Neonatal circumcision: Techniques

INTRODUCTION — Circumcision is the surgical removal of all or part of the distal penile foreskin (prepuce). This topic will review the patient selection, analgesia, and techniques for neonatal circumcision, including the Gomco clamp, Plastibell device, and Mogen clamp. Discussions of the risks and benefits of neonatal circumcision, including the controversy surrounding the procedure, and management of complications are presented separately.

●(See "Neonatal circumcision: Risks and benefits".)

●(See "Complications of circumcision".)

DEVELOPMENT AND ANATOMY — The penis develops as a tri-tubed structure with bilateral corpora cavernosa (erectile bodies) and ventral midline urethra surrounded by corpus spongiosum. The penis is divided into the proximal base, pendulous middle shaft, and distal glans. The corona of the glans and immediately proximal coronal sulcus anatomically differentiate the penile shaft from the glans penis (figure 1 and figure 2).

The foreskin begins development at 12 weeks of gestation as a fold of epithelium at the base of the penis that becomes a bilaminar prepuce covering the entire glans by 18 to 20 weeks. Progression of the foreskin coincides with the development of the penis; therefore, anatomic abnormalities of the penis often result in incomplete or abnormal foreskin. An inner mucocutaneous layer of the prepuce is adherent to the epithelial layer of the glans. Circumcision removes the inner and outer layers of the prepuce as well as the intervening dartos muscle (figure 3) [1].

Physiologic phimosis is the normal inability of the foreskin to retract over the glans penis, which results from the filmy adhesions between inner prepuce and glans. In natural progression, foreskin becomes more retractable over time with epithelial shedding (smegma) and intermittent erections causing separation of these adhesions. Nearly 100 percent of newborn males are unable to have foreskin retracted whereas, after age 5, 92 percent will have fully retractile foreskin and only 1 percent of males age 17 cannot fully retract the foreskin [2].

CONTRAINDICATIONS — The major contraindications to neonatal circumcision include unstable or significantly premature infants, and infants with congenital penile abnormalities [3,4]. Infants with blood dyscrasias or a family history of abnormal bleeding can undergo circumcision, as discussed below. Infants who have not received vitamin K supplementation or have not yet voided should have the procedure delayed until these criteria have been met.

●Unstable or premature infant – Unstable infants or infants with serious medical conditions should not undergo circumcision because it is an elective procedure. We delay circumcision until infants are at least 24 hours of age. This interval allows time for identification of other health issues that may take precedence over an elective circumcision. In general, premature infants have circumcision postponed until they are otherwise healthy and preparing for discharge home.

●Bleeding diathesis – To maximize safety, infants with a bleeding diathesis or family history of blood dyscrasia should undergo circumcision in a setting with clinicians who have experience managing clotting abnormalities and where clotting factor replacement is available. Coagulopathy significantly increases the risk of bleeding associated with circumcision; therefore, the appropriate factor replacement should be given prior to any invasive procedure. (See "Treatment of bleeding and perioperative management in hemophilia A and B", section on 'Circumcision'.)

Identification of children with bleeding disorders is presented separately. (See "Approach to the child with bleeding symptoms", section on 'History'.)

●Congenital penile anomalies – Infants with penile anomalies should not be circumcised. Instead, these patients are referred to a specialist for further evaluation.

Specific penile anomalies that are contraindications to neonatal circumcision include [3,4]:

•Hypospadias with foreskin abnormalities (picture 1 and picture 2) (see "Hypospadias: Pathogenesis, diagnosis, and evaluation")

•Chordee, ventral, or lateral curvature of the penis

•Penile torsion (suggested by a urethral meatus in an orientation >45 degrees from vertical)

•Penoscrotal webbing (ie, webbed penis)

•Buried/hidden/concealed penis or large suprapubic fat pad

•Significant penile edema

•Micropenis

Evaluation of the patient to identify these anomalies is presented below (See 'Examination of penis and scrotum' below.)

TIMING OF PROCEDURE — While there are limited data on the optimal timing of circumcision, clamp- and bell-style circumcisions are generally recommended during the first six weeks of life. Most neonatal circumcisions are performed during the first week of life, with members of the Jewish religion ceremonially performing circumcision on the eighth day. Thus, a large proportion of these early circumcisions are completed during the birth hospitalization prior to initial discharge home. Waiting until at least 24 hours of life provides time to confirm infant stability and assess for medical abnormalities. In general, because neonatal circumcision is an elective procedure, circumcision is delayed in infants with any medical issue (eg, fever, respiratory distress). In an observational study comparing Gomco clamp circumcisions done in the first 30 days of life (local anesthesia) with those done after three months of life (under general anesthesia), 30 percent of patients in the older age group had postoperative bleeding requiring intervention compared with none in the early age group [5]. The increased incidence of postoperative bleeding may have been a result of larger caliber cutaneous vessels encountered in the post-neonatal period.

