Infant Circumcision

The following is information regarding circumcision. Please read the material carefully, as it will detail the pre and post circumcision care of your son. Once you have read the information, please feel free to contact me with any questions via text message or email.

Dr. Greenberg performs infant circumcision on babies between the ages of 5 days and 8 weeks who weigh at least 2.5kg (5.5lbs).

Mogen Circumcision Technique with Pain Control Protocol

The Process

All the following steps are taken to insure that your son has minimal discomfort during the procedure:

Give your son 0.5 mL of Infants’ Tylenol or Tempra Infant Drops (if available) approximately one hour prior to the procedure, before coming to the office. Please ensure that your child has been well fed prior to the circumcision. Please finish feeding him at least 45 60 minutes prior to the circumcision.
Please arrive at the office at least 15 minutes before your scheduled apportionment time.
To avoid crowding in the office, we allow only two adults to attend with the baby. Please do not bring any other children.
As of June 11th, 2022, wearing a mask in doctor’s office is optional.
Upon arrival, check in at the front desk and sign the consent form. Dr. Greenberg will then bring you and your son into one of our examination/treatment rooms. You will be able to discuss any questions and concerns with Dr. Greenberg before the circumcision takes place.
Dr. Greenberg will administer a local anaesthetic (lidocaine HCl) by subcutaneous injection, which will numb your child’s penis. The circumcision will then be performed. Afterwards, you will be asked to sit with your son and feed him if he wishes to feed.
Dr. Greenberg will examine your son approximately 20 minutes after the circumcision and demonstrate the after care to you.

Anatomy of the Circumcision

Figure 1


The uncircumcised penis, with the foreskin covering the glans (head of the penis). This is how it would appear looking from the side.

Figure 2


The same penis as in Figure 1 but drawn as if the foreskin was transparent. Here, you can see the foreskin in relation to the glans. Notice the adhesions (indicated by arrows) between the inner side of the foreskin and the glans. These are present at birth in almost all babies and must be released before the actual circumcision.

Figure 3


This shows the foreskin stretched forward and through the central slit of the Mogen. Notice the outline of the glans (shaded, indicated by arrows) safely behind the Mogen. The cut is made along the front surface of the Mogen.

Figure 4


The same penis, following circumcision. Notice that the cut edge of the skin retracts to just behind the back rim of the glans (indicated by arrows). This is the site of the healing.

Parental Anxiety

Some parents become anxious immediately before and during the procedure. This response is understandable. However, the baby will notice if a parent is behaving in a noticeable nervous or anxious manner and this in turn will cause the child to experience nervousness and anxiety. It is therefore essential that the parents remain calm while in the procedure, as it will make the procedure easier for your son.

Why Do Parents Choose to Circumcise Their Sons?

Circumcision has been shown to reduce the risk of urinary tract infections (UTI). It reduces the risk of penile infections. It eliminates the need to do it later in life, when up to 6% of boys/men will require circumcision because of various problems. When done in later life it is a more costly and difficult procedure, with higher risk requiring a general anaesthetic, and is more painful. Circumcision has been shown to reduce the risk of acquiring some sexually transmitted diseases (STIs), including HIV. Circumcision has been shown to reduce the risk of penile cancer. Some studies also show that circumcised men have less risk of sexual dysfunction later in life.

Why Do Parents Choose not to Circumcise Their Sons?

They are concerned that they may be doing a procedure on an otherwise healthy baby that may cause pain or complications. They wonder whether the child will wish that he had not been circumcised. They are unsure of the medical reasons to circumcise their sons.

Why Do the Circumcision in My Office?

The procedure done in my office uses the Mogen Clamp, a less intricate and easier to use instrument than that used in hospitals. Using this instrument, the circumcision can be done more quickly, usually in less than one minute, as compared to a hospital circumcision which can take up to 15 minutes. I use a pain control method; Acetaminophen, and a penile nerve block (freezing needle). There are no additional hospital administration fees. Hospitals charge administrative fees in addition to the doctor’s fee for the procedure. Thus a family may save up to 50% of the cost of a hospital circumcision.

Pre-Operative Instructions

Finish feeding the baby one full hour before the circumcision. This avoids painful indigestion from a recent meal, though is not so long that your baby will be overly hungry. For the circumcision, your son should be dressed in short T-shirt, socks, and wrapped in a flannel receiving blanket. Give your baby 0.5 mL of Infants’ Tylenol or Tempra Infant Drops approximately one hour prior to the circumcision. This will help reduce pain during and after the procedure.

Post-Operative Care

Care Following Circumcision First 24 Hours

Keep your son snugly swaddled. The less he moves his legs the less discomfort he will have.

Materials needed for aftercare are an antibiotic topical ointment and 4″×4″ sterile gauze pads. All materials needed for aftercare can be purchased in our pharmacy.

