Information for doctors

Contents:

Circumcision under local anesthesia

Besnijdenis Centrum Nederland (BCN) performs circumcisions on boys and adult males under local anesthesia. Due to our vast experience and expertise (over 90.000 circumcisions since 2001), we achieve excellent results and minimal complications.

The circumcision is a very important event to the parents of the boy. In our clinics, both parents are welcome to be with their son for distraction and comfort.

Reasons to undergo circumcision are:

Medical indication (phimosis, recurring balanitis);
Religious reasons;
Hygienic and/or preventive reasons.

Premedication and anesthesia
Boys over the age of 6 months will receive Midazolam as premedication, administered suppository via enema. The penis is injected with Lidocaïne 2% with adrenaline, resulting in a penis nerve block anesthesia.

Circumcision technique
We perform circumcision in a classical, surgical way. After checking the anesthesia, the corona glandis is marked and the skin disinfected. The physiological adhesions between the glans and foreskin are released, after which the preputium and inner skin layer are cut away in two stages. Bleeding blood vessels are coagulated by way of diathermy. The shaft skin is sutured onto the remaining foreskin underneath the corona with Vicryl Rapide sutures. Adult males will receive a compressing bandage around the penis, boys will have the wound covered with Vaseline. The sutures are dissolvable in 7 to 21 days and do not need to be removed.

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.

Contra-indications

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

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), and the healing process is optimal. It is not true that the boy should be over 1 year old to be circumcised!

We perform circumcisions at all ages, including on adult males.

Informed consent of 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. In case of a ?normal? healing process, the wound is closed after 2 to 3 weeks. In older boys, missing school after circumcision is usually not needed.

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. This layer indicates an ongoing healing process underneath it and will disappear after 7 to 10 days.

Hematoma
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

The following things may occur, impeding the healing process:

Bleeding, less than 2 days after the circumcision
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 for hemostasis. Bleedings occur rarely in our clinics (<1%). 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.

Micturition problems
Some boys may have trouble urinating after the circumcision. Putting him in a lukewarm bath should urge him to urinate spontaneously.

Signs of infection, without pain
In case signs of a mild infection without pain appear, we advise parents/guardians to bathe the boy twice a day. Sometimes the infection may be treated with Fucidine ointment 3x a day.

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. Antibiotics of choice is Amoxicillin/clavulanic acid, dosed according to the boy?s age. In case of penicillin allergy, we prescribe Azithromycin.

Fever
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.

Wound dehiscence
A stitch may become untied (usually on the ventral side) due to erections, causing the wound to open on the ventral side. Conservative management will lead to secondary wound healing.

The wound looks bad
The penis may be swollen, red, and ?crooked? shortly after the circumcision. 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.

Severe complications
Severe complications could occur after circumcision in very rare cases, such as severe bleeding, extensive infection of the penis and scrotum, urethral meatus stenosis, glans lesion, development of a urinal fistula, and urine retention due to cicatricial circumcision. Due to our vast experience, the risk of these kinds of complications is minimal.

Aftercare

The head doctor will be on duty for 48 hours after the circumcision, which means (the parents of) the patient is/are able to call in case of a bleeding etc. The parents or the patient 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.

Consulting with a doctor of Besnijdenis Centrum Nederland

To consult with one of our doctors, please dial 035-6929213 (Central Doctor Service).

Results of our circumcisions and patient satisfaction rates

A few weeks after the circumcision, we reach out to our patients to get informed on the healing process, 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).