Nursing

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After reading the article you should be able to:

1. Compare and contrast the three methods of circumcision.
2. Discuss nursing and medical management for a circumcised newborn.
3. Develop a teaching plan for a circumcised newborn.

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By BETTY BROWN-TRASK, RN, MPA, PNP-BC; SHARON L. VAN SELL, RN, EdD, PAHM; SHERRY CARTER, RN, PhD, WHRP; and CHRIS KINDRED, RN, MS, PNP

BETTY BROWN-TRASK is a pediatric nurse practitioner at Parkland Hospital in Dallas. SHARON L. VAN SELL, Professor; SHERRY CARTER, Associate Professor; and CHRIS KINDRED, Associate Clinical Professor are educators for the College of Nursing at Texas Woman's University in Dallas. The authors have no financial relationships to disclose. STAFF EDITOR: MARTHA K. RAYMOND, RN, BSN, BS

THOUGH CIRCUMCISION CAN BE A DEBATABLE TOPIC, the American Academy of Pediatrics (AAP) in 1999 determined that scientific evidence demonstrated potential medical benefits of newborn male circumcision. However, there was insufficient data to prove neonatal circumcision is medically essential. The opinion of the AAP was reaffirmed in 2005.¹ Therefore, nurses in the postpartum units often address questions about circumcision. Moreover, learning about circumcision's standard of care is a great opportunity to add to evidence-based clinical knowledge for the nursing profession.

Parents ask about circumcision procedures and post-circumcision care. But first, nurses need to understand circumcision, which is the surgical removal of the foreskin — prepuce — from the tip of the penis, exposing the glans of a male newborn.² Neonatal circumcision is one of the most commonly performed surgical procedures in the United States and worldwide. Statistics show that from 1979 to 2001, between 59% and 65% of male infants were circumcised in the hospital, and that number remained relatively constant. However, from 2001 to 2003, the percentage of circumcisions decreased from 63% to 56%³ and remained at 56% through 2005, which represents the most current data.⁴

The AAP recommends that providers who perform circumcision be skilled at the technical aspects of the procedure in order to minimize complications.¹ In spite of these recommendations, there are no national standards or guidelines for neonatal circumcision.⁵

However, circumcision has many benefits.⁶ Circumcision can prevent urinary tract infections, phimosis, paraphimosis, and sexually transmitted infections, including HIV. For example, in a randomized control trial, circumcision reduced the risk of acquiring HIV infection by 53%.⁷

Though circumcision allots benefits, parents are often still reluctant toward the procedure. On the other hand, many parents choose to circumcise their sons based on their religious, cultural, and ethnic beliefs and traditions.⁶

Insurance benefits are also a factor in the parents' decision-making process. Circumcision rates were 24% higher in states with Medicaid programs that cover the procedure than in those that don't.⁸

Whether choosing circumcision for medical or cultural reasons, parents need to understand informed consent, pain control during the procedure, and how to reduce post-circumcision complications.

THE TIME IS RIGHT Circumcisions should be delayed until the newborn is certain to be in stable condition, which is at least 12 to 24 hours.⁹ Moreover, the maternal record should be reviewed to collect information that might affect the outcome of the neonatal circumcision, such as the family status for hemophilia. Any newborn with hemophilia would not be a candidate for circumcision, due to a risk of bleeding. In addition, male neonates with bilateral large hydroceles, or penile abnormalities such as hypospadius, epispadias, micro-penis, ambiguous genitalia, megalourethra and webbed penis, should not be routinely circumcised.¹⁰

The nurse needs to understand the three methods of circumcision — Plastibell, Mogen clamp, and Gomco clamp — in order to teach the parents about the appropriate post-procedure care. The Plastibell device uses an economical, disposable plastic clamp. A string-tied plastic clamp stays on after the procedure and falls off three to seven days later.¹¹ The benefits are that there's less chance for severe bleeding, and a dorsal slit allows for inspection and complete separation of glans. This method is also the easiest of the three to teach. Possible complications do exist. The clamp can migrate down the penile shaft and possibly cause necroses of distal skin. In addition, because the body may identify the clamp as a foreign object, the chance of infection is greater than with the other two types. The procedure leaves the most skin, and using the wrong clamp size always leaves even more skin. The procedure takes longer to perform than one with the Mogen clamp.¹¹

