Newborn Circumcision Techniques

Folashade Omole, MBChB;​Walkitria Smith, MD;​and Kitty Carter-Wicker, MD

Morehouse School of Medicine, Atlanta, Georgia

Newborn male circumcision is a common elective surgical procedure for the removal of foreskin covering the glans penis. The
American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the Centers for Disease Control
and Prevention, and the American Academy of Family Physicians recognize that there are health benefits of newborn male
circumcision but do not universally recommend the procedure. Performing male circumcision during the neonatal period
has several advantages, including a lower risk of complications, faster healing, and lower cost. The three most common
techniques for newborn male circumcision utilize the Mogen clamp, the Gomco clamp, or the Plastibell device. Complica-
tions are uncommon and can include bleeding, injury to the penis, adhesions, excessive skin removal, phimosis, and meatal
stenosis. Anatomic and medical contraindications may require that the procedure be deferred beyond the neonatal period.
Infants with anatomic abnormalities should be referred to a pediatric urologist. Physicians should present information about
potential benefits and risks rather than withholding or recommending circumcision. Parents should weigh the health benefits
and risks and consider their own religious, cultural, and personal preferences when making the decision. (Am Fam Physician.
2020;​101(11):​680-685. Copyright © 2020 American Academy of Family Physicians.)

Newborn male circumcision is a common elective sur- Established health benefits of circumcision include a
gical procedure for the removal of foreskin covering the reduced lifetime incidence of urinary tract infections,
glans penis. It is most often performed in the first days of penile cancer, phimosis, HIV, and several other sexually
life.1 According to the World Health Organization, there transmitted infections.3,6,8-10 A 2017 systematic review con-
are several advantages of circumcising males at a younger cluded that the health benefits of newborn circumcision
age, including a lower risk of complications, faster healing, are greater than the risks associated with the procedure.11
and lower cost.2,3 The frequency of adverse events is four Despite these benefits, the newborn male circumcision rate
per 1,000 procedures for early infant circumcision, but this has declined in the United States, from 83% in the 1960s
number increases 10- to 20‐fold in older boys.4 Physicians to 77% in 2010.12 There are racial and ethnic differences in
should present information about potential benefits and the overall circumcision rate:​over the past decade, 91% of
risks rather than withholding or recommending circumci- white males reported having been circumcised compared
sion, and parents should consider their own religious, cul- with 76% of black males and 44% of Hispanic males.5,8,11,13 In
tural, and personal preferences when making the decision.3,5 some states, these differences may be related to an increas-
The American Academy of Pediatrics (AAP), the Ameri- ing Hispanic population and lack of Medicaid coverage.11
can College of Obstetricians and Gynecologists, the Centers The data used by the AAP and CDC to support their pol-
for Disease Control and Prevention (CDC), and the Amer- icy statements have largely been extrapolated from adult
ican Academy of Family Physicians (AAFP) recognize the circumcision studies performed in the sub-Saharan region
potential health benefits of newborn male circumcision, but of Africa. Because of the lack of direct evidence of bene-
they do not universally recommend the procedure.3,6,7 The fit, some consider newborn circumcision unnecessary.9,14 A
AAFP recommends that circumcision be available and cov- 2010 systematic review found that although complications
ered by health insurance for those who desire it.7 are rare, there is little evidence to support circumcision.15

Embryology and Anatomy

This clinical content conforms to AAFP criteria for
CME
CME. See CME Quiz on page 649. Knowledge of penile embryology and anatomy is impera-
Author disclosure:​ No relevant financial affiliations. tive before attempting circumcision.16,17 Male development is
Patient information:​ A handout on this topic is available at
influenced by the Y chromosome, which begins development
https://​family​doctor.org/circumcision. of the external genitalia at seven to 17 weeks’ gestation.16 The
nerve sensation of the penile skin is supplied by the dorsal

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 NEWBORN CIRCUMCISION
SORT:​KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating Comments