If a patient presents for circumcision after the neonatal period, intervention is often delayed until approximately six months of age because the patient will require general anesthetic and a sleeve-type circumcision, rather than a clamp or bell procedure performed with local anesthetic.

PAIN CONTROL — Since analgesia reduces procedural pain with minimal risk, it is routinely provided when neonatal circumcision is performed [3,4]. Effective analgesic options for neonatal circumcision include topical agents and injected nerve blocks [3,6]. As no technique is clearly superior, selection depends on the training of the clinician and the availability of agents.

Our approach — We have found that the combination of oral sucrose and dorsal penile nerve block provides excellent analgesia, and thus we use this approach in our practice. Use of a positioning board (supine position) provides excellent exposure, supports the infant, and protects the areas of interest from injury due to inadvertent movement. In our practice, we use oral sucrose in conjunction with a pacifier, if approved by the parents or caregivers, to further soothe the infant [7]. The dorsal penile block with lidocaine 1% without epinephrine or 0.25% bupivacaine without epinephrine is our preferred method for local anesthetic because use of a single injection reduces the risk of penile edema in comparison with the ring block. Additionally, at least one meta-analysis reports superiority in pain relief by dorsal penile block over topical anesthetics [8].

Local topical anesthetics — Local topical anesthetics commonly used for circumcision include lidocaine 4% cream (LMX4) and EMLA cream (a eutectic mixture of lidocaine 2.5% and prilocaine 2.5%). EMLA cream use has been associated with decreased heart rate and crying time compared with no treatment when applied prior to circumcision [9]. Pain control appears to be similar among LMX4, EMLA cream, and dorsal penile nerve block (DPNB). While a 2004 meta-analysis of three trials (133 infants total) comparing EMLA with DPNB reported lower heart rate and pain scores with DPNB, subsequent trials reported similar or improved pain relief with EMLA. In a trial of 54 healthy, term, male infants randomly assigned to pretreatment with lidocaine 4% cream, EMLA, or DPNB, no differences were noted in overall pain control as assessed by heart rate [6]. Respiratory rates were higher for infants treated with EMLA cream and lowest for infants who received DPNB. Local skin reactions occurred in three infants (lidocaine cream = 1, EMLA cream = 2). No adverse outcomes occurred in the DPNB group. In a different trial comparing EMLA and DPNB in 100 children undergoing circumcision at less than six months of age, the overall pain control was similar in both groups, although the DPNB group had higher neonatal infant pain scale scores during certain steps of the procedure [10].

Advantages of local topical anesthetics include ease of use and lack of need for specialized training. The main disadvantage is skin irritation, with studies reporting an 8 to 14 percent incidence of erythema, swelling, and, rarely, blistering [6,9,11]. Low birth weight infants may be at increased risk for severe skin reactions such as blistering, and therefore at least one society advises against the use of topical anesthetics for low birth weight infants [3,12,13]. Disadvantages specific to EMLA include higher cost and the rare associated risk of methemoglobinemia in newborns, particularly premature infants, with a deficiency of methemoglobin reductase [14].

Topical anesthetics are applied generously to the foreskin (1 to 2 g) with recommended dwell times of at least 60 minutes for EMLA cream and 30 minutes for LMX4 [3]. One study reported efficacy with using reduced dwell times of 30 minutes and 20 minutes, respectively, with effective pain relief [6]. Following application, an occlusive dressing is placed to ensure continued and full contact with the foreskin. Prior to circumcision, the dressing is removed, cream wiped away, and penis cleaned and prepared as discussed in the section on techniques.

Penile nerve block

Anatomy for nerve block — A pair of dorsal penile nerves provide sensation to the glans and shaft of the penis as well as to the foreskin. These nerves traverse along the penis, below Buck's fascia at the 1 to 2 o'clock and 9 to 10 o'clock positions (figure 1). At the level of the pubis in neonates, the nerves run at a depth of 3 to 5 mm, depending on the patient's body habitus. Of importance, the superficial dorsal penile vessels run along the dorsal midline of the penis. It is imperative to avoid damage to these as troublesome bleeding may occur.

