Ask Dr. HKSH - Paediatric Circumcision

Dr. LEUNG Chi Lun, Yvonne

Specialist in Paediatric Surgery

Q 1. What is phimosis?

Phimosis is the inability to retract the foreskin to expose the glans penis due to a narrow ring in the prepuce. In many cases, phimosis is a normal physiological finding at birth. With time, the foreskin gradually loosens and the glans can be exposed. By the end of one year old, half of the boys will have retractable foreskin and this increases to 90% by three years old. If phimosis is present, it may lead to complications such as balanoposthitis (infection of the foreskin) or paraphimosis. Paraphimosis occurs when the retracted foreskin failing to return to its normal position due to the constricted ring, which may cause loss of the surrounding tissue and become a medical emergency.

Q2. What are the indications for circumcision?

Before consideration of surgery, phimosis may be managed by topical steroid application. If this treatment is ineffective, surgery may then be considered. The indications for circumcisions can be generally divided into two categories: surgical and non-surgical. Surgical indications include phimosis resistant to medical treatment, recurrent infections, paraphimosis, and urinary tract anomalies that predispose to urinary tract infection. Non-surgical indications are mainly cultural preference or religious practice.

Q3. When is the best timing for surgery?

There is no single best answer to this question. Whether surgery is needed depends on the child’s clinical indications. For example, some newborns have congenital urological abnormalities should undergo surgery at an early stage. In some cases, surgery is needed for recurrent balanoposthitis. Some adolescents experience problems when the phimosis interferes with physiological processes, such as erection, and surgery is considered necessary only then.

Q4. What are the different methods for surgery?

Regardless of the patient’s age and the type of procedure, the surgery takes only about 20 to 30 minutes.

For newborns, circumcision can be performed under local anaesthesia in the neonatal unit. The doctor will gently retract the foreskin and place a device around the glans to remove the excessive prepuce. The device will remain in place until the wound has healed, which usually takes about two weeks. Once healing is complete, it will fall off on its own. Even while the device is in place, it does not intervene with the baby’s normal urination.

For older children and adolescents, circumcision is performed in the operating room under general anaesthesia. The doctor will remove the excessive prepuce including the tight ring, and then close the wound with absorbable sutures. The patient can usually be discharged on the same day after surgery.

In rare cases, if other anomalies are discovered during surgery, the patient may warrant additional treatment or the surgery may need to be rescheduled for a different procedure.

Q5. What are the potential complications and how to manage the wound postoperatively?

Circumcision is a safe procedure in general. Potential general complications can include wound infection or bleeding, and wound dehiscence. Specific complications may include injury to the glans or urethral meatus, or trapped penis from excessive skin removal. Some may require additional surgical correction.

The surgical team will provide detailed advice on wound care. In general, minor swelling around the wound and nearby tissue is expected in the first two weeks postoperatively. General advice will include wound irrigation with normal saline or distilled water after each voiding. It is important to take analgesics as instructed for optimal pain control as excessive wound pain can cause urinary retention. Protective underwear is optional.

Q6. What is the expected time for recovery and is sick leave indicated?

The expected time for recovery is about two weeks on average. During this period, sick leave and prolonged exemption from physical activities will be issued. Some children with better pain tolerance or faster recovery may return to the school earlier but physical education classes should be avoided. Heavy physical activities should only be resumed four weeks after surgery or until the wound is fully healed.