The second type of procedure uses the Mogen Clamp. It has only one working part and is the fastest to use. Some consequences of this procedure are a higher bleeding potential. It's also a blind procedure, and there's no dorsal slit. Drawbacks include reported cases of partial amputation and incomplete freeing of inner skin. As for the appearance, the method may produce a V-shaped notch or "dog ears."¹¹

The third most common device is the Gomco clamp with four working parts for individual sizing. The procedure takes about the same length of time as the Plastibell or longer. However, there's more potential for bleeding than with the Plastibell. The Gomco clamp method is probably the most difficult to learn, as it relies on a crush technique instead of cutting. A benefit is the dorsal slit. The proper clamp size removes the correct amount of foreskin and can leave as little as a 1.5 mm inner layer.¹¹

PAIN CONTROL Neonates do experience pain and physiologic stress. Evidence shows that newborns who are circumcised without analgesia experience changes in heart rate, blood pressure, oxygen saturation, and cortisol levels.¹ Pain management for neonates during and following circumcision uses various medication and procedures. Eutectic mixture of local anesthetic (EMLA) is a topical anesthetic used for minor procedures, such as circumcisions. EMLA cream is comprised of 2.5% lidocaine and 2.5% prilocaine. It has its maximum therapeutic effect when applied 30 to 90 minutes prior to the procedure.

The dorsal penile nerve block (DPNB) is very effective in decreasing behavioral and physiological pain responses in the newborn. A 27-gauge needle is used to inject the 0.4 mL of 1% lidocaine, which is administered at 10-o'clock and 2-o'clock positions.

Another option for pain control is a subcutaneous ring block of 0.2 mL of 1% lidocaine without epinephrine administered in the mid shaft of the penis at 10-o'clock, 2-o'clock, 5-o'clock, and 7-o'clock positions. This technique was more effective than EMLA or the DPNB. The ring block diminished crying and reduced increases in heart rate when compared to the EMLA or DPNB pain control measures. EMLA, DPNB, and the subcutaneous ring blocks all reduce procedural pain. However, the subcutaneous ring block was the most effective.^1,12

TEACHING After the circumcision, teach parents to care for the circumcision and to observe for complications, though the complication rate is low—about 2 per 1,000 cases—and the majority of the problems are minor. The most common complications include infection, bleeding, and not removing enough foreskin.⁹ In addition, penile adhesion is a potential problem. Adhesions can occur when the remaining skin that is left after circumcision is not retracted. Without diligent post-circumcision care, the epithelium of the inner prepuce can reattach to the epithelium of the glans penis and cause a penile adhesion.

Another problem that can occur with newborn circumcision is meatal stenosis, which is caused by intraoperative vascular injury to the frenular vessels, or from chronic diaper irritation and can result in deflection of the urinary stream, dysuria, and occult hematuria.¹⁰

Many circumcision complications can be prevented if parents are armed with extensive knowledge about the care of their circumcised infant. The parents should be prepared for how the freshly circumcised penis will appear. Parents must understand that their responsibility for care has just begun in the circumcision process. Typically, there may be swelling and bruising noted after the circumcision secondarily to the injection of anesthesia. The swelling should subside over the next week. Frequent changing of the infant's diaper is required in order to prevent irritation from soiling.¹³

The parents should be instructed by the bedside nurse to notify their healthcare provider if the newborn has increased bleeding or drainage. In addition, if the baby is having problems voiding or doesn't urinate normally within six to eight hours after the circumcision, they should alert the practitioner. Also, a temperature over 38°C is another reason for concern. A yellow discharge, especially with an odor, that drains from the penis possibly is a complication. A sign of infection is also the presence of pus-filled blisters. Lastly, they should notify the provider of any amount of swelling or redness around the tip of the penis that gets worse after three days.¹⁴

It takes about seven to ten days for the scab over an incision to fall off, and about the same amount of time or a little longer for the Plastibell to fall off. Be sure not to pull on the Plastibell, as it can cause soreness and bleeding. After the scab or Plastibell falls off, no further care is needed outside of normal good hygiene. If the Plastibell does not fall off after two weeks, contact your healthcare provider. Lastly, the parents should inspect their son's penis daily. If there is any foreskin, the parents should be instructed to keep the foreskin pushed back, even after the circumcision is healed.

