Advantages and disadvantages of having a circumcision
Various persons and groups have advocated for and against circumcision, often citing various advantages or disadvantages to back up their respective positions. Some advantages according to Elist (2013a), the National Health Service (NHS) (2016) and Webmd (2014) include the reduced risk of developing urinary tract infections (UTIs), sexually transmitted diseases (STDs) especially HIV, cancer of the penis and cervical cancer in female partners. It also acts as prophylaxis against balanitis, balanoposthitis phimosis and paraphimosis as well as facilitates the maintenance of penis hygiene (Elist, 2013b; NHS, 2016; Webmd, 2014; Wiswell, 1997). Disadvantages of the procedure include complications which may arise from the procedure such as pain, excessive bleeding, problems with the wound healing and post-operative infection (Elist, 2013b) as well as the decreased sensitivity with associated reduced pleasure during sexual intercourse (Wiswell, 1997).
The three circumcision procedures
a. Plastibell Circumcision Procedure: This procedure like the others begins with restraining the baby with straps on a circumcision board to prevent movement capable of interrupting the procedure followed by cleaning of the penis with an antibiotic solution for the administration of a short term anaesthetic into the skin at the base of the penis. This is followed by cleaning of the area with an iodine solution after which sterile drapes are placed over the surgical site. Adhesions of the mucous membrane of the inner foreskin to the glans are loosened with a haemostat after which a slit is made to the loosened foreskin to allow the fixing of the plastibell (a small plastic device with a clear plastic ring having a handle) which is placed at the tip of the penis (underneath the loosened foreskin). A string is used to tie off the foreskin after which this redundant foreskin is excised and the handle of plastibell broken off leaving the head of the plastibell in place at the tip of the penis where it would remain for about 5-7days during which the circumcised penis would be tended with ointment till the plastibell ring falls off leaving an even edge. After the procedure, antibiotic ointment is applied to the circumcision area to reduce the chances of infection, promote healing and help keep the diaper from sticking to the penis.
b. Gomco Clamp Circumcision Procedure: Like the above mentioned procedure, the baby’s arms and legs are restrained followed by cleaning of the penis and anaesthetic (dorsal penile nerve block) injection. Adhesions of the inner mucosal layer to the glans are gently broken after which a haemostat is used to crush the foreskin not only to reduce the chances of bleeding when a slit is made but also to reduce the chances of the child feeling the cut. The glans is then inserted into the clamp bell and the bell stem is pulled through its bevel hole at the base plate of the clamp pulling along with a predetermined amount of loosened foreskin which hangs outside the bell. By adjusting the nut which in turn raises the top plate, the loosened foreskin is clamped between the bell and the base plate, allowing the foreskin to be neatly excised with a scalpel. This Gomco clamp is designed such that it applies pressure against the cut site, keeping it from bleeding unless a blood vessel is cut or the child has a bleeding disorder. After the procedure, the clamp is carefully removed and the tip of the penis is removed from the clamp bell, followed by cleaning of the site with Vaseline gauze.
c. Mogen Clamp Circumcision Procedure: The Mogen clamp is a hinged device with a bevelled edge and a clamping lever that holds the mechanism closed. The procedure commences with sterilisation of the base of the penis, administration of anaesthetic through the sterilised site and cleaning with betadine. This is followed by placing of a sterile drape around the surgical site and opening of the foreskin through the orifice. Separation of attached foreskin from the glans penis is carefully done to pave way for the application of the clamp in such a way that the head of the penis is beneath the clamp while the foreskin to be excised is above. The clamp is then closed applying pressure at the cut site hence shutting out blood supply to the skin to be excised. A neat excision is done followed by removal of the clamp and prying apart of the clamped tissues, revealing the exposed glans. Petroleum jelly is finally applied after confirming the cessation of bleeding (if there is any).
The nurse’s role before, during and after the procedure
Before the circumcision procedure, the nurse prepares the baby for the procedure by strapping him down to the circumcision board, applying restraints and removing his diapers. During the procedure, the nurse helps maintain the field sterile for the physician, soothes the baby by gentle rubbing and/or with the use of a pacifier and suctions the baby’s nose and/or mouth if the need arises during the procedure. After the procedure, the nurse diapers, swaddles and returns the baby to his mother.
Pain response and pain management during circumcision
Circumcision is a painful and physiologically stressful process which can cause negative responses such as apnea, changes in blood pressure and heart rate, cyanosis and decreased cortisol level and oxygen concentration (AAP, 1999; AAP, 2005; Anand et al., 2005; Berde and Sethna, 2002). Dorsal penile nerve block (DPNB), an injection of lidocaine which is commonly used during this procedure has been reported to be effective in pain relief (Taddio 2001). Other techniques include Ring block which has been reported to have similar effect as DPNB, water-based lidocaine cream which is not as effective as DPNB and the use of sucrose dipped pacifiers (Taddio, 2001; WebMd, 2004). Despite successfully relieving pain, no single method completely eliminates the pain and studies have revealed that combining two or more techniques is significantly better than using a single technique (Taddio, 2001; WebMd, 2004).
References
American Academy of Pediatrics & American Pain Society. (2001). The assessment and management of acute pain in infants, children, and adolescents. Pediatrics, 108(3): 793-797.
American Academy of Pediatrics Task Force on Circumcision. (1999). Circumcision policy statement. Pediatrics, 103(3): 686-693. Reaffirmed (2005).
Anand, K., Johnston, C., Oberlander, T., Taddio, A., Lehr, V., & Walco, G. (2005). Analgesia and local anesthesia during invasive procedures in the neonate. Clinical Therapeutics, 27(6): 844-876.
Berde, C. & Sethna, N. (2002). Analgesics for the treatment of pain in children. New England Journal of Medicine, 347(14): 1094-1103.
James J. Elist (2013a). Circumcision Benefits and Facts. Retrieved online from http://www.drelist.com/circumcision-benefits/ on the 8th of August, 2016.
James J. Elist (2013b). Circumcision Advantages and Disadvantages. Retrieved online from http://www.drelist.com/circumcision-advantages/ on the 8th of August, 2016.
National Health Service (2016). Circumcision in adults. Retrieved online on the 8th of August, 2016 from http://www.nhs.uk/Conditions/Circumcision/Pages/Introduction.aspx.
Taddio, A. (2001). Pain management for neonatal circumcision. Paediatric Drugs, 3(2):101-11
Thomas E. Wiswell (1997). Circumcision Circumspection. The New England Journal of Medicine, 336:1244-1245.
WebMD (2004). Docs Recommend Pain Relief for Circumcision; Say Anaesthetics Work Best During Procedure. By Miranda Hitti and reviewed by Charlotte E. Grayson Mathis. Retrieved online from http://www.webmd.com/parenting/baby/news/20041018/docs-recommend-pain-relief-for-circumcision on the 8th of August, 2016.
WebMD (2014). Circumcision Basics, Reviewed by Jennifer Robinson and retrieved online from http://www.webmd.com/sexual-conditions/guide/circumcision on the 8th of August, 2016.
