Circumcision in boys

Circumcision in boys: what’s the procedure

First, the doctor performing the circumcision will inform on the boy s general health and will check if there are no medical reasons to not do the circumcision. The doctor will also give information and answer potential questions.

If the boy is older than 6 months, he will receive Midazolam, a sedating and fear-reducing medicine. The medicine will be administered either suppository or with a nose spray. It will take a few minutes for the boy to calm down (note: he will not fall asleep). Side-effects are dizziness and loss of strength, meaning you cannot let him walk off (he may fall) or give him small foods (he may choke on them). After 3-4 hours the effects of the medicine will wear off.

Next, the doctor will anesthetize the penis with a few injections of xylocaine 2% with adrenaline. The injections are a little painful, but will not take long. Before the procedure is started, the doctor will check if the penis is fully anesthetized. This is done by pinching the foreskin with a surgical clamp; the boy should not feel this. It is always possible to inject more anesthetic medicine if necessary.

When the doctor is convinced that the penis is fully anesthetized, he will start the procedure by releasing the foreskin from the glans (head of the penis). Next, the foreskin will be pulled up and cut at the right height, after which the inner layer of the foreskin will be trimmed accordingly. Using electric surgical tweezers, the bleeding blood vessels will be burned closed (cauterized). The doctor will suture the wound, and the penis will be covered in Vaseline. After that, the circumcision is done.

The anesthesia wears off after approx. 1 hour. The boy may experience some after-pain for a short time, which is treatable with Paracetamol. The sutures will dissolve after 2-3 weeks, and do not need to be removed.

The circumcision is, of course, a very important event to the parents. In our clinics, both parents are welcome to be with their son for distraction and comfort. Please bring up to 4 family members or friends with you into the operating room to prevent crowding. The boy may be dressed in traditional clothing and may be filmed or photographed during the procedure. Please try to give the doctor enough space in the process.

Besnijdenis Centrum Nederland (BCN) refrains from using technical circumcision devices like the Smartclamp or Plastibell. These devices have been designed for doctors less experienced with the classical surgical method. We have used these devices in the past, but the results were not satisfactory. Furthermore, these devices tend to cause more issues, and wearing them for a few days is uncomfortable for a boy. In short, we prefer a classical surgical circumcision, performed by an experienced doctor, over these technical circumcision devices.

Reasons to do a circumcision

Reasons to do a circumcision are:

• Religious obligation;
• Medical indication;
  • Phimosis: a narrowed foreskin, so much that it is unable to be pulled back;
  • Balanitis: recurring infections under the foreskin.
• Hygienic or preventive reasons: i.e. lower risk of sexually transmitted infections (HIV), prevention of a narrowed foreskin and/or infections.

When is circumcision not an option?

The circumcision cannot be performed in the following cases:

• When both parents/guardians do not approve of the circumcision. Both need to have read and signed the informed consent form;
• When the boy is sick or feverish on the day of the procedure;
• When the boy has received a vaccination less than 3 days before the procedure;
• When the boy has a medical issue (e.g. severe diaper rash or impetigo) to such a degree that the doctor judges the boy unfit to be circumcised;
• When the boy has excess belly fat to such a degree that it covers the penis. This usually occurs from the age of 3 months onward. In this case, the circumcision is postponed until the belly fat has receded;
• When the boy suffers from ?hypospadias?. This means that the urethral opening is not on top of the glans, but is situated lower on the shaft of the penis. In this case, the boy should be seen by a pediatric urologist to have surgery to close the defective opening.

Parents need to know that circumcision cannot be performed in some cases, especially if there is a circumcision party organized afterward. When in doubt about your son s health, please contact us to consult on this matter. In case of excess belly fat, it is possible to make an intake appointment to check if the circumcision can be performed.

Age, pain and fear

We advise parents to do the circumcision at a young age. When the boy is a couple of weeks or months old, he will experience very little of the circumcision (except for the anesthetic injection). The younger, the better!

Older boys will need good instructions from their parents first. They need to understand that they will receive a painful injection, after which the pain during the procedure will be gone. If the parents fail to instruct and prepare their son, it will lead to fear and stress, which could have been avoided. In our opinion, circumcision performed under total anesthesia (narcosis) is too much stress for the boy and too expensive for the parents.

Informed consent parents/guardians

Both parents/guardians need to have read and signed the informed consent form before the circumcision. In it, they state that:

• They have requested the doctor to circumcise their son, and are both responsible for the fact that their son will be circumcised;
• They realize that the circumcision is a medical operation, which in rare cases can lead to complications;
• They have read and accepted the terms and conditions of the care and aftercare offered by BCN.

What is a normal healing process?

In most cases, the wound heals without any problems. After the anesthesia has worn off, the boy may experience some after-pain. This usually lasts about 30 to 60 minutes. In case of a normal healing process, the wound is closed after 2 to 3 weeks.

Bathing and Vaseline
The boy must be bathed daily, from the day after the circumcision onwards. The parents should put him in a lukewarm bath, without soap/shampoo/oil etc.  for 15 minutes, towel him dry, apply Vaseline on the wound, and put on his diaper or underwear. This should be done until the wound is healed.

Painkillers
Usually, Paracetamol is only needed on the day of the circumcision and the following night. If the boy is still experiencing pain in the following days, he may have more.

Yellow substance on the glans
Frequently, the glans is covered in a white/yellow layer or may be fiery red after the circumcision. This is due to the release of the foreskin from the glans, causing very superficial abrasions. Like a scab on skin abrasions, the white/yellow layer indicates an ongoing healing process underneath it. This will disappear after 7 to 10 days.