REFERENCES

1. American Academy of Pediatrics. (2005). AAP publications retired and reaffirmed: Policy statement: Task force on circumcision policy statement. Pediatrics, 116. Retrieved Jan. 8, 2009. http://aappolicy.aappublications.org/cgi/content/full/pediatrics;116/3/796

2. Geyer, J., Ellsbury, D., et al. (2002). An evidence-based multidisciplinary protocol for neonatal circumcision pain management. Obstet Gynecol Neonatal Nurs, 31(4), 403-410.

3. Child Trends Data Bank. (2004) Male Infant Circumcision. Retrieved Jan. 19, 2009. http://www.childtrendsdatabank.org/indicators/85MaleCircumcision.cfm

4. Agency for Healthcare Research and Quality. (Jan. 2008). Healthcare cost and utilization project. Circumcisions performed in U.S. community hospitals, 2005. Retrieved Jan. 19, 2009. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb45.pdf

5. Kunin, S.A. (2007a). Improved newborn circumcision utilizing dorsal foreskin local anesthesia. Presentation given at the Western Section Urological Association Meeting in Scottsdale, Arizona, Retrieved Jan. 17, 2009. http://www.samkuninmd.com/docinfo/Improved_GOMCO_Circumcision_handout.pdf

6. Ridings, H. & Amaya, M. (2007). Male neonatal circumcision: an evidence-based review. Journal of the American Academy of Physician Assistants, 20(2), 32-34, 36.

7. Bailey, R. C., Moses, S., et al. (Feb. 2007). Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomized controlled trial. The Lancet, (369)9562, 643-656.

8. Leibowitz, A. A., Desmond, K., & Belin, T. (Jan. 2009). Determinants and policy implications of male circumcision in the United States. American Journal of Public Health, 99(1), 138 - 145.

9. American Academy of Family Physicians. (2007). Circumcision: Position paper on neonatal circumcision. Retrieved Jan. 23, 2009. http://www.aafp.org/online/en/home/clinical/clinicalrecs/circumcision.html

10. Steadman, B., & Ellsworth, P. (2006). To circ or not to circ: Indications, risks, and alternatives to circumcision in the pediatric population with phimosis Urologic Nursing, 26(3), 181-194.

11. Weismiller, D. G. (Oct. 2008). Up-to-date Web site. Procedures for neonatal circumcision. Retrieved Jan. 13, 2009. http://www.uptodate.com/patients/content/topic.do?topicKey=~ck0Lfx43A3jQg0

12. American Academy of Pediatrics. (1999). Task force on circumcision: circumcision policy statement. Pediatrics, 103(3), 686-693.

13. Gilgal Society. (2004). Preparation and after-care for your child's circumcision. Retrieved Jan. 8, 2009. http://www.circinfo.com/prepandcare/ccc.html

14. American Pregnancy Association. (2007). Circumcision. Retrieved Jan. 9, 2009. http://www.americanpregnancy.org/labornbirth/circumcision.html

15. Shoemaker, C. (2008). Circumcisions in male infants. Up-to-date Web site. Retrieved Jan. 8, 2009. http://www.uptodate.com/patients/content/topic.do?topicKey=~7/FKOEbeSE50S7

16. Angel, C. A., & Cantu, S., Jr. (2006). Circumcision. Emedicine. Retrieved Jan. 8, 2009. http://emedicine.medscape.com/article/1015820-overview

Post-Newborn Circumcision Care and Teaching

• Return infant to his mother post-circumcision.
• Obtain vital signs.
• Assess the circumcision site for active bleeding and observe bleeding up to two to four hours after the procedure.
• After 30 to 60 minutes, the local anesthetic will wear off, and the newborn may be fussy. Instruct the mother to comfort the infant by:
  • Cuddling and holding the infant.
  • Not putting pressure on the penis.
  • Feeding the infant.
  • Checking the diaper every two to three hours. If wet or dirty, change it promptly. Put diapers on loosely.
  • Rocking and singing to infant, playing relaxing music.
• The infant should have wet diapers as usual. The baby may have pain while urinating, when healing skin comes in contact with urine.
• The penis may look red, swollen, or bruised. This tender appearance should gradually disappear in the next few days. Keep in mind that even though your baby's penis will usually start feeling better after three days, it may look worse. The penis will usually look like it's getting better about seven to ten days after the procedure.

