Frequently Asked Questions (FAQs)
Disclaimer:
The information provided in this Frequently Asked Questions (FAQ) section reflects the opinions and general guidance of The Circumcision Clinic. It is intended for informational purposes only and should not be considered as a substitute for professional medical advice, diagnosis, or treatment. We strongly recommend consultation with one of our healthcare professionals to address your specific concerns and receive personalized care. Every individual’s medical needs are unique, and only a thorough evaluation can provide the most accurate and tailored recommendations.
What to Expect During Your Visit:
You should expect to be in the clinic for 1-1.5 hours.
The time spent in the clinic is typically broken down as follows:
Informed consent discussion (5-10 min)
Nerve block injection (5 min)
Time for the nerve block injection to be fully effective / time to feed your baby (10-20 min)
Circumcision procedure (10-15 min)
Teaching how to complete diaper changes and aftercare following the procedure (5 min)
Discharge home from clinic.
What is circumcision?
Circumcision is a procedure in which the foreskin (fold of skin that covers the end of the penis) is surgically removed.
Why do people choose to have their child circumcised?
• A decision to circumcise or not to circumcise a newborn son is a personal choice.
• Most newborn circumcisions are done for prevention of urinary tract infections, sexually transmitted diseases, and skin problems unique to the foreskin
• As well as traditional, cultural, or religious reasons.
• Custom / Culture / Religion
• Circumcision of the male infant is commonly done by custom. Many parents feel it is important that their son looks like his father or peers or have a religious obligation to have their son circumcised.
• Cleanliness
• Circumcision does make cleanliness of the penis easier. A normal secretion, which is cream colored and somewhat waxy, is formed under the intact foreskin. If allowed to accumulate, it can irritate the head of the penis and may lead to infection. Circumcision prevents this, but the build-up can also be prevented by proper hygiene during bathing. Circumcision does not eliminate the need for proper hygiene, though it does makes it easier.
• Prevention of cancer of the penis
• Penile cancer is an extremely rare condition of adult life. It is less common in circumcised men and is usually found only in conditions of very poor hygiene, suggesting that proper hygiene provides as much protection as circumcision.
• Decreased incidence of infection
• Circumcision will slightly reduce the risk of urinary tract infections in males, both as infants and in adulthood. The incidence of such infections in the first year of life is reduced from 1 in 100 (hundred) to 1 in 1,000 (thousand). Circumcision has also been shown to be associated with a lower risk for some sexually transmitted infections, including HIV, particularly in areas where the use of safe sexual practices is low.
• Prevention of paraphimosis
• Rarely, parents may retract a still-tight foreskin while vigorously cleansing the penis to eliminate the waxy secretion mentioned above. If the foreskin is left retracted, it can act as a tourniquet, decreasing blood supply to the tip of the penis. This may need to be surgically corrected. Circumcision prevents this uncommon complication from occurring.
REASONS TO CHOOSE NOT TO HAVE A CIRCUMCISION
Pain
Although the maximum pain-relieving actions will be taken for your baby's comfort on the day of the procedure, there will be some degree of discomfort during the visit and through the first few days of recovery.
Surgical risk
The vast majority of circumcisions are performed without any complications. However, no surgical procedure (and circumcision is a surgical procedure) can be totally risk-free. Complications include: bleeding, infection, adhesion formation, cosmetic deformity, trauma to the penis, excessive removal of the foreskin, and functional defects. These occur once every 500 circumcisions.
Expense
Routine newborn circumcision is not covered by OHIP and therefore there is a cost attached to the procedure. Although parents have the option of delaying circumcision until a time beyond the newborn period, these delayed circumcisions represent a more involved surgical procedure, usually performed with general or regional anesthesia. It is important to note that 1 in 100 uncircumcised adults may require a circumcision for medical reasons.
Surgical risk in detail:
Minor short-term problems:
Slight oozing or slight bleeding (normal and expected)
Bruising and swelling
Superficial infection of the circumcision site or at the tip of the penis.
