Circumcision

What is circumcision and how it is done?

Medically, circumcision is removal of the foreskin, covering the glans penis.
The procedure, at least according to the Jewish religion, has a few main parts:
Mila – cutting and removing of the foreskin.
Periah – removal of the remaining foreskin, and all membrane between the glans penis the foreskin.
Metzizah – suctioning of the blood by the Mohel. The purpose of Metzizah is to prevent discontinuation of the blood supply to the glans penis, due to physiological mechanisms that happens after preforming the cut and damaging the blood supply to the area. It can be done directly (the mouth of the mohel on the penis) or indirectly (using a tube or a syringe).
After the procedure, the Mohel will address the wound and put gauze to prevent further bleeding.

When is circumcision being done, and on what situations should you postpone it?

In Judaism, circumcision is done on the 8th day after birth.
If the baby is born before sunset, you consider the birth day to the first day, and then count 8 days. For example, if a baby is born on Monday on 16:00 before sunset, than his circumcision should be on Monday on the following week. If the baby is born after sunset, than the first day is the following day. So if a baby is born on Monday at 18:00 (which is after sunset), than his circumcision will be on Tuesday the following week.

Who cannot have circumcision at that time?

There are no clear criteria, and there may be differences between different Mohels. Having said that, there is some consensus on the following criteria:
– Illness: babies with a significant medical history or babies with an acute infection should consult with their pediatrician.
– Babies with blood coagulation problems.
– Genital anomalies: hypospadias (incorrect location of the urethral opening), babies who are born half circumcised, and more. In these cases you should consult with an expert (urologist or a Mohel-doctor) before circumcision.
– Weight: it is accustomed to perform the procedure above 2.5 kg.
– No known neonatal jaundice. It is accustomed to perform the procedure for babies with bilirubin which is not rising and is lower than 15 mg/dL. Please read more here on neonatal jaundice.

What are the medical consequences of circumcision for the long and short term?

Like any other surgical procedure, this one has complications and advantages, some short term and some for the long term.
The immediate complications of circumcision are:
Pain – in the website of one of the most respectable HMO in Israel, there was a saying “the surgical procedure is less painful as younger as the patient is”. This is very, very inaccurate.
You can say that when the baby is younger he complain less (at least with words), but there is research that cannot be argue with, stating that the procedure is painful. In a beautiful research by Prof. Gidi Koren, a pediatrician, it was proven that babies who were circumcised without local anesthetic is suffering more pain from routine vaccination, than those who were treated with local anesthetic during circumcision. This means that not only the procedure hurts; it is somehow remembered throughout life.
This does not mean you should pass on circumcision. It just means that you should lower pain during the procedure.
Bleeding – a prevalence of 0.08-0.18%. More common in babies who did not receive vitamin K injection after birth. The risk for bleeding at 8 days is lower that bleeding in older babies.
Infections – infection in the site of the circumcision is not common but can happen. Urinary tract infection which is related to circumcision is more common (see later on about bandaging the area). Herpetic infection is rare but can cause serious damage (see later about Metzizah).
Injuring the penis – very rare.
The long term complications of circumcision are:
The most important complication is stenosis of the urethral opening. When there is no foreskin, the tip of the penis and especially the urethral opening is rubbing against the diaper. This may cause local inflammation at the tip of the penis. The clinical signs are redness at the urethral opening (meatitis, inflammation of the urethral opening).
In most cases the infection goes away on its own without complications, but in cases were the inflammation continue, there can be stenosis of the urethral opening or scare tissue that blocks a part of the opening that can cause problems with urination later on. There is a common urologic surgery called meatotomy (expansion of the urethral opening) which is mostly the result of an untreated meatitis. You can read about it in this next post.
I recommend the person changing the diapers, in any age when the child still needs the diaper, to look at the tip of the penis. If you see any redness in the area, apply a bit of the diaper ointment on the area. There is no need to worry – the opening will not be blocked with ointment, and the baby will be able to pee. The ointment will prevent friction and stop the inflammation.
I will emphasis that meatal stenosis is not a direct complication of circumcision, but a condition that is more prevalent in circumcised babies.

What are the medical advantages of circumcision?