With each diaper change:
Squeeze some antibiotic topical ointment, an amount about the size of a Loonie, onto the centre of a sterile 4″×4″ gauze pad and set to the side.
Remove the dirty diaper, clean the baby, and place a clean diaper underneath the child.
Remove the existing 4″×4″ pad by gently peeling from bottom up. Expect to find some light blood stains with the first few changes. They should lighten with each subsequent change.
Inspect the area for fresh blood. If there is no new bleeding, place the new gauze pad over the penis so that the mound of ointment is applied directly over the tip of the penis and then close the diaper.

Care Following Circumcision General Care

Expect your son to be a little irritable for about one day. Most babies like to nurse in a quiet environment following the circumcision. Babies who cry for more than a few minutes are usually suffering from air swallowed during the procedure and need to be burped. Most babies sleep quite well following the circumcision. The best sleeping position for your baby is on his side, supported by a blanket roll. Healing is promoted by keeping the area clean and dry. Warm water and a soft cloth are preferred for cleaning the area around the penis. Avoid pre-moistened towelletes, alcohol, powders, and lotions as they may cause irritation. Disposable diapers are strongly recommended for the first week as they tend to be less irritating and are much drier than cloth diapers. Avoid unnecessary travel as car seats can be irritating to the newly circumcised baby, and can delay healing. Do not bathe your baby for the first 3 days after the circumcision (this includes immersion baptism). Sponge baths are allowed (as is affusion baptism). Continue with the antibiotic topical ointment dressing for 3 days after the circumcision. Have your son examined by your Family Doctor or Paediatrician within 10 days of the circumcision.

Bleeding

IF THERE IS ACTIVE BLEEDING

You treat bleeding on the penis the same as you would for the tip of a finger. If this occurs:

Apply pressure to the penis for 3 minutes. Do this by grasping the penis between two or three fingers over the 4″×4″ gauze pad.

DO NOT REMOVE THE PAD as this may cause more bleeding.
Inspect the area for continued bleeding. Continued bleeding will be evident if the gauze pad continues to become redder with blood. If bleeding continues, apply another 4″×4″ gauze pad over the existing one and repeat step 1. When the bleeding stops, leave the pads on the penis and close the diaper.

IN ALL CASES OF FRESH BLEEDING, PLEASE CALL ME IMMEDIATELY FOR FURTHER INSTRUCTIONS.

Healing Process

Healing is usually rapid and can be viewed in several stages. It should be remembered that this is like any other cut and that there are many factors that influence healing. Every child heals differently.

First, the cut edge seals and bleeding ceases within minutes. Within hours, maybe a day, the area just behind the glans (especially the underside) will become swollen. This inflammation subsides within a week or two. One to two days following the circumcision there may be an off white or yellowish, patchy appearance of the glans. These patches are a type of scab and are associated with normal healing. You will also notice that the glans is red and glossy. This is because the underside of the foreskin, which covers the glans of the uncircumcised penis, is a mucous membrane (like the inside of your cheek). Once exposed, the mucous membrane will toughen (a process called keratinisation), and in time will take on a normal appearance. The penis should take on a “normal” appearance within about one month’s time.

Circumcision is associated with few and infrequent complications, though as with any surgical procedure there are occasional problems.

The most common complication is bleeding. In most cases, bleeding is controlled by direct pressure as described in a preceding section.
There are reported cases of infection, although these are rare in this setting. Common signs of infection include a pus discharge, a foul smell, excessive swelling or redness, local warmth, fever or rash in the penile area. With development of any of these signs, please call me immediately and I will give you further instructions.
Some infections which do not cause a fever, but only mild symptoms, can usually be treated with a topical antibiotic ointment.

Final appearance of the penis is dictated by many factors. The final appearance of the penis is the greatest cause for concern amongst parents. It should be remembered that everyone’s anatomy is different and as such, penises come in all shapes and sizes. The result of one circumcision cannot be identical to the next. While most penises begin to look “normal” within days of the procedure, some do not take on a completely “normal” appearance until after the penis begins to grow.

Furthermore, the penis may look smaller after the circumcision. On occasion, a poor aesthetic result occurs when too little or too much foreskin is removed or more likely when the cut edge of the skin attaches too high or too low along the length of the penis. The latter is sometimes caused by a penile erection or hydrocele. In nearly all cases, the penis will heal properly and in time take on a “normal” appearance.

Any concerns should be brought to Dr. Greenberg’s attention, as early treatment, if needed is always best. In case of emergency, Dr. Greenberg can be reached by cellular phone at 416-702-8990.
The best way to reach the doctor is by text message. Medically urgent messages after circumcision will be answered when the doctor as soon as possible them. Otherwise, the doctor may not answer until the Tuesday or Thursday. The doctor will not respond to non-urgent messages and calls on Jewish Holidays and weekends.

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