Dorsal penile block — DPNB involves injecting 0.4 mL of 1% lidocaine, without epinephrine, bilaterally into the base of the penis at 2 and 10 o'clock (figure 4). It is important to note that epinephrine-containing solutions should never be used on the external genitalia because severe vasoconstriction can occur and lead to varying degrees of penile loss.

In a meta-analysis of 35 trials comparing DPNB with placebo, no treatment, and topical anesthetics for pain control in infants undergoing neonatal circumcision, DPNB was found to provide superior pain relief, although subsequent small trials have reported similar efficacy between DPNB and EMLA [6,8,10]. While lidocaine 1% without epinephrine is the most commonly used agent, bupivacaine 0.25% without epinephrine can also be utilized [15]. Lidocaine is often preferred because the onset of action is 1 to 5 minutes versus 5 to 10 minutes for bupivacaine. However, the duration of effect is shorter for lidocaine compared with bupivacaine (2 to 3 hours versus 4 to 8 hours for bupivacaine).

Supplies needed for dorsal penile block are as follows:

●Restraint (eg, papoose, Circumstraint) (picture 3)

●1 mL syringe with 27 or 30 gauge needle for injection

●Larger gauge needle for drawing up solution

●Lidocaine 1% or bupivacaine 0.25% (without epinephrine)

●Alcohol prep pad

Procedure — While several techniques exist for dorsal penile block, the ultimate goal is injection of local anesthetic at the 2 and 10 o'clock positions at the base of the penis (figure 4). The author prefers to insert the injection needle through the skin at the midline, and then advance the tip of the needle laterally to inject medication at the correct positions (picture 4). The advantage is that there is only one injection site, but the clinician must take care to avoid the midline vessels. Alternately, the clinician can insert the needle at each planned injection site and infuse the medication. This method requires two passes through the skin but avoids the midline vessels altogether.

Injection that is too superficial can cause anesthetic tracking along the penile shaft, which distorts landmarks and complicates the circumcision. Insertion of the needle too deeply can cause damage to midline penile vessels and lead to hematoma, penile distortion, and, rarely, uncontrolled bleeding. Intravascular injection of local anesthetic can cause cardiac arrhythmias. Frequent negative pressure aspiration of the syringe avoids the risk of intravascular injection.

We take the following approach:

●Palpate the recess below the pubic bone at the base of the penis. Many infants have an enlarged suprapubic fat pad that can obscure the base of the penis. Palpating the pubic bone can help identify the location and depth of the base of the penis in comparison to the pubic bone, ultimately helping guide the angle and depth of injection.

●Prep the base of the penis inferior to the pubic bone with an alcohol prep pad.

●Puncture the skin with the 27-gauge needle at the midline. The needle remains subcutaneous. The clinician then angles the needle posterolateral and advances it approximately 3-5mm under the pubic bone toward the base of the penis. The clinician may feel a slight pop as the needle traverses Buck's fascia, but this is not always evident when a small-gauge needle is used in a newborn. In addition, gentle traction on the penis can help stabilize the overlying skin and reduce the effect of the suprapubic fat.

●Maintaining a posterolateral angle avoids the midline penile vessels. Once at the 2 or 10 o'clock position, the clinician aspirates to ensure the needle is not intravascular and then injects approximately 0.4 mL of anesthetic.

●After injection of one side, the needle is withdrawn to the level of the skin but not removed. The needle is then angled to the opposite side to complete injections at both the 2 and 10 o'clock positions.

●The clinician should then wait at least 5 minutes for lidocaine or 10 minutes for bupivacaine to provide adequate analgesia.

Ring block — Similar to dorsal penile block, 1% lidocaine or 0.25% bupivacaine, without epinephrine, can be injected circumferentially around the base or shaft of the penis to create a ring block. With any penile block, epinephrine-containing solutions should never be used on the external genitalia. Tracking of anesthetic along the penile shaft can also distort the penile anatomy and render circumcision more difficult. Support for ring block comes from two small studies reporting that the ring block was superior to placebo, and possibly superior to DPNB and EMLA [14,16]. The onset and duration of action are the same as for the DPNB. (See 'Dorsal penile block' above.)

The key steps in performing a penile ring block include:

●Dorsal surface – A bolus of local anesthetic, typically 0.4 mL of 1% lidocaine without epinephrine, is injected subcutaneously at the base of the penis transversely across the dorsal surface.