Blue discoloration of the skin
In some cases, the skin of the penis or scrotum may turn blue after the circumcision. This indicates a small, harmless hemorrhage, caused by the anesthetic injection. This will disappear after 1 or 2 weeks.

Possible complications after the circumcision

Because of our vast experience with circumcisions, complications rarely occur. Of course, there is always a risk of complications, which may impede the healing process. The following things may occur:

Bleeding, less than 2 days after the circumcision
This occurs on the same or following day of the circumcision. A little bit of blood (a red spot in the diaper) is normal, but it should not keep on bleeding. If the bleeding will not stop after 5 to 10 minutes of applying pressure on the wound, the parents/guardians should call our doctor on duty, available day and night within the first 48 hours. The doctor may decide to see the boy back in our clinic to stop the bleeding. Bleedings occur rarely in our clinics (<1%), but, of course, the risk is always there. Bleeding, more than 2 days after the circumcision
In some cases, the wound may start to bleed a bit after a few days. This is caused by erections (which also occur in small boys) and is totally harmless. To stop this, we advise parents/guardians to put the boy in a bath, towel him dry, apply Vaseline on the wound, and put on his diaper. The bleeding should have stopped.

Not being able to urinate
Some boys may have trouble urinating after the circumcision. If he has not urinated within 12 hours, he should be put in a bath with lukewarm water. This should push him to pee (urine is sterile, so this will not affect the healing process). If this does not work, the parents/guardians should call our doctor on duty.

Signs of infection, without pain
A mild infection may occur after the circumcision, meaning the penis will become red and swollen with some yellow discharge. Touching the wound should not be painful. By bathing the boy twice a day, these signs should disappear. Medication is rarely needed.

Signs of infection, with pain
In case the skin of the penis turns red and swollen after a few days, and there is pain present, the infection should be treated with antibiotics. In babies, wound infection is paired with symptoms like excess crying, not being able to sleep, and little fluid intake. Older boys can verbalize their pain. Parents/guardians should get in contact with a doctor, be it their own general practitioner, or a doctor of our clinic.

Fever
A fever emerging after a circumcision rarely occurs, except in case of severe wound infection. In all other cases, this is due to some other cause (e.g. viral infection, ear infection, or teething). Parents should see their general practitioner to examine the cause of the fever and start treatment.

Opening wound
A stitch may become untied, causing the wound to open. This is usually caused by an erection and is totally harmless. Traditionally, the wound of the circumcision was not sutured closed, but healed properly nonetheless. Although it may take some more time, the wound edges will grow towards each other and heal. It is important to bathe the boy daily, and see a doctor in case the pain worsens.

The wound looks bad
The penis may be swollen, red, and ?crooked? shortly after the circumcision. If the boy is not experiencing any pain and shows no signs of infection, this is okay. The swelling and redness will disappear, and the final results will be reached after 3 weeks. In case the penis still looks bad after 3 weeks, you may book a check-up appointment with our head doctor. Due to our years of experience, we know that in most cases the wound will heal properly and the end results will be good.

Severe complications
Severe complications could occur after circumcision in very rare cases, such as severe bleeding, extensive infection of the penis and scrotum, narrowing of the urethral opening, damage of the glans, development of an abnormal passage between urethra and skin (fistula), and narrowing of the remaining skin causing difficulty urinating.

Due to our vast experience, the risk of these kinds of complications is minimal, but never zero. In case there is a complication, we will do a check-up to examine the patient and give advice on further treatment. If needed, we can refer the patient to a medical specialist.

Aftercare

The head doctor will be on duty for 48 hours after the circumcision, which means parents/guardians are able to call in case of a bleeding etc. Parents/guardians will receive the aftercare form including the telephone number after the circumcision. After the initial 48 hours, acute issues will not occur anymore (note: infections develop over time). We will be reachable then on weekdays between 9 AM and 5 PM.

Telephone interview on end results and satisfaction
A few weeks after the circumcision, we reach out to parents/guardians to get informed on the healing process of the boy, and whether the end results and our service were satisfactory. If needed, we can make a check-up appointment. The results of these interviews are good: the number of complications (i.e. bleeding, infection) is very low, and the mean satisfaction rate is high (8.9/10).

Costs and reimbursement

The total cost of a circumcision of a boy under 16 years is 325,- EUR. In case the circumcision has a religious or cultural reason, this will not be reimbursed by health insurance. In case of a medical reason, this may (partially) be reimbursed, depending on the insurance company.

Complaints and disputes

Complaints and disputes policy of Besnijdenis Centrum Nederland 2018
Complaints on the procedure or treatment may be filed with the performing doctor or the board of BCN. One of our board members will then speak with the complainant on the case and will try to get to a solution. If a solution is not found, our complaints officer will be brought in to mediate between the complainant and board member. In case this proves insufficient, the complainant will put his complaint on paper. Our complaints officer might help if needed. Our complaints officer will then reflect on the case and will hear the perspectives of the involving doctor and other health care providers. There will be a fair hearing during this process. After the case is settled, the complainant will receive a letter from the involving doctor with his/her point of view on the case and, if applicable, taken measures. If needed, our complaints officer may help writing this letter.

If the complaint involves multiple care providers, our complaints officer may include the other care providers in the process. This way, the complainant will not have to tell his/her story multiple times, and will not need to file the same complaint with different institutions.

Regional complaints committee
If the case cannot be solved with our complaints officer, the complainant may turn to the regional complaints committee with which BCN is affiliated. If our mediation is not wanted, we could get you directly in contact with the committee.

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