Ways to control circumcision pain
Circumcision is the surgical removal of the skin covering the glans penis, which has been practised since the ancient times.
Clearly, there were limited choices of the intervention and definitely no option of anaesthesia in those days. As many parents are making decisions to have their sons circumcised for religious and medical reasons these days, the issue of the types of surgical methods and anaesthesia for the children become a subject of concern.
Many surgical techniques have been developed and evolved over the last century. These methods can be broadly grouped into three categories including clamps, slits and excisions.
The clamp techniques requires the foreskin to be pulled out away from the glans, with metal shield slid over the shield, followed by a scalpel for removal of the skin. No stitches are applied to the wound, as it is simply bandaged to stop the bleeding.
Various devices providing shield and clamp have also been developed favouring the paediatric circumcisions, as the size of the penises are more suitable for such intervention. The clamps with various names are available in the market; these include Mogen clamp, plastibell and Gomco commonly used in the United States. Our Malaysian contribution of the industry comes from a device named TARA KLamp. The device is a plastic arms lock in place to force two surfaces into tight contact, trapping the foreskin before the cut, reducing the risk of bleeding.
The other method of circumcision is dorsal slit, which is a limited cut to the foreskin to free it from adhesion.
Finally, the excision technique is the conventional technique that allows the “sleeve resection”. This circumferential incision is made around the shaft of the inner and outer prepuce. A modification of using the scalpel is the utilisation of laser. The advantages of laser precision and sealing off the blood vessels allowing several benefits of faster recovery. However, under normal circumstances, such intervention may not be necessary.
Anaesthesia was not advocated for infant circumcision, as it was believed the procedure caused little or no pain to the child. On the hand, the side effects of medications and injections outweigh the benefits. It is now known that infants do experience pain, and such experience may interfere with mother-infant interaction and even results in behavioural changes in adulthood. Therefore, the usage of analgesia and anaesthesia are generally encouraged.
The utilisation of anaesthesia can be pharmacological and non-pharmacological. The injection of local anaesthesia as ring or dorsal block is simple and safe, even for premature low birth-weight newborn infants. The use of aesthetic cream on the foreskin, before the operation, has also been shown to be effective.
Despite the benefit and proven safety of anaesthesia for infants undergoing circumcision, a recent study in the US revealed the non-usage of anaesthesia ranges from 54% to 96%. Another study demonstrated only 71% of paediatricians, 56% of family practitioners and 25% of obstetricians offered anaesthesia to infants when discussing the operation.
Although the age-old practice of circumcision without anaesthesia dates back centuries, the marvel of modern medicine ensures the safety and benefits of such protection to vulnerable infants.