●Ventral surface – The needle is then introduced at the ventral base of the penis and advanced in the subcutaneous tissues laterally to each side until anesthetic is infiltrated circumferentially. Care is taken to ensure the needle remains superficial to the ventrally located urethra. A small amount of 1% lidocaine without epinephrine is injected continuously, for a total injected volume of 0.8 mL for the entire ring block.

Non-pharmacologic adjuncts — Non-pharmacologic techniques include non-nutritive sucking (eg, pacifier or gloved finger), oral sucrose solution, and positioning [7]. While these techniques do not provide adequate procedure or post-procedure analgesia when used alone, they can be used in conjunction with pharmacologic techniques to further soothe the patient [3,13,17,18].

PRE-PROCEDURE PREPARATION

Informed consent — Prior to the procedure, the clinician should provide a balanced explanation of the risks and benefits of both circumcision and not circumcising in addition to discussing the risks and benefits specific to the procedure itself. Parents or caretakers should be given sufficient time to ask questions. Written information is also provided that reviews the risks and benefits (table 1) and the postoperative care (table 2). After satisfactory discussion, a written consent is obtained. (See "Neonatal circumcision: Risks and benefits", section on 'Counseling'.)

Preparation — Prior to performing circumcision, the clinician should confirm that the patient has voided at least once since birth (the time of the void relative to the procedure is not important) and received vitamin K, consistent with recommendations from pediatric societies [3,19-22]. In addition, routine patient safety procedures are performed, such as confirming the correct identity of the patient.

●(See "Overview of the routine management of the healthy newborn infant", section on 'Vitamin K'.)

●(See "Patient safety in the operating room", section on 'Approaches to risk reduction'.)

Many institutions utilize a standardized circumcision kit. For those who do not, we suggest the following materials and instruments:

●Restraint with padded leg straps for patient support and immobilization (eg, Circumstraint, Stang chair) (picture 3)

●Fenestrated drape or sterile towels

●Device (Gomco, Mogen, Plastibell) with appropriate sizes. For the Gomco, the bell and base plate size must match (picture 5 and picture 6 and picture 7)

●Hemostatic agents: Gauze, fine absorbable sutures, compressive dressing (eg, Coban), silver nitrate, thrombin, and other hemostatic agents (eg, Gelfoam or Surgicel)

●Antiseptic agent: Betadine or chlorhexidine gluconate

●Sucrose 24% on pacifier

●Local anesthetic and alcohol prep pad (see 'Dorsal penile block' above)

●Post-circumcision dressing: Antibiotic ointment, petroleum gauze, compressive dressing

Examination of penis and scrotum — Prior to performing circumcision, we perform a physical examination to evaluate the anatomy, make an operative plan, and exclude visible congenital anomalies.

We take the following approach to examination of the penis and scrotum:

●Evaluate the urethral meatal position – Evaluation of the meatus (slit-like opening of the urethra at the tip of the penis) is critical to exclude hypospadias and penile torsion. The normal meatus should be vertical and located in the center of the tip (picture 8). If the urethra is not at the tip or rotated from vertical, circumcision is not performed. One challenge is that tight physiologic phimosis often obscures meatal visualization until the preputial orifice is dilated at the start of circumcision.

●Evaluate the median raphe – The median raphe, which normally runs the length of the penis and scrotum in the midline, may deviate to the side. While a deviated median raphe is not itself an absolute contraindication to circumcision, it can represent underlying penile abnormalities, such as penile curvature or torsion. Circumcision is not performed if penile torsion or curvature is present.

●Evaluate the scrotum for penoscrotal webbing – The normal scrotum attaches at the base of the penis with a well-defined junction. If the junction is not well defined, it may be attached higher on the shaft of the penis. Circumcision can lead to scrotal attachment very near the glans, which shortens the ventral shaft skin. We apply gentle traction on the scrotum to define the point of attachment with the foreskin and assess the level of ventral tethering.

●Perform bedside erection test – To evaluate the curvature of the penis, and identify potential penile chordee or ventral curvature, we perform the bedside erection test by applying pressure with the thumb and index finger at the base of the penis to simulate an erection.

The bedside erection test also allows the clinician to evaluate for a buried penis or a large suprapubic fat pad. Identification of these findings is important because these infants have a greater chance of the penis retracting below the skin surface post-circumcision, which can result in penile adhesions or circumferential scarring of the incision (cicatrix) that traps the penis below the skin surface. Such scarring can require circumcision revision under general anesthesia at a future date.

