMY OF PEDIATRICS

Task Force on CircumcisionCircumcision Policy Statement

Pediatrics 103: 686, 1999

ABSTRACT. Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. If a decision for circumcision is made, procedural analgesia should be provided.

Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision.

In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child.

To make an informed choice, parents of all male infants

should be given accurate and unbiased information and be provided the opportunity to

discuss this decision.

A CONUNDRUM?A CONUNDRUM?• The American Academy of Pediatrics Committee

on Bioethics holds that health care providers "have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses." And "the pediatrician's responsibilities to his or her patient exist independent of parental desires or proxy consent.“

• The Committee on Bioethics approved the 1999 Circumcision Policy statement of the American Academy of Pediatrics indicating parents should make such a decision based upon information about the potential benefits and risks.

A NEONATAL A NEONATAL CIRCUMCISION IS CIRCUMCISION IS

FREQUENTLY NOT A FREQUENTLY NOT A TECHNICALLY EASY TECHNICALLY EASY

PROCEDUREPROCEDURE

ALL NEWBORN ALL NEWBORN BOY’S PENISES BOY’S PENISES ARE NOT THE ARE NOT THE

SAMESAME

IF YOUR OPINION (ON CRITICAL IF YOUR OPINION (ON CRITICAL EXAMINATION OF THE PENIS) IS EXAMINATION OF THE PENIS) IS THAT THE PENIS IS PROBABLY THAT THE PENIS IS PROBABLY

NORMAL, BUT THAT ITS NORMAL, BUT THAT ITS CONFIGURATION IS SUCH THAT CONFIGURATION IS SUCH THAT

YOU DO NOT BELIEVE THAT YOU DO NOT BELIEVE THAT YOU CAN PERFORM A YOU CAN PERFORM A

PERFECT, OR NEAR PERFECT, PERFECT, OR NEAR PERFECT, CIRCUMCISION----- DO NOT BE CIRCUMCISION----- DO NOT BE

PRESSURED TO PROCEED.PRESSURED TO PROCEED.

HOW DO YOU EXAMINE THE HOW DO YOU EXAMINE THE NEONATE'S PENIS?NEONATE'S PENIS?

• BY SIMPLE INSPECTION DECIDE IF THE PENIS HAS A NORMAL APPEARANCE.

• OBSERVE WHETHER THE PENIS IS SHORT OR SMALL.

• COMPRESS THE PUBIC SKIN AT THE BASE OF THE PENIS AND DETERMINE IF THERE IS ADEQUATE DORSAL SHAFT SKIN OR IF THE PREPUCE APPEARS TO ARISE FROM THE PUBIC SKIN .

• INSPECT THE VENTRUM OF THE PENIS AND DETERMINE IF THERE IS A DISTINCT SHAFT SKIN OR IF THE PREPUCE APPEARS TO BE CONTIGUOUS WITH THE SCROTUM (WEBBED PENIS).

• COMPRESS THE ERECTILE BODIES AT THE BASE OF THE PENIS TO PRODUCE AN ERECTILE STATE AND DETERMINE THERE IS ANY CURVATURE OF THE PENIS.

• INSPECT FOR TORSION OF THE PENIS

• INSPECT THE PREPUCE TO SEE IF IT IS COMPLETE OR DOES IT APPEAR TO BE HOODED ON THE DORSUM OR DEFICIENT ON THE VENTRUM OF THE PENIS

• INSPECT FOR WRINKLED OR REDUNDANT SKIN ON THE DISTAL DORSUM OF THE PENIS

• CAREFULLY VISUALIZE THE MEATUS--- DOES IT EXIT AT THE TIP OR IS IT LOCATED MORE PROXIMAL

THE FINAL INSPECTION THE FINAL INSPECTION BEFORE MAKING AN INCISIONBEFORE MAKING AN INCISION

• USE A SKIN PENCIL TO MARK THE LEVEL OF THE CORONA. IF THE SHAFT SKIN IS DEFICIENT – ABORT THE PROCEDURE.

• USE A HEMOSTAT TO WIDEN THE PREPUTIAL ORIFICE IF NECESSARY TO VISUALIZE THE MEATUS. IF THE MEATUS IS HYPOSPADIAC ----ABORT THE PROCEDURE.

ANATOMIC CONTRAINDICATIONS ANATOMIC CONTRAINDICATIONS TO NEONATAL CIRCUMCISIONTO NEONATAL CIRCUMCISION

• HYPOSPADIASHYPOSPADIAS

• HOODED PREPUCEHOODED PREPUCE

• PENILE CURVATUREPENILE CURVATURE

• PENILE TORSIONPENILE TORSION

• BURIED PENISBURIED PENIS

• SMALL PENISSMALL PENIS

• LARGE SCROTAL OR LARGE SCROTAL OR INQUINOSCROTAL HYDROCELES INQUINOSCROTAL HYDROCELES

HYPOSPADIASHYPOSPADIAS

HOODED PREPUCEHOODED PREPUCE

PENILE CURVATUREPENILE CURVATURE

PENILE TORSIONPENILE TORSION

BURIED PENISBURIED PENIS

SMALL PENISSMALL PENIS

LARGE SCROTAL OR LARGE SCROTAL OR INQUINOSCROTAL HYDROCELESINQUINOSCROTAL HYDROCELES

THE BASIC PRINCIPLE TO THE BASIC PRINCIPLE TO AVOID CIRCUMCISION IN A BOY AVOID CIRCUMCISION IN A BOY

WITH AN ANATOMIC WITH AN ANATOMIC CONTRAINDICATIONCONTRAINDICATION

IF THE PENIS IS NOT IF THE PENIS IS NOT NORMAL ----- DO NOT NORMAL ----- DO NOT PROCEED WITH THE PROCEED WITH THE

CIRCUMCISION!CIRCUMCISION!

THE CONSEQUENCES OF NOTTHE CONSEQUENCES OF NOT RECOGNIZING ANATOMIC RECOGNIZING ANATOMIC

CONTRAINDICATIONSCONTRAINDICATIONS • DEFICIENT EPITHELIUM TO PERFORM DEFICIENT EPITHELIUM TO PERFORM

HYPOSPADIAS SURGERYHYPOSPADIAS SURGERY• DEFICIENT INNER LEAF OF THE PREPUCE TO DEFICIENT INNER LEAF OF THE PREPUCE TO

FORM A FIRLIT COLLARFORM A FIRLIT COLLAR• DEFICIENT SKIN FOR SHAFT COVERAGE IN DEFICIENT SKIN FOR SHAFT COVERAGE IN

CASES OF PENILE CURVATURE OR TORSIONCASES OF PENILE CURVATURE OR TORSION• DEFICIENT INNER LEAF OF PREPUCE FOR DEFICIENT INNER LEAF OF PREPUCE FOR

REPAIR OF BURIED PENISREPAIR OF BURIED PENIS• DISTAL CICATRIX FORMATION (CONCEALED DISTAL CICATRIX FORMATION (CONCEALED

PENIS)PENIS)• REDUNDANT OR IRREGULAR RESIDUAL REDUNDANT OR IRREGULAR RESIDUAL

PREPUCE NECESSITATING CIRCUMCISION PREPUCE NECESSITATING CIRCUMCISION REVISIONREVISION