Irritation of the exposed tip of the penis (glans).
Minor long-term problems:
The urethra, which leads from the bladder to the tip of the penis, can be damaged at its point of exit.
The newly exposed meatus (urethral opening) can become stenotic (small) due to chronic irritation now that it is exposed to the diaper.
Inappropriate scarring.
Unintended removal of excessive skin layer (or layers) of the penis.
Unintended removal of too little skin, leaving some redundant foreskin behind.
Asymmetry to the cut line
The site of foreskin removal can scar, leaving an opening too small for the skin to retract over the penis (post circumcision phimosis).
Major problems that are very uncommon:
Complete removal of the skin covering the shaft of the penis.
Significant, life threatening, bleeding, requiring stitches or other measure to stop the bleeding. Fluid administration or blood transfusion are needed in cases of severe blood loss.
Serious, life-threatening bacterial infection.
Partial or full removal (amputation) of the tip of the penis.
What to know about the local anesthetic nerve block injection and pain control during the procedure.
Pain control for the circumcision is achieved by injecting a small amount of local anesthetic (usually 1mL of 0.25% Bupivacaine with 1:200,000 epinephrine) in the area where the nerves are located that provided sensation to the end of the penis and the foreskin (dorsal penile ring nerve block).
Injection is done with an extremely thin 27-gauge needle.
Needle insertion causes minimal pain; however, the medication stings as it enters the body.
The best analogy for most parents is that the feeling is like the injection that dentists use in the gums prior to a dental procedure
To maximize the baby’s comfort during the injection, sucrose (sugar water) is given on a pacifier or gloved finger with therapeutic suck to help soothe the baby.
Bupivacaine is a long-acting local anesthetic and theoretically there should be complete block of any pain sensation for the first 3-6 hours after injection.
The local anesthetic doesn’t turn off at the 3-6 hour mark. The effects slowly fade away for up to 12 hours, meaning there is some degree of decreased pain for 12-18 hours after injection.
It is normal to see swelling or fullness in the area around the injection sites where the local anesthetic is infiltrated / injected underneath the skin.
It is normal to see some evidence of bleeding or bruising at the injection sites that will resolve as the circumcision wound heals – over the course of 1 – 2 weeks.
It is normal to see blanching (pale colour) in the area around the injection sites (this is from the epinephrine causing slightly reduced blood flow in the area).
The local anesthetic come pre-mixed with a low concentration of epinephrine. The addition of epinephrine helps in several ways.
It causes constriction of the small capillaries in the area where the medication is deposited. This means the medication is not cleared away from this area by the blood flow as quickly, increasing the duration of the block.
Because the medication is not cleared away in the blood stream as quickly, it lowers the chance of spiking high concentration of local anesthetic in the blood, thereby lowering the chance of a systemic toxicity.
The capillary constriction reduces the amount of bleeding during and after the procedure.
Why not use a topical anesthetic ointment or cream (EMLA) instead of a nerve block:
Some doctors perform circumcision after application of a topical anesthetic cream (such as EMLA) instead of an injectable nerve block.
Creams are only partially affective at reducing the sensation of the circumcision and cannot achieve a complete block.
The duration of action of the cream is much shorter than the injectable medication.
An injection offers a total block of any pain sensation during and after the procedure for several hours.
How do you know the nerve block is working before you start the procedure?
Test by pinching
If there is evidence of inadequate block we inject more and wait
Sometimes there is discomfort for other reasons
We gauge whether fussiness is due to pain based on whether the crying is in keeping with the surgical manipulation, or independent.
Though pain is blocked by the anesthetic, pushing and pulling are still perceived and can also lead to the baby reacting.
Fussiness and movement will not interfere with the technical success of the procedure.
The procedure is designed to be safe even with relatively large movements by the baby.
Does the baby need to have received a Vitamin K injection to have a circumcision?
Vitamin K is crucial for blood clotting because it's a cofactor for enzymes that produce clotting factors, proteins essential for forming blood clots.