●Assess foreskin edema – If a circumcision is performed in the setting of excessive foreskin edema, there is increased risk of penile retraction with subsequent trapping of the glans below the skin surface as well as scarring that may require revision. This is especially important in patients who have a prolonged stay in the neonatal intensive care unit prior to circumcision, as edema can be present from resuscitative efforts. If the foreskin does not have the normal thin supple appearance and instead appears thickened, then we defer circumcision.

Unfortunately, some abnormalities are not uncovered until the fully intact foreskin is retracted and both the glans and meatal position can be assessed. If a hypospadias is identified after incision of the prepuce, at least three studies have reinforced that circumcision can be safely completed in patients who have a circumferentially intact prepuce and incidentally discovered hypospadias [23-25]. For these patients, our practice is to advise completing the circumcision because completion avoids the need for future general anesthesia to perform circumcision revision and allows discussion with the family whether a very distal (glanular) hypospadias requires repair.

TECHNIQUES

Choice of technique — The three commonly used devices for neonatal circumcision are the Gomco clamp, Plastibell device, and Mogen clamp, or devices based on the principles of these three techniques [3,4]. In randomly assigned trials, no one device is clearly superior [26-28]. Each has its own advantages and disadvantages in terms of number of parts, risk of sizing error, duration of procedure, reusability, and potential complications (table 3 and table 4). Thus, the choice of technique is determined by the clinician's training and device availability [3,4,28]. To ensure maximum patient safety, circumcision should be performed by practitioners who are educated and competent in the procedure [3,4,29]. In a study that utilized a checklist to further optimize patient selection, 67 percent of infants were approved for the procedure and 100 percent of these patients had a successful procedure with no complications [30]. Although 33 percent of infants were deemed unsuitable, this percentage reflects patients seen in a referral pediatric urology practice and is likely higher than that of the general population.

Initial steps — While three different devices are commonly used to perform circumcision, the initial steps of the procedure are the same for all:

●Place the patient in a restraint device (eg, Circumstraint (picture 3)) with padded leg straps and cover the patient with a blanket to maintain normothermia.

●Examine the patient, exclude penile and scrotal abnormalities, plan the amount of foreskin to be removed, and mark the corona.

●Apply or infiltrate local anesthetic as discussed in detail above and wait the appropriate amount of time for onset of action. Of note, as topical local anesthetics require at least 20 to 30 minutes for onset of action, these agents are typically applied before the infant is restrained. (See 'Pain control' above.)

●Sterilize the penis and surrounding area with antiseptic (betadine or chlorhexidine gluconate) (picture 9). Place a sterile fenestrated drape allowing visualization of the entire phallus including the base (picture 10).

●Grasp the foreskin at the 3 and 9 o'clock positions with two hemostats (picture 11).

•Pass a straight clamp into the preputial orifice and gently sweep from side to side across the distal glans to disrupt adhesions.

•Open the jaws of the clamp and retract the clamp to gently stretch the preputial opening (picture 12), allow access to the glans, and visualize the urethral meatus to ensure there are no abnormalities.

•Of note, it is important to angle the clamp dorsally when traversing the preputial orifice so the tips of the clamp do not enter the meatus of the glans. Spreading the hemostat within the meatus can lead to troublesome bleeding and injury to the glans.

●With the foreskin on stretch from traction on the hemostats, a straight clamp is placed and engaged in the midline of the dorsal foreskin (picture 13). The clamp is allowed to remain for approximately 10 seconds to devitalize a strip of foreskin. Divide the devitalized strip with straight scissors to complete a dorsal slit (picture 14). The exact length of the dorsal slit varies by circumcision technique and will be discussed with each.

●At this point, to maximize cosmetic appearance and avoid complications, the clinician should fully retract the foreskin, completely lyse any adhesions, and clearly visualize the coronal sulcus (picture 8 and picture 15).

The remaining steps include placing the device, leaving the device engaged long enough to ensure hemostasis, and removing the foreskin.

Gomco clamp — The Gomco clamp device is made up of multiple parts (the bell, base plate, yoke and nut) that result in a thin crushed tissue edge that provides hemostasis. The excess foreskin is completely removed at the time of the procedure; no tissue falls off or is removed at a later date. The bell protects the glans and urethra from injury during prepuce removal. However, the multiple parts of the device can cause unique challenges.