– Circumcised babies have less urinary tract infections (a part from the time after circumcision until 1 month).
– Circumcised boys have lower prevalence of HIV and sexually transmitted disease, like herpes, syphilis and human papilloma virus.
– Circumcised man has less penile cancer and fewer infections (balanitis and phimosis).
– Spouses of circumcised man have a lower rate of infection with human papilloma virus (and less prevalence of cervical cancer).
It is important to say that circumcision does not affect pleasure from intercourse later in life.

What do you need to do before and after circumcision?

Preparation for the circumcision will be done according to the specific instruction of the Mohel, as for feeding before and what to prepare to the ceremony and after it is done.
Treatment after circumcision includes washing the area gently with water and baby soap, and oiling the area. The penis may look yellowish because of the fibrin layer, a few days after the procedure (even up to 7-10 days). Oiling will prevent adhesions and direct contact with urine and stools. In this matter you will receive guidance from the Mohel.
As for urine output – see ahead about bandaging the wound, but I will ask you right now – look out for urine output. There should be a wet diaper every few hours, even after circumcision.
And off course, you can give some analgesia (paracetamol in this age).
Fever above 38.0 Celsius requires medical attention.
I expect babies to take a few hours for recovery and then be back to their normal self. Meaning – if a baby does not wake up for feeding as he usually do, or if he looks lethargic or quieter than usual – you should consider calling the Mohel and consult your pediatrician.

A few tips regarding circumcision:

My recommendation for choosing the right Mohel is based on medical considerations. The Mohel (being a certified physician or not) needs to be a professional, experienced, working in a sterile technique and be aware and attentive to the issue of pain management.

How can you reduce pain during the procedure?

Giving the baby sugar on the pacifier or your finger, paracetamol and a relaxed atmosphere are important, but are not a substitute for pain management in children.
In every circumcision there is room for combining an addition of numbing cream, posterior nerve block or circular subcutaneous nerve block.
Nerve block is a local anesthesia method in which Lidocaine (in concentration of 2%-4%, much as in dental treatment of before epidural) is injected in a small amount (without adrenaline) with a very small gage needle. In a posterior nerve block the injection is done in the base of the foreskin to the subcutaneous area (there is no injection to the penis or the scrotal area). This area will be numb and free of pain for a few hours, and in this manner the circumcision will not hurt at all.

What about suction (Metzizah) in circumcision?

I’m want to remind you that the goal of Metzizah is to prevent damaging the blood supply to the penis. There is no religious reason to do this procedure without a tube or a disposable sterile syringe.
In my opinion there should be a ban on direct suction, which may expose the baby to herpes from the Mohel’s mouth. The herpes virus is a virus which remains latent in the nervous system after infection. In a study from Israel done in 2006, it was found that 70% of the grownup population in Israel have had herpes in the past (60% herpes type 1, 10% herpes type 2). I guess that if you would ask the participants, they would not know or remember that they had an infection to begin with. There are a small group of people who would get “sore wounds” occasionally, especially in the mouth area. But, and this is what I want you to remember, that secretion of the virus can occur even without active visible lesions. Meaning that there are people reading this article, with herpes virus in their saliva right now.
When practicing direct suction, you can infect the baby with herpes, and with young babies herpes infection has severe morbidity. There is an order from the Chief rabbinate in Israel that the Mohel needs to inform the parents of both options (direct and indirect suction). In my opinion – it is not done regularly.
I presume that those of you who are reading this post are already convinced and perhaps already choose a Mohel who is responsible enough to not preform direct suction at all. But I suggest you ask the Mohel directly.
I’ve seen a few cases of herpes infection after circumcision, and the consequences are grave. Since it is happening in some populations more than others, it is hard to eradicate this pheromone.
But you should not let this happen to you. If you are still debating, read more here.

What is the correct way to apply a bandage after the circumcision?

After the circumcision there is always some bandages applied to the area. Mostly it is a material that absorbs liquids and falls off on its own, and not a bandage that needs to be removed the day after. The most common one is Kaltostat (a bandage made from seaweed) which falls off on its own. A light bandage such as this will not cause pressure that would prevent urination.
You should differentiate this bandage from others that need to be removed the day after circumcision, such as gauze. This type of bandage puts pressure on the penis, interferes with urination, and when the urine accumulates at the end of the bandages, it can cause bacteria to infect the urinary tract. In addition, there is a danger in these bandages when it’s too tight, since it can damage the blood supply to the veins or arteries of the glans penis.