Parents should be offered newborn circumcision in a nonbiased C Expert opinion and consensus
conversation regarding potential benefits and harms. 3,6,7 guidelines

The Mogen clamp, the Gomco clamp, and the Plastibell device C Usual practice and expert opinion in the
can be used effectively for newborn circumcision.19 absence of clinical trials

Local anesthesia should be used during newborn B Randomized controlled trials and
circumcision. 26-30 meta-analyses showing benefit

Infants with abnormal penile anatomy should be referred to a C Usual practice and expert opinion in the
pediatric urologist for circumcision.1,20,22 absence of clinical trials

A = consistent, good-quality patient-oriented evidence;​B = inconsistent or limited-quality patient-oriented evidence;​C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://​w ww.aafp.
org/afpsort.

nerve, which is absent at the 12 o’clock position. The internal

pudendal artery is the main blood supply of the penis, and FIGURE 1
it is drained by the deep dorsal vein. The cavernosal, dor-
A
sal, and bulbourethral arteries and veins are the offshoots of
these two main vessels. In newborns, prepuce or preputial
adhesions between the glans and foreskin are normal.1

Circumcision Techniques
The three most common techniques  18 for circumcision uti-
lize the Mogen clamp (Figure 1), the Gomco clamp (Figure 2),
or the Plastibell device (Figure 3). Because these techniques
are equally effective, the choice of device should be guided
by the physician’s experience and comfort level.19,20 The
Mogen and Gomco clamps protect the glans, and the Plas-
B
tibell induces tissue necrosis, which is sloughed off with the
plastic shield.21
When using the Gomco clamp or Plastibell, the choice
of device size depends on the diameter of the glans rather
than penile length.22 The Gomco clamp ranges from 1.1 to
1.6 cm, and the Plastibell from 1.1 to 1.7 cm. The most com-
monly used size for either device is 1.3 cm.23 Circumcision
using the Mogen clamp can be completed in less than five
minutes, whereas procedures using the Gomco clamp or
Plastibell can take up to 10 minutes.24,25 In general, the time
required to complete the procedure is inversely related to Mogen clamp in the open (A) and closed (B) positions.
the physician’s level of experience.

Anesthesia 0.2- to 0.4-mL injections on either side of the midline at the

Anesthesia should be provided to all newborns undergoing base of the penis (Figure 4A), and a ring block requires a
circumcision, regardless of the technique.26-30 A random- 0.8-mL injection circumferentially around the base of the
ized trial suggested that procedures using the Mogen clamp penis (Figure 4B). A 2004 Cochrane review found that the
produce less pain than those using the Gomco clamp.25 ring block or dorsal penile nerve block is more effective
Pain relief can be achieved using lidocaine/prilocaine than topical lidocaine/prilocaine alone.28 A sucrose pacifier
cream applied to the foreskin 30 to 60 minutes before the (i.e., sucrose solution squirted in the mouth followed by a
procedure. Alternatively, nerve blocks can be performed pacifier) is another analgesic option.26 A recent random-
about five minutes before the procedure using 1% lidocaine ized controlled trial comparing lidocaine/prilocaine cream
without epinephrine:​a dorsal penile nerve block requires alone with combination analgesics (lidocaine/prilocaine

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 NEWBORN CIRCUMCISION
FIGURE 2
A B

Gomco clamp in the open (A) and closed (B) positions.

of the device used 21 (Table 1 22). There is little variation

FIGURE 3 in the first few steps once analgesia has been achieved.
Straight hemostats are applied to the distal end of the fore-
skin at the 10 and 2 o’clock positions. A lubricated curved
hemostat (pointed away from the penis) is used to lyse the
adhesions on the right and left sides of the glans, avoiding
the ventral frenulum.20