Prior to initiating any Gomco clamp circumcision, ensure proper fit between the bell and base plate being used. Some sets have the size embossed into the metal of both the plate and bell; however, occasionally no markings exist. For a proper fit, the lip of the bell should seat perfectly into the base plate without any gaps. We check to ensure that no light penetrates the junction. Additionally, there should be a gap of 2 mm between the arm of the bell and the plate before the nut is tightened. If the device has been damaged or packaged with a non-corresponding size, delay circumcision until a properly fit device is available. A mismatched or damaged device could result in significant bleeding because of an inadequate seal [31].

After the initial steps above have been performed, circumcision with a Gomco clamp is completed in the following manner:

●Cut a dorsal slit to a level just distal to the coronal margin (within 2 to 3 mm) (figure 1).

●Insert the bell of the Gomco clamp under the foreskin and cover the glans (picture 16). A correctly fit bell should just cover the glans without excessively stretching the foreskin (picture 17). If not adequately covered, then the glans could sustain injury during amputation of the foreskin. While the most commonly used size in the neonatal period is 1.3, a full set of sizes needs to be available to ensure patient safety.

●Thread the foreskin through the hole in the base plate. This step is often the most challenging part of the Gomco clamp circumcision. Several techniques exist for this maneuver, and clinician preference dictates which is used:

•Hemostat method – Grasp the foreskin through the base plate with two hemostats at the same 3 and 9 o'clock positions. Use gentle traction to deliver the foreskin through the base plate and seat the bell into the plate. Even traction is applied to maintain a symmetric appearance. A single hemostat is then used to grasp the cut edges of the dorsal slit and reapproximate it at the 12 o'clock position. This will lock the foreskin around the arm of the bell for delivery through the base plate (picture 18).

•Safety pin method – Insert a sterile safety pin placed through the cut edges of the dorsal slit at 12 o'clock. This will accomplish the same goal as the single hemostat described above (picture 19 and picture 20).

●Tension the foreskin appropriately.

•The skin should be flat and supple, but without folds of skin or on stretch. Excessive traction leads to excision of too much shaft skin, whereas folds of foreskin below the base plate results in an incomplete circumcision with excess skin. Care is taken to avoid excessive pressure on the ventral glans that can disrupt the frenular vessels and cause bleeding.

•Use the markings for the corona (made at the beginning of the procedure) to guide how much foreskin to remove.

•In general, leaving a little excess foreskin is better than removing too much, which will often result in denuded area of the shaft. If excessive foreskin is removed, these patients should be referred to an urologist for evaluation. Fortunately, most will heal by secondary intention.

●Once the clamp is properly positioned, release the traction on the foreskin and tighten the nut firmly.

•Of note, the Gomco clamp is heavy and excessive movement can cause pain despite adequate penile block. To minimize movement, the clamp rests well on the rise between the legs on the Circumstraint board (picture 21).

•The clamp remains locked in place for 5 minutes, timed by the clock. Removing the clamp prior to the 5-minute mark can result in bleeding.

●Excise all foreskin above the base plate using a scalpel.

●Loosen the nut and disassemble the device.

•There should be excellent hemostasis at this point.

●The bell will be stuck to the remaining shaft skin and prepuce (picture 22). Sweep the skin gently off the bell with gauze or blunt probe.

●Evaluate for cosmetic appearance and apply the dressing of choice (picture 23). Some options are antibiotic ointment, petroleum-impregnated gauze (picture 24 and picture 25), and compressive wrap.

●After conclusion of Gomco circumcision, we evaluate for bleeding at 30 minutes and 1 hour before discharging home.

Plastibell — The Plastibell device is a plastic ring with a groove on the outside that fits over the glans to protect it (figure 5). A string is tied around the bell and tightened to devitalize the prepuce. All foreskin distal to the ligature will become necrotic and fall away with the bell in a few days to a week. Since the glans is protected by the ring and the foreskin is allowed to fall off on its own, the risk of glans amputation or urethral injury is minimal.

A neonatal circumcision with Plastibell shares the initial steps with the other techniques. A minor difference is the extent of dorsal slit needed. The Plastibell device requires more foreskin to remain intact circumferentially for positioning of the string around the plastic bell. Therefore, just enough of a dorsal slit (if any) is made to fully retract the foreskin, clear away any adhesions and place the proper sized bell over the glans within the foreskin [32,33].

●After an adequate dorsal slit is made and the glans is evaluated, choose the appropriate size bell. The bell should cover most of the glans, with the meatus of the penis at the distal opening of the bell.

•If the bell is too large, the bell will cover the entire glans but the glans will protrude through the distal opening in the bell. Further, the ring can slide down the shaft of the penis causing pressure injury to the glans or urethra [34].

