There is no evidence of any long-term psychological harm arising from circumcision. The risk of damage to the penis is extremely rare and avoidable by using a competent, experienced doctor. Unfortunately, because it is such a simple, low-risk procedure, it had once been the practice to assign this job to junior medical staff, with occasional devastating results. Anecdotes of such rare events from the past should be viewed in perspective. Parents or patients nevertheless need to have some re-assurance about the competence of the operator. Also the teaching of circumcision to medical students and practitioners needs to be given greater attention because it is performed so commonly and needs to be done well. A model to teach interns has, moreover, been produced [167].
Surgical methods often use a procedure that protects the penis during excision of the foreskin. In the USA the most commonly used devices are the GOMCO (GOldstein Medical Company) clamp (67%) invented in 1934, MOGEN clamp (10%) invented in 1945 and PlastiBell (19%) [542] invented by Hollister Inc, USA in 1950. Pictures of these can be found in refs [12, 324], and the latter in particular discusses the procedure, as well as contraindications.
See diagram above (modified from Elder [[163]]). The Plastibell is a clear plastic ring with handle and has a deep groove running circumferentially
Plastibell method:
The Plastibell is a clear plastic ring with handle and has a deep groove running circumferentially. It provides a ‘no scalpel’ circumcision in that the foreskin is not cut off the penis during the procedure. The adhesions between glans and foreskin are divided with a hemastat (artery forceps). Then the foreskin is cut longitudinally starting at the distal end dorsally to allow it to be retracted so that the glans (the head of penis) is exposed. The Plastibell comes in 6 sizes. The appropriate one is chosen and applied to the head. The ring is then covered over by the foreskin. A ligature is tied firmly around the foreskin, crushing the skin against the groove in the Plastibell. Then the excess skin protruding beyond the ring is trimmed off. Finally, the handle is broken off at the end of the procedure. The entire procedure takes 5 to 10 minutes, depending on the experience and skill of the surgeon. The compression against the underlying plastic shield causes the foreskin tissue to necrose (die). The ring falls off in 3 to 7 days leaving a circumferential wound that will heal over the following week. Typically, the glans will appear red or yellow until it has cornified. Thus the Plastibell method eliminates the need to actually cut the foreskin off [199, 249].
As described in the next section, all circumcisions should involve adequate anesthesia, using either EMLA cream, dorsal penile nerve block, penile ring block, or a combination of these prior to operation.
Whatever the method post-operative care, as advised by the doctor, must be undertaken, usually by the parents. Cosmetic results have met with unanimous parental acceptance [159].
Dr Terry Russell, OAM, in Brisbane, Australia, has developed a simple, pain-free method involving 2 hours EMLA cream with the penis wrapped in cling wrap (done by the parents prior to arrival at the clinic), followed by a modified Plastibell circumcision [300]. The technique is described in detail on his website (www.circumcision.com.au). Dr Russell has used it in over 18,000 circumcisions on boys of all ages from neonate to puberty. Because complete anesthesia is achieved by EMLA cream for 2 hours, Dr Russell reports that no pain is experienced for 5 hours after the Plastibell is applied, meaning the circumcision is completely pain free at all stages. These were all a complete success with no serious or moderate complications, apart from one boy who developed mild methemoglobinemia (from the EMLA cream) that overnight resolved spontaneously with no medical intervention after immediate hospital admission.
In collaboration with Prof Roger Short, a video (“no scalpel circumcision”) that teaches the Russell method was produced for Botswana, and another, filmed in Vanuatu was produced for use in Papua New Guinea. These were aimed primarily to reduce HIV/AIDS in these countries. Moreover, since the simple plastic Plastibell device is now off patent it can be produced at very low cost to help reduce AIDS in poor countries [528]. More on the Russell protocol can be found in the next section.
Gomco clamp method:
First of all, a dorsal slit is made in the foreskin and the foreskin is separated from the glans. The bell of the Gomco clamp is then placed over the glans, and the foreskin is pulled over the bell. The base of the Gomco clamp is placed over the bell, and the Gomco clamp's arm is fitted. After the surgeon confirms correct fitting and placement (and the amount of foreskin to be excised), the nut on the Gomco clamp is tightened, causing the clamping of nerves and blood flow to the foreskin. The Gomco clamp is left in place for about 5 minutes to allow clotting of blood to occur, then the foreskin is dissected off using a scalpel. The Gomco's base and bell are then removed, and the penis is bandaged. It is a fairly bloodless circumcision technique. The circumcision is relatively quick compared to the Plastibell. It was the most popular method for circumcisions between 1950 and 1980 and is still common today, especially in the USA. There are also Gomco methods for adults.
Mogen clamp method:
Firstly adhesion between glans and foreskin are divided and a hemostat is placed along the dorsal midline with its tip about 3 mm short of the corona before being locked into place. The Mogen clamp is opened fully. A key step in Mogen circumcision is the safe placement of the clamp. To push the glans out of the way, the surgeon's thumb and index finger pinch the foreskin below the dorsal hemostat. The Mogen clamp is then slid across the foreskin from dorsal to ventral following along the same angle as the corona. The hollow side of the clamp faces the glans. Before locking the clamp shut, the glans is manipulated to be sure it is free of the clamp’s jaw. If it is, the clamp is locked. Once locked the foreskin is excised flush with the flat surface of the clamp with a 10 inch blade scalpel. The clamp is left on for a few moments to ensure hemotosis. It is then unlocked and removed. The crush line covers the glans line fully with penile shaft skin. The glans is liberated by thumb-traction at the 3 and 4 o'clock positions that pull the crush line apart.
