When my 2 ½-year-old was potty training last summer, he insisted on standing to pee “like a big boy.” I thought it was odd that his aim consistently went upward. After a check-up with the pediatrician and follow-up appointment with a pediatric urologist, the specialist diagnosed a pocket on the tip of my son’s penis, which was pushing the urine stream up, making his aim for the potty nearly impossible. This was due to the way his newborn circumcision healed. Surgery was recommended. We were also aware of the fact that he had adhesions at the base of the penis. The urologist suggested fixing those at the same time. As I spoke to other moms about my son’s upcoming surgery I was surprised to find out how many other little boys had undergone the knife “down there.” Some circumstances were the result of abnormalities at birth and others developed after circumcisions had been performed.
For the majority of Americans, the decision to circumcise is an easy, social choice. At Anne Arundel Medical Center, over 2,000 newborn boys are circumcised each year. Although the debate about circumcising a newborn can still be heard across the country, many studies do reveal the medical benefits of circumcision. Dr. David McDermott, Urologist with Anne Arundel Urology, spoke about a recent study that shows 60% less transmission of AIDS in African men who were circumcised. He explains that germs aren’t transferred on the dry shaft surface as easily. “We are significantly lowering the percentage of sexually transmitted diseases in our children when they are adults,” says McDermott.
So, when should the expecting parents be educated about circumcisions? Dr. Henry Sobel, Chair of the Children’s and Women’s Initiative at Anne Arundel Medical Center, explains that this decision should be discussed with the obstetrician during prenatal visits. It should be discussed in a manner that it is a “social, elective decision,” says Dr. Sobel.
Why an OB?
In most cases it is the mother’s obstetrician that performs a newborn boy’s circumcision. Parents often wonder why the pediatrician or an urologist isn’t taking on this first surgery. Sobel says, “OBs do them (circumcisions) as a courtesy for parents, but babies are in a pediatrician’s care.” McDermott further explains that it’s a matter of numbers. “There are probably 40 OBs and one pediatric urologist at the hospital. In some places pediatricians do them, but they are not surgeons by trade,” says McDermott. So, by default, circumcisions fall on the duties of obstetricians and they have been fully trained to do so during their residency. If the family is Jewish, a trained mohel can also
perform the circumcision at the traditional ceremony.
Circumcision surgically removes the foreskin that covers the end of the penis, exposing the tip. Many surgeons use a local anesthetic such as Xylocaine to numb the area and babies usually cry when the needle is inserted, but not during the circumcision. McDermott also explains that large fat pads, fluid in the scrotum, and the size of the penis can make a perfect circumcision difficult to achieve. When size or anatomy is a major concern the surgeon will opt to delay the procedure. “The surgeon has to be comfortable,” says Sobel. These cases are then referred to a pediatric urologist.
Complications or Circumstances?
Although complications are rare, they can include bleeding, infection, cutting the foreskin too short or too long, and improper healing. After a circumcision, parents are typically instructed to use petroleum jelly for a short period of time, but do parents know how to prevent problems after this fragile period of time? Circumcision care is very important as most every baby boy encounters adhesions around the base of the shaft. These can usually be avoided by faithfully cleaning around the rim and pulling the fat pad down during diaper changes. McDermott says that adhesions should not really be classified as a complication of circumcision, but a side effect of the diaper environment instead. Feces, which consists of 90% bacteria, urine and an enclosed space for typically 2 ½ years can easily give way to adhesions on the penis. In most cases the pediatrician or pediatric urologist can dislodge these in their office. But, in cases where they are severe, surgery may be necessary.
A pediatrician should be consulted whenever there are concerns and they can refer patients to a pediatric urologist if necessary. McDermott suggests that if there are genital problems in children that they be corrected before the age of two. “It’s an emotional thing when they are older and they may remember too much after that age,” says McDermott.
For my son’s surgery, the urologist had to reopen the pocket on the tip of the penis to make it to the appropriate size. He was under general anesthesia and handled that part relatively well. He even urinated before we left the hospital without complaining of the customary burning feeling after a surgery of that nature. For the next two weeks, we had to put lidocaine on the tip and use a little pointed tool to insert into the tip of the penis so that it wouldn’t reclose and heal incorrectly. That was the hardest part. It hurt him the first few days since the area was still tender from surgery, but after that period he was a trooper.
To fix the adhesions around the base of the shaft the surgeon cut a ring around to reopen them. We were instructed to put K-Y Jelly around the ring each time he went to the bathroom for the first month. After that, we put the K-Y on just after his bath and first thing in the morning. This is something that we have to monitor to ensure that it doesn’t happen again.
After the simple and successful surgery, my son can proudly go into the bathroom independently. His recovery was uncomfortable but quick and we are grateful that his circumcision problem was caught early. Now, if I could only get him to wash his hands!
Jennifer Murphy is a freelance writer, wife and mother of two.