Without enough Vitamin K, the body can't make these proteins, leading to impaired blood clotting and potential bleeding problems.
Babies are born with low Vitamin K levels because it doesn't readily pass from mother to fetus during pregnancy.
In Canada, all newborns routinely receive a Vitamin K injection shortly after birth to prevent Vitamin K Deficiency Bleeding (VKDB).
VKDB is a rare but serious condition where a baby's blood cannot clot properly, potentially leading to severe bleeding in the brain and other organs. The injection is a standard preventative measure, given within the first six hours after birth, and is considered highly effective.
Some parent decline for the baby to receive the Vitamin K injection at birth. These children have a higher risk of post-circumcision bleeding (and other bleeding). This risk likely returns to normal somewhere between 8 weeks and 6 months of age.
When families have chosen not to give their child the vitamin K injection, The Circumcision Clinic will only offer a circumcision after 2 months of age.
Some families opt to give their child Vitimin K by mouth instead of by injection. This rout of administration is less reliable in increasing the clotting factors and we also will only offer a circumcision after 2 months of age.
Can a child with Jaundice have a newborn circumcision?
Jaundice in newborns is the yellow coloring in an infant’s skin. Jaundice occurs when bilirubin (pronounced “bil-ih-ROO-bin”) builds up in the baby’s blood. Hyperbilirubinemia is the medical term for this condition.
Bilirubin is a yellow substance the body creates when red blood cells break down as part of normal function. During pregnancy, the mothers liver removes the bilirubin. After birth, the baby’s liver must begin removing bilirubin. If the liver isn’t developed enough, it may not be able to get rid of bilirubin. When excess bilirubin builds up, the baby’s skin may appear yellow.
Jaundice in infants is common. It’s usually not serious and goes away within a couple of weeks. Severe jaundice can lead to brain damage if it goes untreated. It’s important for the baby’s healthcare provider to check jaundice levels and treat if it is severe.
50–80% of term newborns develop jaundice, or hyperbilirubinemia (HB), in their first week.
The vast majority have benign causes, including physiologic jaundice of the newborn and breast milk/breastfeeding jaundice, which do not affect the livers ability to make clotting factors.
Though uncommon, HB in the setting of sepsis, biliary obstruction, or metabolic disease, may increase bleeding risk. These babies typically show signs that they are sick, beyond the jaundice itself (fever, poor feeding, lethargy)
A review of the scientific literature suggests that isolated HB in otherwise healthy newborns does not increase bleeding risk.
Review of the scientific literature suggests that in otherwise healthy neonates, jaundice likely represents benign causes and is unlikely to increase bleeding risk
At The Circumcision Clinic we are happy to offer circumcision procedures to children with mild jaundice who are otherwise healthy.
https://www.sciencedirect.com/science/article/abs/pii/S1477513120305659
What is ‘sucrose’ and why do you give sucrose to the babies during the local anesthetic injection and during the procedure?
Sucrose is the chemical name for table sugar.
The use of sucrose is established and used routinely in pediatric hospitals due to a well researched reflex where newborn relax upon tasting.
Many parents might have seen sucrose used to help calm their newborns during the heel-prick blood draw or vitamin K injection shortly after birth.
The concentration we use is shown in the medical literature to maximize the baby’s comfort during procedures (24% sucrose in water).
We apply the sucrose on a pacifier or gloved finger before and during injection and again during the actual circumcision procedure.
There is more to calming babies than the taste of sucrose alone – the staff that give the sucrose have a special skill for calming the babies with gentle touch, shushing and soothing. The entire package is what helps keep babies calm. This is a skill gained through experience.
Even though the penis is completely numbed from the nerve block injection prior to starting the circumcision procedure, we give sucrose to help babies feel relaxed while their legs are gently restrained with Velcro straps, and they are lying flat on their backs.
It is the taste of the sucrose that leads to the reflex to relax. Therefore, we are not feeding the sucrose like you would feed milk. We use a dropper to flavour the pacifier or gloved finger and only use 1-5mL throughout the entire clinic visit.
