Fellow’s Corner: Referral for Newborn Circumcision: What to Know

Karl F. Godlewski, MD Newborn circumcision rates vary greatly within the continental United States, with circumcisions more frequent in rural states compared to urban areas. Based on data from the National Hospital Discharge Survey compiled by the National Center for Health Statistics, the overall circumcision rate of newborn males in the United States from 1994 to 2006 varied between 55% and 60%.

Although circumcision is generally a safe and low-risk procedure, one of the most common complications is bleeding, which occurs in approximately 1 in 200 children. This risk increases significantly when the child is past the neonatal period or has not received vitamin K. Vitamin K is a fat-soluble vitamin processed in the liver and essential for the synthesis of procoagulant factors VII, IX, X, protein C, and protein S. Newborn boys who do not receive vitamin K have a reported 6-fold increase in post-circumcision bleeding. For this reason, our current policy requires verification that vitamin K was administered before a circumcision is performed.

Sooner better than later

In many instances, and for a variety of reasons, circumcision is deferred at birth. In these cases, it is prudent to perform a circumcision before the child gains too much weight, ideally within the first few weeks of life. One study by Kin et al showed a 4-fold increased risk of bleeding if the infant was >5.1kg.

Any anatomic anomalies of the shaft skin, phallus, and scrotum should also give practitioners pause prior to performing a newborn circumcision. Knowledge and understanding of these conditions can facilitate appropriate referral to pediatric urologists and help limit unsatisfactory cosmetic outcomes, post-circumcision complications, and the morbidity of post-circumcision reconstructive surgery.

Considerations for anatomic anomalies

Hypospadias occurs when the urethral meatus is ectopic anywhere along the ventral shaft, scrotum, or even perineum. This condition is often associated with excess dorsal foreskin, incomplete dysplastic ventral skin, and penile curvature. These children should not undergo newborn circumcision and instead should be referred to a pediatric urologist for operative counseling.

• Chordee, or congenital penile curvature, can be easily assessed in the clinic by pushing down at the base of the penis alongside the penile shaft and simulating an erection. Curvature can be dorsal, ventral, or lateral. Although mild curvature may have little functional or cosmetic consequences, any concern for chordee should prompt referral to a pediatric urologist for further evaluation. Penile torsion, or twisting of the penis, that would cause a functional issue is actually quite uncommon. The ventral median raphe often wanders and usually does not preclude a newborn circumcision.
• Penile concealment is typically caused by a paucity of penile shaft skin, poor fixation of skin at the base of the penis, or an excess of suprapubic adipose tissue making the penis appear “buried.” These boys can be at high risk of scarring (cicatrix) after newborn circumcision and thus should be examined by a pediatric urologist before proceeding. If the concealment is severe, a circumcision and concealed penis repair in the operating room after the age of 6 months may prove to be in the best interest of the child.

The decision whether or not to circumcise remains steadfastly with the parents, but as practitioners we have a responsibility to carefully educate parents about risks and appropriately refer those infants who are in need of expert examination and care.

Reference and selected reading

The Circumcision Reference Library. http://www.cirp.org/library/statistics/USA/. Revised January 14, 2012. Accessed March 13, 2023.

Kin JK, Koyle MA, Chua ME, et al. Assessment of risk factors for surgical complications after neonatal circumcision clinic. Can Urol Assoc J. 2019;13(4):E 108-112.

American Academy of Pediatrics Committee on Fetus and Newborn. Controversies concerning vitamin K and the newborn. Pediatrics. 2003;112 (1 pt 1):191–192.

Centers for Disease Control and Prevention. Trends in in-hospital newborn male circumcision 1999-2010. MMWR Morb Mortal Wkly Rep. 2011;60(34):1167-1168.