GOMCO CLAMP
A video demonstrating a circumcision using a Gomco
clamp is available at https://​v imeo.com/74547358. A
straight hemostat is applied at the 12 o’clock position to
create a crush line. With blunt-edge scissors facing the
glans, a small incision is made one-third to one-half the
distance from the coronal margin to expose the glans. The
foreskin is retracted to break away any remaining adhe-
sions. The bell of the clamp is placed under the foreskin
and over the glans, and the foreskin is pulled over the bell
Plastibell device. with the attached hemostats. A hemostat or a small safety
pin is used to bring the edges of the dorsal incision together
over the flare of the bell before the base plate is applied. The
plus sucrose;​lidocaine/prilocaine plus sucrose plus dorsal hemostats at the 10 and 2 o’clock positions are removed,
penile nerve block;​and lidocaine/prilocaine plus sucrose the foreskin is gently pulled through the hole in the base
plus ring block) showed that combination analgesics, espe- plate, and the base plate is placed over the bell. The tip of
cially topical anesthetic plus sucrose plus ring block, are the incision should be visible above the base plate. The yoke
more effective.30 of the top plate (rocker arm) is attached to the arms of the
bell, and the other end of the top plate is tightened to the
Procedure base plate and left in place for five minutes. During this
The duration of the procedure, bleeding, and complications time, excess foreskin is removed with a scalpel. After five
vary depending on which device is used. The Mogen clamp minutes, the plates are loosened and the clamp disassem-
requires the least training and procedure time, and it is bled, and sterile gauze is used to gently tease the crushed
associated with less bleeding and fewer complications. The foreskin off of the bell.
Gomco clamp and Plastibell require more training and lon-
ger procedures, and are associated with more bleeding and MOGEN CLAMP
more complications.18,25,31,32 A video demonstrating a circumcision using a
The procedure setup, including the aseptic field, anes- Mogen clamp is available at https://​med.stanford.
thesia, and positioning of the infant, is the same regardless edu/newborns/professional-education/circumcision/

682 American Family Physician www.aafp.org/afp Volume 101, Number 11 ◆ June 1, 2020
 NEWBORN CIRCUMCISION
FIGURE 4

A Dorsal penile Superficial dorsal Deep dorsal

artery penile vein penile vein

10 o’clock 2 o’clock
Dorsal nerve
of penis Deep
(Buck’s)
fascia

Corpus
cavernosum

Urethra Dorsal penile

nerves

Cross-section

Nerve blocks used for anesthesia during circumcision. (A) Dorsal penile nerve block. With a single syringe, inject
0.2 to 0.4 mL of lidocaine subcutaneously at the base of the penis in the 10 and 2 o’clock positions to anesthetize
both branches of the dorsal penile nerve. (B) Ring block. With a single syringe, inject 0.8 mL of lidocaine subcu-
taneously around the perimeter of the base of the penis. Two or more injections will be needed to complete the
circumferential block.
Illustration by Dave Klemm

mogen-clamp-technique.html. Once the adhesions have injuring the urethra, the probe is used to gently separate the
been lysed, the glans is pushed downward. The foreskin is foreskin, then push it down below the corona, fully expos-
held with hemostats at the 9 and 3 o’clock positions, then ing the glans and breaking away any remaining adhesions.
slid between the narrowly opened (3 mm) Mogen clamp. The
clamp is applied with the concave surface facing downward PLASTIBELL
after ensuring that the distal glans (tip of the penis) is not The Plastibell technique begins similarly to the Gomco
caught in the clamp. The clamp is closed and left on for 60 to clamp technique. A straight hemostat is applied at the
90 seconds. Excess foreskin is removed with a scalpel, 12 o’clock position to create a crush line, then with blunt-
then the clamp is removed. Starting at either end to avoid edge scissors facing the glans, a small incision is made