•If the bell is too small, the ring may injure the glans or leave excess foreskin.

●With hemostats grasping the foreskin at the 3 and 9 o'clock positions, secure the Plastibell by simultaneously pulling up on the foreskin and applying gentle downward pressure on the bell (picture 26). Care is taken to avoid excessive pressure on the ventral glans that can disrupt the frenular vessels and cause bleeding.

●Once the bell is properly positioned, wrap the string circumferentially around the groove in the ring, tighten firmly, and tie in place (picture 27 and picture 28). The distal foreskin may darken in color, indicating successful devascularization. The skin can be trimmed at the distal edge of the ring, which maintains adequate overlap of the skin to prevent the bell from slipping but limits the amount of necrotic tissue left to fall off. Once complete, we break the tab off the bell, if present (picture 29).

The devitalized skin and bell will fall off within a few days to a week. If the bell remains for a longer period or becomes malpositioned, the bell may need to be removed. A ring cutter (usually found in the emergency department) is helpful in safely removing the bell when it has migrated proximally on the shaft.

Mogen clamp — The technique for the Mogen clamp is faster and less painful compared with the Gomco clamp [35]. In order to properly use the Mogen clamp, more skill is required since the glans is not well protected and injury to the glans and urethra can occur with improper use. The Mogen clamp is often utilized for ceremonial Jewish circumcisions. The clamp itself is a simple hinged metal plate that is curved on one side. The clamp is divided by a 3 mm slit that allows passage of the foreskin but helps prevent glans entrapment and injury.

After the initial steps above have been performed, circumcision with a Mogen clamp is completed in the following manner:

●Release all preputial adhesions. Incise a dorsal slit only if necessary to fully retract the foreskin. Evaluate the glans and urethra.

●Place a single hemostat along the dorsal midline of the foreskin and grasp the glans with the thumb and forefinger of the non-dominant hand.

●The Mogen clamp (picture 30) is then opened and placed across the foreskin between the hemostat and grasped glans (picture 31). The side with the groove is aligned toward the glans. The Mogen clamp is angled to mimic that of the corona, and thus removes more foreskin dorsally than ventrally.

●It is critical to release any tension on the hemostat and foreskin. Traction on the frenulum can rotate the glans dorsally placing the ventral glans and urethra in danger of being incorporated into the clamp and subsequently amputated. In a retrospective review of 6 cases of glans amputation and urethral injury from Mogen clamp circumcision, traction on the frenulum appeared to increase the risk of this devastating complication [36].

●Close and lock the clamp. Once locked, the Mogen clamp remains in place for a few minutes to ensure hemostasis. Since the Mogen clamp seals a wider area than the Gomco clamp, a full 5 minutes may not be necessary.

●Amputate any foreskin distal to the clamp with a scalpel (picture 32).

●Release the clamp. The remaining skin will be stuck together distally over the glans. The skin is separated and retracted to free the glans.

●Apply dressings of choice.

HEMOSTASIS — If bleeding occurs, electrocautery should never be used in conjunction with metal clamps because devastating penile loss can occur.

Bleeding most commonly results from disruption of the frenular vessels in response to excessive force on the frenulum. Other causes of bleeding include a mismatched Gomco bell and plate (which results in poor compression of the cut edge), premature removal of the clamps, older patients (who have larger caliber vessels), and a loose Plastibell string.

We take the following approach to bleeding:

●First, we apply direct pressure, as this will stop most bleeding. A compressive wrap such as Coban can resolve modest bleeding.

●For mild continued bleeding, we apply hemostatic agents such as thrombin, Gelfoam, or Surgicel. Choice depends on availability of the products. Additionally, hemostatic agents can be used in conjunction with a compressive wrap around the penis. Of note, when using the Plastibell device, hemostatic agents should not be packed into the bell obscuring the meatus. This can lead to difficulty urinating.

●However, for excessive bleeding, particularly frenular bleeding or when a vessel can be identified, we suture the bleeding edge with a fine absorbable suture placed transversely. Our preference is a 5-0 Vicryl suture. Care must be taken to place the suture superficially, as the urethra lies in the ventral midline and can easily be incorporated in the suture. An inadvertently sutured urethra can result in an urethrocutaneous fistula. Vicryl suture placed to control bleeding is allowed to naturally dissolve and fall off.