Sources: Gilgal Society. (2004). Preparation and after-care for your child's circumcision. Retrieved Jan. 8, 2009. http://www.circinfo.com/prepandcare/ccc.html

American Pregnancy Association. (2007). Circumcision. Retrieved Jan. 9, 2009. http://www.americanpregnancy.org/labornbirth/circumcision.html

Design problems

At birth, a foreskin or prepuce firmly covers the glans of the penis. The foreskin is lined with two layers—an external keratinized layer and internal mucosal layer. By age four, approximately 95% of males can fully retract their foreskins.¹² However, in some, the separation process doesn't proceed smoothly and is complicated by phimosis. In this condition, the distal prepuce doesn't retract over the glans. During an assessment, the foreskin may have thin adhesions to the glans, appear tight, and be nonretractable. In physiologic phimosis, this arrangement usually subsides during progressive keratinization of the epithelial layers, when the glans and the inner prepuce detach. In contrast, severe phimosis presents as a bulging foreskin during urination. Though phimosis doesn't obstruct the urinary stream, inadequate hygiene predisposes the individual to yeast infections, chronic skin irritations, prepuce infections or posthitis, and glans infections or balanitis.

In addition, forcefully retracting the foreskin may result in paraphimosis, where a retracted foreskin can't be reposition ed over the glans. Other causes of paraphimosis occur when caregivers retract the foreskin forcefully to clean the penis or insert a catheter and don't return the foreskin. During paraphimosis, venous engorgement and edema effect the glans and foreskin. This condition leads to arterial occlusion and potential ische-mic loss of portions or even the whole glans. Because paraphimosis is a urologic emergency, it should be treated immediately. Caregivers may learn a manual technique to replace the foreskin, and if this fails, a dorsal incision may free the foreskin.¹⁶

Sources: Shoemaker, C. (2008). Circumcisions in male infants. Up-to-date Web site. Retrieved on Jan. 8, 2009. http://www.uptodate.com/patients/content/topic.do?topicKey=~7/FKOEbeSE50S7

Angel, C.A., & Cantu, S., Jr. (2006). Circumcision. Emedicine. Retrieved on Jan. 8, 2009, from http://emedicine.medscape.com/article/1015820-overview

Tips

• The baby may be irritable, not sleep as well, and may seem fussy while the circumcision site heals.
• If infant continues to be in pain, acetaminophen (Tylenol) is usually given, as instructed by the practitioner.
• Diaper changing
  • Always wash hands.
  • Remove the old gauze with each diaper change.
  • Gently wash the penis with warm water after each diaper change to remove stool or urine and pat dry—avoid rubbing. (Some swelling and yellow crust formation around the site is normal. Do not attempt to remove the film that forms on the penis. This film will go away by itself.)
  • Apply petroleum jelly liberally to raw areas on the head and/or shaft of the penis during each diaper change. The petroleum jelly prevents the scab from sticking to the diaper and helps protect the healing area.
  • Make sure diapers are fastened loosely to decrease irritation of the penis.
  • Wash hands after each diaper change.

HOME-GOING TEACHING FOR PARENTS

GOMCO CLAMP AND MOGEN CLAMP CIRCUMCISION

A small piece of gauze with petroleum jelly is wrapped around the penis after circumcision. The gauze should fall off after a few diaper changes. Do not reapply gauze; only apply a large amount of petroleum jelly for a few days to assist with healing and comfort. If gauze has not fallen off within 24 to 48 hours after circumcision, soak with warm water or a washcloth, and carefully remove and apply petroleum jelly for two to four more days. Do not forcibly remove gauze. This dressing helps prevent any irritation to the site and the diaper from sticking to the skin. The penis can be washed with warm water and should be kept clean of stool.

PLASTIBELL CIRCUMCISION

No dressings are used. A dark brown or black ring of dead tissue encircling the plastic rim is normal and will fall off with the plastic ring, in three to seven days after circumcision. If there is unusual swelling, a foul smell, or active bleeding, or if the plastic ring is still in place after two weeks, the physician should be notified immediately.

Sources: Gilgal Society. (2004). Preparation and after-care for your child's circumcision. Retrieved Jan. 8, 2009. http://www.circinfo.com/prepandcare/ccc.html

American Pregnancy Association. (2007). Circumcision. Retrieved Jan. 9, 2009. http://www.americanpregnancy.org/labornbirth/circumcision.html.