Disposable clamp:
A plastic clamp (SmartClampCircumcisonDevice; SCD, Hengelo, The Netherlands) has been developed [13]. This fits on the penis much as the others do. After 4 days the connection between its inner tube and casing is cut and removed. The inner tube is then left to fall off spontaneously in time. Median operative time is 8 min, compared with 18 min for conventional dissection, and cosmetic result, judged blinded by a urologist, was better [13]. Parents’ satisfaction scores were the same.
General comments:
The various devices serve to protect the penis when excising the prepuce. The type of clamp used affects the time taken for the procedure, being on average 81 seconds for the Mogen clamp and 209 seconds for the Gomco clamp [316]. In a head-to-head trial of length of procedure the Mogen took 12 minutes, compared with 20 minutes for the Plastibell [562]. Although simpler to use and more pain-free than the other two [291, 316, 562], the Mogen removes less foreskin. The Gomco is the oldest, having been invented in 1935, and is the most refined instrument [600]. Since some of these more elaborate methods can take up to 30 min to perform they therefore expose the baby to a greater period of discomfort. In contrast, a circumcision can be completed in 15-30 seconds by a competent practitioner using methods that are part of traditional cultures.
Interestingly, strict sterile conditions were reported not to be necessary to prevent infection in ritual neonatal circumcision in Israel [384].
Rather than tightly strapping the baby down, swaddling and a pacifier has been suggested [243, 252, 253]. A special padded, 'physiological' restraint chair has moreover been devised and shown to reduce distress scores by more than 50% [541]. Exposure to a familiar odor (their mother’s milk or vanilla) reduces distress after common painful procedures in newborns [209, 210, 457].
Dr Tom Wiswell and other experts strongly advocate the neonatal period as being the best time to perform circumcision, pointing out that the child will not need ligatures (owing to the thinness of the foreskin [505]) or general anaesthesia, nor additional hospitalization [634, 636, 638, 639, 641]. Without an anaesthetic the child experiences pain and pain is also present for from a few up to a maximum of 12-24 hours afterwards. The child does not, however, have any long-term memory of having had a circumcision performed. A greater responsiveness to subsequent injection for routine immunization may suggest, however, that the baby could remember for a short time [559]. Local anesthesia is therefore advocated (see below). Healing is rapid in infancy [505], complication rate is very low (0.2%), and cost is about one-tenth (discussed later).
Older children
Circumcision is more traumatic, disruptive and expensive for older boys [512]. For children aged 4 months to 15 years some authorities advocate a general anaesthetic. Others strongly disagree, saying that since a general anesthetic carries a small risk, a local anesthesic, often with a mild sedative, should be used for all children [512].
It should also be noted that ligatures (sutures/stitches) are usually needed for older children, although use of a tissue glue [419, 552] or a synthetic tissue adhesive (Dermabond) [165] have proven to be effective alternatives. The latter also reduce operating time and give a better cosmetic appearance [165, 419].
Excellent cosmetic results were reported for all of 346 patients aged 14 to 38 months using electro-surgery, which presents a bloodless operative field [438]. Metal of any kind (such as the Gomco clamp) has to of course be avoided in this procedure.
Gentle tissue dissection with simultaneous hemostasis was achieved using an ultrasound dissection scalpel for circumcision [178].
Circumcision later obviously requires a separate (occasionally overnight) visit to hospital. Healing is slower than in newborns, and rate of complications is greater, but still low (<1% to 3%%). The incidence of penile adhesions decreases with age, but at any age they often resolve spontaneously [444]. Pain sometimes can last for days afterwards and those older than 1-2 years may remember. Cost is also much greater than for neonatal circumcision.
For boys with hemophilia, special pre-operative treatment is required. A satisfactory outcome can also be achieved with a specialized cost-effective device [287].
Adults
Much of what is stated above for older boys applies to adults. Stitches are required and in adults circumcision is more expensive. Cost can be reduced by having it performed on an outpatient basis. A local anesthetic is all that is needed (so reducing anesthetists charges which can be quite high for a general anesthetic). Best results are obtained with the sleeve-resection technique, described in a series of diagrams with technical details by Elder [163]. This method takes longer and for this reason many surgeons will insist on a general anesthetic being used if this method is chosen.
Pain can last for up to a week or so afterwards, during which time absence from work is required. Some however report no pain, just minor discomfort from the stitches. Vasectomy in men previously circumcised as adults (and who can thus attest to the difference) is said to be much more painful. Interestingly, genital surgery in women often involves a course of topical estrogen in advance to increase thickening, cornification and keratinization of the vaginal epithelium [529]. This helps surgical outcome and has led to the suggestion that similar pre-treatment be carried out prior to male circumcision.
Conclusion:
Thus when considering when is the best time, it would appear that circumcision in the newborn period is safe and technically easy. It is also more convenient, is not remembered by the male, and much cheaper, as discussed in the next section, as well as providing the maximum lifetime benefit.