POST-CIRCUMCISION CARE — Basic surgical principles guide post-circumcision care. There are no data to guide choice of dressing and the selection is based on the clinician's preference. We apply a barrier cream to reduce the risk of penile adhesions and meatal stenosis [37]. We typically use a petroleum jelly for the duration of treatment (ie, until the skin has healed, or generally two weeks). The shaft skin should not be forcibly retracted; however, in some boys, the shaft skin will preferentially sit upon the glans due to penile retraction or suprapubic adipose tissue. For these patients, gently retracting the skin to visualize the incision and applying ointment may help reduce the rate of penile adhesions requiring revision. We also instruct parents or care providers to apply the barrier ointment to the glans and diaper to help prevent meatal stenosis. We provide written information on the care of the penis for the parents or caretakers. One example is provided in the table (table 1).

COMPLICATIONS AND MANAGEMENT — The complications of circumcision and their management are presented in detail separately. (See "Complications of circumcision".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Neonatal circumcision".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Should I have my baby circumcised? (The Basics)")

●Beyond the Basics topics (see "Patient education: Circumcision in baby boys (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Definition and anatomy – Circumcision removes the inner and outer layers of the prepuce as well as the intervening dartos muscle (figure 3). Neonatal circumcision is extremely common and can be safely performed starting 24 hours after birth up to six weeks of life. (See 'Development and anatomy' above and 'Timing of procedure' above.)

●Contraindications – Circumcision should not be performed in unstable or significantly premature infants, or if congenital penile anomalies are present. Development of the foreskin coincides with the development of the penis; therefore, anatomic abnormalities of the penis often result in incomplete or abnormal foreskin. Relative contraindications include lack of vitamin K supplementation, no documented void, and bleeding disorder or family history of abnormal bleeding. For these patients, the procedure is delayed until these criteria have been met or until the procedure can be performed at an adequately prepared facility. (See 'Contraindications' above.)

●Informed consent – The risks and benefits of circumcision versus not circumcising, as well as the risks and benefits of the procedure itself, should be fully discussed with the parents or caretakers as part of the consent process. Parents or caretakers should be given sufficient time to ask questions. Written information is also provided that reviews the risks and benefits (table 1) and the postoperative care (table 2). After satisfactory discussion, a written consent is obtained. (See 'Informed consent' above.)

●Analgesia – Analgesia, in the form of topical anesthetics or nerve blocks, is routinely provided when neonatal circumcision is performed. As no technique is clearly superior, selection depends on the training of the clinician and the availability of agents. Non-pharmacologic techniques, such as non-nutritive sucking (eg, pacifier or gloved finger), oral sucrose solution, and positioning, do not provide adequate analgesia but can be used in conjunction with pharmacologic techniques to further soothe the patient. (See 'Pain control' above.)

●Physical examination – Prior to performing circumcision, we perform a physical examination to evaluate the anatomy, make an operative plan, and exclude visible congenital anomalies. When hypospadias is encountered during the circumcision in a patient with fully intact prepuce preprocedure, the circumcision can be safely completed without compromising future repair. Stopping the procedure after a dorsal slit commits the patient to a further surgical procedure under general anesthesia for revision. (See 'Examination of penis and scrotum' above.)

●Choice of technique– For patients undergoing neonatal circumcision, we suggest any of the three circumcision techniques (Gomco clamp, Plastibell, or Mogen clamp) (table 3) (Grade 2A). The proceduralist must be well trained in the specific technique utilized. (See 'Choice of technique' above.)

•Initial steps – The initial steps of the procedure are the same regardless of surgical device. Key steps for improving cosmetic appearance and minimizing complications include ensuring complete separation of preputial adhesions from the glanular epithelium, full visualization of the coronal sulcus, and proper tensioning of the foreskin prior to excision. The foreskin should be straight, without folds, but not stretched. (See 'Initial steps' above.)

•Control of bleeding – If bleeding occurs, electrocautery should never be used in conjunction with metal clamps because devastating penile loss can occur. Techniques to control bleeding include applying pressure, use of hemostatic agents, and suture. (See 'Hemostasis' above.)

●Post-circumcision care – Basic surgical principles guide post-circumcision care. There are no data to guide choice of dressing and the selection is based on the clinician's preference. We apply a barrier cream to reduce the risk of penile adhesions and meatal stenosis. Parents or caretakers are given written instructions on care (table 2). (See 'Post-circumcision care' above.)

●Complications – Surgical complication can occur with any of the surgical devices; the relative likelihood of a specific issue varies by type (table 4). The complications of circumcision and their management are presented in detail separately. (See "Complications of circumcision".)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges David G Weismiller, MD, ScM, who contributed to an earlier version of this topic review.