Sunday, February 26, 2006

Circumcision

This is a hot topic....and I have been amazed at the number of people who ask if midwives perform circumcision. We don't. My experience has been that midwives either feel very clear that the penis should be left intact or that it is the job of the midwife to inform and the choice is the parents. What I have found interesting is that in Oregon, about 60% of boys are not circumcised. This is in part because of progressive views, but also because the procedure is generally not covered by insurance. The AMA decided that the procedure is not longer medically necessary and is now considered cosmetic surgery, making insurance companies less likely to cover the cost. What I would recommend to parents who are considering circumcision is that they educate themselves as to the risks and benefits and that they watch a video of the procedure. A lot of parents don't like the idea of seeing a circumcision performed, but I think that it is important to know what the choices being made look like.

Here is some more information....

http://www.icgi.org/birth_care_providers.htm

What is male circumcision?

Circumcision is the removal of the foreskin of the penis. It usually takes place in the hospital during the fist day of life, or is performed on the eighth day of life by a religious attendant. It may be performed for cultural or religious reasons and beliefs.

Circumcision may be performed in a few different ways. The most common are the Gomco clamp and the Plastibell clamp. In religious ceremonies a Mogen clamp is used. It allows for a quicker procedure, but may have a greater risk of cutting penile anomalies, because the glands of the penis are not visible.

The use of the clamp in the Gomco and Plastibell procedures may allow for greater visibility, but are done at a slower pace, and therefore may be more painful. Both the Gomco clamp and Plastibell clamp procedures are relatively the same, however, the Plastibell clamp has a small, grooved ring that remains around the penis after the circumcision is finished. The ring stays on for approximately one week. With these procedures a probe is used to separate the glands of the penis from the foreskin and a small incision (dorsal cut) is made down the foreskin to allow for the placement of the bell of the Gomco clamp over the glands. The clamp is then put in place. The foreskin that is to be cut sits above the base of the clamp, thus protecting the rest of the penis from being cut. A scalpel is used to remove the foreskin above the base of the Gomco clamp.

The Gomco clamp is thought to have lower infection rates than the use of the Plastibell clamp. Both procedures take more time than the Mogen clamp procedure, but allow for greater visualization of the circumcision.

Circumcision may be performed with no anesthetic. This is not recommended. If you are planning on circumcising your newborn, make sure that an anesthetic is being provided.
Lidocaine is the most common anesthetic. It may be given in the form of a penile nerve block, which involves injecting 1% lidocaine in to the area where the dorsal nerve of the penis begins. The injection itself is painful. Topical or local lidocaine, 2%, is another form of anesthetic. Because it is not an injection, its effects are more superficial. There is no pain from administration, but it may not provide complete pain relief.

What the American Academy of Pediatrics says:

While circumcision may be performed for religious or cultural reasons, the World Health Organization and the American Academy of Pediatrics do not recommend circumcision as a routine procedure. It is considered cosmetic surgery, and therefore may not be covered by your insurance policy.
The American Academy of Pediatrics states: “Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these date 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.”

Some facts:

Circumcision was originally practiced for religious reasons. It involved a mosaic cut, or a small cut above the penile glands in which only the tip of the foreskin was removed.

In the UK circumcision is not commonly practiced because there is little evidence to support it as being beneficial.

It is considered a safe procedure

Bleeding and infection occur in 1% of the cases

It takes about 1 week for the penis to heal

Circumcision is often performed with no anesthesia

Circumcision has been linked to a 50% reduction in penile cancer.

Penile cancer is very rare. 1 in 100,000 men get penile cancer each year.

There is a 1 in 476 chance of complication associated with circumcision.

Disadvantages to circumcision:

It is difficult to prevent the newborn from feeling the pain associated with circumcision. There are several types of anesthesia to help numb the penile area, although some studies question to what extent these anesthetics work. In some instances no anesthetic is used.

Risk of infection

Risk of amputation

Risk of severing the frenulum

Increased bleeding

Mutilation of the penis or areas of the penis

Increased risk of scaring

Increased risk of scaring leading to sexual dysfunction

Causes fear in the infant

Causes decreased sexual sensitivity

If not covered by insurance, the procedure can be costly.

Advantages to circumcision:

Allows for participation in a cultural custom

May be easier to clean under adverse conditions (where clean water is not available)

No foreskin cancer

Allows for participation in religious beliefs and customs

Newborn can look like dad

Care for the circumcised penis:

Make sure to discuss care with the practitioner conducting the circumcision. Get clear instructions that you understand and find easy to follow.

*The dressing on the penis should be removed after 24 hours.

*If it needs replacing, do so, under the advice or your practitioner.

*If there is excess bleeding be sure to notify a nurse or the doctor immediately.

*Make sure that any dressings placed on the penis are clean.

*Always wash your hands before handling the circumcised area.

*Clean the area with lukewarm water during the first few days.

*DO NOT use soap or alcohol on the penis. This will cause the newborn pain.

*It may take 3 days to 1 week for the penis to heal.

*Do not be surprised if the baby is irritable.

*Provide warm, loving care for the newborn. Tell the baby he is safe and loved.

*Report any signs of redness, swelling, bleeding, or excess pus immediately.
*Signs of infection include lethargy, poor or no feeding, no wet diapers, and a temperature at or above 101 degrees F.

*Arnica and rescue remedy may be given internally; ask your midwife for specific dosage. Arnica gel or ointment can also be given at the base of the shaft, but should not be put on the circumcised area.

Care for the uncircumcised penis:

The tip of the penis should be wiped off and gently washed without retracting the foreskin. Over time, the babyÂ’s foreskin will retract, even if left alone. By the age of three (and around the time of potty-training), the child should be able to retract the foreskin and taught to clean the penis on his own.


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