This is not enough sugar to impact blood sugar or metabolism in a harmful way.
What to expect immediately following the procedure:
If the parents are not already in the room during the procedure, we bring them in immediately afterwards to have a close look at the results of the circumcision.
It is important for parents to see the results of the procedure so they can better appreciate how it will evolve during the healing, and to see that there were no surgical complications.
Note: In the rare event of a surgical complication, parent are still brought in so they can be shown anything that is abnormal and discuss next steps in management.
Parents can expect to find their child lying on their backs with their legs gently strapped to a specially designed board.
An assistant will be using a gloved finger or a pacifier to sooth the baby.
Most babies, especially those less than two months old at the time of the procedure, will be calm and not showing any discomfort when parents are brought into the room.
Babies older than 2 months are typically much more active and don’t respond the same way to the sucrose sedation. Parents can expect them to be fussy throughout all elements of the circumcision process – even when the nerve block is working perfectly.
Some babies will be fussy, either due to some discomfort from being restrained, maybe they are gassy and uncomfortable on their backs (we never know for sure). In cases where the baby is obviously uncomfortable, we will speed up the discussion of the anatomy and healing to get the child back into a comfortable position in the parents' arms.
How will the penis look immediately after the circumcision and during healing?
The doctors at The Circumcision Clinic all use a Mogen clamp to guide the incision. When the circular shaft skin is squeezed in the straight clamp, pinched skin results at the top (12 o’clock / dorsal) and underside (6 o’clock / ventral). Immediately after the surgery, these pinches are present. As the wounds heals, they disappear, resulting in the expected final cosmetic appearance.
The pinch at the underside (6 o’clock / ventral) is typically more pronounced. Sometimes the scar thickens at this point leading to an appearance like a small pimple. As children grow, this invariably softens, falls flat and becomes imperceptible by sexual maturity (puberty)
As the healing progresses, the wound will develop a scab.
Due to the mucosal nature of this skin, if present at all, the scab will be a whitish or light yellowish crust.
This scab will be mixing with urine / petroleum jelly and stool and can have a mucous like appearance, often confused with puss.
This crust / secretions will be adherent to the penis and will slough off on their own. It should not be removed with forceful wiping.
By two weeks, the incision line should be fully healed.
There can be different pigmentation of the shaft skin and mucosal collar, which is normal.
Immediately after the circumcision, the head and area underneath (mucosal skin) will be raw and red, there is minimal swelling at this point so parents will gain a sense of the final proportions.
The cut line is the transitional line between the mucosal skin, which will have a pink or red colour, and the shaft skin that you are used to seeing from before the circumcision.
Over the next few minutes and hours, the areas adjacent to the cut line (the mucosal skin and shaft shin) will get very swollen. The mucosal skin often appears as a doughnut sitting under the head.
Note, even after the wound has fully healed, there can be some fullness, or puffiness of the mucosal collar just below the head of the penis for months.
The head of the penis (glans) is typically slightly red. This is because the foreskin of newborns is adherent to the head. During the circumcision, the inner foreskin is peeled off of the head. In the act of separating the foreskin from the head, a thin layer of skin cells is stripped away, leading to some redness (similar to a skin exfoliation).
You may see sterile ink near the incision site—this is applied with a sterile marker and will disappear over time.
In cases where there is some early bleeding, or in older children, we may apply a skin glue (Dermabond or SkinAffix). The skin glue has a light purple hue. As the glue hardens, it can look like small dried flakes of plastic that will slough off into the diaper while the wound heals—do not pull off these flakes. See the section on skin glue for more information.
You may see small white- or cream-coloured speckles called smegma (normal dried skin that had been trapped behind the foreskin before it was removed). The smegma will slough off with time.
Our usual practice is to leave the penis naked in the diaper without a dressing / wrap or bandage. Approximately 1/20 babies will have some bleeding that requires a bandage to be applied. Having a bandage is the exception rather than the rule. Please see the section on the bandage for more information.