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 NEWBORN CIRCUMCISION

on the bell, then excess foreskin past the outer edge is

TABLE 1 removed with a scalpel and the handle is broken off, leav-
ing the ring in place.
Preparation for Newborn Circumcision
Lidocaine/prilocaine 2.5%/2.5% cream is applied 30 to Postprocedure Care
60 minutes before the procedure Petroleum jelly and gauze are applied to the glans after the
The infant is placed in a supine position and restrained procedure to keep the diaper from sticking to the wound
by an assistant or in an infant holder with hook-and-loop during the healing period. The newborn can be discharged
fastener straps from the hospital after the procedure;​it is not necessary to
The penis and scrotum are cleaned with povidone-iodine wait until he urinates. The parents are usually advised to
solution and draped in a sterile fashion follow up in three to five days and should be counseled on
applying the dressing with each diaper change until healing
Local anesthetic (dorsal penile nerve block or ring block
[Figure 4]) is injected before the procedure is complete or until the Plastibell falls off. This usually takes
five to seven days.21,34
The distal end of the foreskin is clamped at the 10 and
2 o’clock positions with straight hemostats Complications
A lubricated curved hemostat (pointed away from penis) The frequency of adverse events is four per 1,000 for early
is used to lyse the adhesions on the right and left sides to infant circumcision and 10- to 20‐fold higher in older
the base of the glans penis, avoiding the ventral frenulum
boys, according to a 2014 study assessing adverse outcome
Information from reference 22. rates by age at circumcision.4 Minor bleeding is the most
common early complication.20 Infants who are vitamin K
deficient may have prolonged bleeding. Postprocedure
bleeding commonly occurs during the first week of life, but
TABLE 2
it can occur for up to eight weeks.
Contraindications to Newborn Circumcision Glans injury can occur with all three techniques, and
insufficient or excessive skin removal can occur with the
Anatomic contraindications
Mogen and Gomco clamps.20 Meatal stenosis is the most
Chordee
common late complication and is usually prevented by
Concealed penis
advising parents to apply petroleum jelly to the glans.35
Congenital megaprepuce
More serious and late complications include penile injury
Epispadias
or amputation, infection, necrosis of the glans, incision of
Hypospadias
the glans or urethra, adhesions, phimosis, and meatal ste-
Penile torsion
nosis and scarring. Infants with these conditions should be
Penoscrotal webbing
referred to a pediatric urologist.3,4,7,20,32,36
Medical contraindications
Admission to neonatal intensive care unit Contraindications
Age < 12 hours There are anatomic and medical contraindications to new-
Bleeding dyscrasias (e.g., hemophilia) born circumcision (Table 2).1 In some cases, an anatomic
Current illness variant may not be noticed until after the procedure has
Jaundice begun and the foreskin retracted.1,17,22 Newborns with
abnormal penile anatomy should be referred to a pediatric
Information from reference 1.
urologist for appropriate care.20,22
This article updates a previous article on this topic by Peleg and
Steiner. 22
one-third to one-half the distance from the coronal mar- Data Sources:​ A PubMed search was completed using the key
gin to expose the glans. 33 The foreskin is retracted to break terms newborn circumcision, Mogen clamp, Gomco clamp and
away any remaining adhesions. The Plastibell is placed Plastibell, anesthesia and circumcision, and treatment options.
The search included meta-analyses, randomized controlled tri-
under the foreskin and over the glans, then the foreskin
als, clinical trials, and reviews. We also searched the Cochrane
is pulled over the Plastibell and stabilized by clamping it database and Essential Evidence Plus. References in these
to the handle of the Plastibell with hemostats. The Plasti- resources were also searched. Search dates:​November 2018 to
bell is secured in place by tying a string around the groove March 2020.

684 American Family Physician www.aafp.org/afp Volume 101, Number 11 ◆ June 1, 2020
 NEWBORN CIRCUMCISION

15. Perera CL, Bridgewater FH, Thavaneswaran P, et al. Safety and effi-
The Authors cacy of nontherapeutic male circumcision:​a systematic review. Ann
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