Over the next hours the wound swells, bleeds as it clots naturally. Therefore, it is normal and expected to see blood streaks on the surface of the diaper for the first few diapers as the cut is establishing a scab. Please see the section on bleeding for a more detailed explanation.
With newborn circumcision, the healing occurs by a process called ‘'primary or secondary intention’, whereby the body forms a clot, the clot transitions to a scab which eventually falls away leaving a thin scar.
Healing by ‘primary intention’ is when the cut edges stay in close contact during the healing, and there is typically minimal scabbing which often looks like mucous (rather than the crust most people think about when they think of a scab). This mucous appearance is because the scab is kept moist with petroleum jelly in the diaper.
Often, areas of the cut line separate by a few millimeters. This gap undergoes a healing process called ‘secondary intention’ where the body develops granulation tissue (which appears like a straw-coloured plaque) spanning the gap as new skin develops underneath. The most common area for the wound to separate and undergo healing by secondary intention is the underside.
Note: The healing process is different from older child or adult circumcision which requires the skin edges to be stitched or glued together.
We only perform suture-less circumcision and limit our practice to babies and children that are young enough for this approach. Usually, within 1-2 weeks the scab has resolved and the incision is fully healed.
Can you explain a bit more about how you use SKIN GLUE / TOPICAL SKIN ADHESIVE / GLUE STITCH?
For older children, or in cases where there is more bleeding immediately after the procedure than usual, we occasionally apply a surgical skin glue / topical skin adhesive.
This is a commonly used sterile medical glue often used in emergency departments or by outdoor enthusiasts instead of stitches.
The generic name for the skin glue is 2-octyl cyanoacrylate.
Brand names include Dermabond®, Skin Affix ® or GluStitch ®
It is a sterile, liquid, skin adhesive that holds wound edges together.
The film will usually remain in place for 5 to 10 days, then, naturally slough (fall) off.
It appears like small plastic flakes when it sloughs off (like superglue coming off off your fingers!)
Do not actively remove the dried glue as it can sometimes pull away the scab leading to some fresh bleeding. Allows the glue to naturally slough (fall) off.
If a skin glue was used for your child, the doctor will let you know so you can anticipate what is described above.
What to know about the DRESSING OR BANDAGE?
On occasion there is more bleeding than usual immediately after the procedure and we apply a dressing / bandage to contain the bleeding while the wound established a clot.
WE ONLY APPLY A DRESSING FOR ABOUT 5% OF PATIENTS – THE MAJORITY ARE LEFT NAKED IN THE DIAPER AFTER THE CIRCUMCISION.
Ie. Don’t be alarmed or surprised if there is not a bandage or dressing. Most babies do not have anything on the penis after the procedure.
The inner layer of the bandage is a sterile Vaseline-impregnated gauze, then overtop is an elastic bandage, followed by some tape.
This dressing helps to control any fresh bleeding as the wound clots in the first few minutes. The dressing is not essential to the wound healing and may fall off early (even as early as the first diaper change). If the dressing falls off, just continue to apply Vaseline to the penis and diaper as described below.
If the dressing has not fallen off on its own within three days of the circumcision, it should be gently removed.
Sometimes the clot and scab are integrated into the bandage such that the bandage wont slide off easily when it is time to be removed (3 days after the procedure).
Do not pull the bandage off with force. Rather, unwrap or slip off the bandage partially (whatever can be achieved), apply a thick application of Vaseline, and allow the Vaseline to continue to soften the attachment for another diaper change.
Repeat over as many diaper changes as necessary until the bandage slips off.
If the scab pulls off with the bandage, it can lead to some fresh spotting of blood.
This is normal and no cause for concern. This type of bleeding almost always clots off naturally and does not require re-application of a dressing.
If the bleeding is excessive at this point, please go directly to the nearest emergency department.
Spotting or fresh bleeding a few days after the circumcision does not alter the final cosmetic outcome and will clot and heal as though there was never an issue.
WHAT TO DO IN CASE OF BLEEDING?
SCENARIO – Blood streaking and/or blood diluted with urine and Vaseline in the diaper, but no blood flowing from the wound:
This is common and expected for the first 1-2 days after circumcision. This is a result of the wound undergoing the normal process of clotting and healing. There is no need for any medical attention.
SCENARIO – Moderate bleeding, more blood in the diaper than expected, but no blood flowing from the wound:
This is a relatively common and a challenge for parents and providers. Our approach is to ask patients to upload photos of the blood in the diaper which triggered the concern, and then to send a second photo of the diaper 1-2 hours later. Please also call the clinic to alert us. If the amount of blood is not excessive, and the rate of bleeding is slowing, then there is nothing extra to do. If the bleeding is significant and persistent it is important to have the wound evaluated and potentially treated. Treatment may include ongoing observation, skin glue, cautery, stitching, or compressive bandaging depending on the specific case.
If a physician from The Circumcision Clinic is available, they will ask you to return to the clinic to offer treatment. If someone from The Circumcision Clinic is not available, it is best to go to your nearest emergency department.
While we do our best to answer calls and check emails consistently on the days we perform procedures, and have almost always been available to guide families, we cannot guarantee timely response or availability to see you personally.
It is always best to err on the side of caution and report to the emergency department if you are concerned.
SCENARIO – Brisk active bleeding:
Brisk, active bleeding is an emergency, and you should report to your local emergency department. It may represent an underlying bleeding disorder, or an injured vessel that needs specific treatment including cautery, stitching or compressive bandaging. The risk of delayed treatment is life threatening blood loss.
Please reach out to The Circumcision Clinic to let us know what is happening. In these cases, someone from our team will try to contact the emergency department while you are on route to alert them of your scenario and immanent arrival.
WHAT TO DO IF THERE IS CONCERN ABOUT INFECTION?
Infection after routine circumcision is rare.
If there is a true infection it requires specialized treatment that can include surgical drainage, antibiotics as part of comprehensive care. Infection can present with increasing sensitivity and pain of the wound, puss, foul smell, and fever which typically begins a few days after the surgery. If you have a concern about infection, reach out to the clinic. If there is a shared concern for infection, the team will coordinate care with a specialist.
More commonly, as part of normal healing, the wound secretes a straw colour liquid. This, mixed with petroleum jelly, may look like puss. In the absence of other symptoms, this is normal and will resolve as the wound heals. Most of the time, when parents send photos with a concern about infection, it is in-fact normal secretions. The Circumcision Clinic will let you know if the photos look normal so you have peace of mind and can avoid unnecessary emergency care.
While we do our best to messages consistently, and have almost always been available to guide families, we cannot guarantee timely response or availability to see you personally.
It is always best to err on the side of caution and report to the emergency department if you are concerned.
WHAT TO DO IF THERE IS CONCERN ABOUT THE HEALING OR COSMETIC OUTCOME?
While most cases heal without issue, up to 10% of cases will develop some degree of wound sticking, asymmetrical swelling, partial or complete re-covering of the head by the shaft skin (‘inni’ appearance) as babies gain weight and grow. None of these problems are an emergency and will often self-resolve with growth and time.
•Wound sticking
In the case of wound sticking, a problem called a skin bridge (abnormal attachment of the wound to the head) can occur. It is relatively straight forward to release these attachments in clinic with pain controlled with topical anesthetic cream or local injection. If you have concern of inappropriate wound sticking, you are welcome to contact our office. If intervention is required, you will be offered a follow-up appointment.
Persistent puffiness under the head, mild to moderate asymmetry, mild to moderate redundancy (partial foreskin left behind)
If there is persistent or asymmetrical swelling, or partial or complete covering of the head due to weight gain, this will almost always resolve over time and requires no extra intervention. Sometimes it is only during puberty that rapid growth leads to improvement in the cosmetic outcome. We are always happy to council patients if there are concerns.
Significant asymmetry or redundancy
If the asymmetry or redundancy is significant, we coordinate referral to a pediatric urologist for consideration for a touch-up to revise the wound. This is rare.