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JSAPA

Surgical Practice

Robert Cywes, MD, PhD

Pediatric General Surgery

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WHAT WE DO

Office Male Circumcision - Newborn to 2 Years Old
Hospital Circumcisions - Over 2 Years of Age

Definition

Circumcision is the surgical removal of the foreskin. The foreskin is a flap of skin that covers the tip of the penis.
We offer circumcisions for babies and children from birth up to two years of age as an office-based procedure under local anesthesia, even if they were born prematurely. The procedure itself takes 5-8 minutes on average and is performed by a fellowship-trained pediatric surgeon who has performed over 10 000 circumcisions (see more details below).

REVISIONAL SURGERIES ANY AGE

We offer evaluations and revisions of complications from previously performed circumcisions. Unfortunately, many babies who have newborn circumcisions often done in the first day or two of life have complications from their circumcisions (see below). If you have any questions or concerns about your son’s previously performed circumcision, we are able to evaluate him in our office and give recommendations. Over the years, our practice has performed a large number of revisional circumcisions with excellent outcomes. Some revisions may be performed in the office under local anesthesia, some require general anesthesia and are performed in the operating room either at the hospital or in our surgicenter (see more details below).

Circumcision over the age of two years, including adults

We offer evaluations and perform circumcisions on children and adults over the age of two years, but these procedures are usually done using a surgical technique that requires general anesthesia and are performed in the operating room either at the hospital or in our surgicenter (see more details below).

Screening for other related conditions and abnormalities

When your son is initially evaluated for circumcision, the surgeon will also evaluate him for other newborn issues such as inguinal hernias, umbilical hernias, femoral hernias, epigastric hernias, undescended or retractile testes, hypospadias/epispadias, chordee and other similar penile problems. We will make recommendations as to treatment of such conditions should it be necessary and we are able to correct these conditions surgically in our surgicenter or at the hospital (see more details below).

COST AND PAYMENT

Payment for Office Circumcision

We charge $275.00 for the entire circumcision process when performed in the office. This includes the initial consultation, evaluation and the procedure (which is usually done at the same time as the initial visit) as well as the mandatory follow-up visit 3-4 weeks after the procedure. It also includes 24 hour access for any questions or concerns during this period. We do not accept insurance for office procedures. You do not require a referral from your family doctor for office procedures but we always recommend that you discuss the procedure with your son’s pediatrician or family doctor. You may call us at the number above or email us to schedule the procedure. Rarely, the surgeon may decide that it is not appropriate to do the circumcision in the office. If so, you will be reimbursed your entire fee. Payment may be made by credit, debit or cash at time of initial consultation.

Payment for Hospital/Surgicenter Circumcision

For boys over the age of 2 years, adults or revisional surgery of other doctors’ circumcisions, we do accept most insurances. You are responsible for a referral from your son’s primary care doctor and all co-pays or deductibles that you will be made aware of prior to any surgery, but we will obtain authorizations as needed. The procedure is usually not performed on the same day as the office consultation for these patients since it is usually done in the Operating Room at the surgicenter or hospital under general anesthesia. Follow-up is done 2-4 weeks after the procedure in the office.

About the doctor

Robert Cywes, MD, PhD

Pediatric General Surgery

JUPITER LOCATION :

641 University Blvd. Suite 105
Jupiter, FL 33458

JACKSONVILLE LOCATION:

8833 Perimeter Park Blvd. Suite 202
Jacksonville, FL 32216

 

(904) 410-3934
(561) 627-4107
(561) 627-5069

DECIDING ABOUT CIRCUMCISION

Deciding to have your son circumcised is usually an intensely personal decision. While we offer circumcision procedures as a service, we do not wish to engage in ethical or emotional debates about the value or not of male circumcision. Our philosophy is that we have extensive experience in doing thousands of circumcisions and have a very low complication rate. So, once you as a family have made the decision to have your son circumcised, we believe we offer a safe low risk environment to do the procedure. There are several reasons to consider having your son circumcised. For many families, the choice is based on social/family tradition (i.e. the other males in the family including Dad are circumcised) cultural or religious beliefs. Circumcision is a religious or cultural ritual for many Christian, Jewish and Islamic families, as well as certain ethnic tribes in Africa and Australia. Sometimes, there is a true medical indication for circumcision such as infections around the foreskin (Balanitis) or the foreskin is too tight and cannot be retracted or pulled back (phimosis). However, if you are not sure about the decision it may be of benefit to read the opinions below, and to discuss the decision with relatives, friends and your son’s family doctor. Remember, there is no time pressure since the procedure can be done in the same manner up to two years of age in the office and you do NOT have to make the decision while your son is still in the hospital after birth.

FACTS AND OPINIONS ABOUT CIRCUMCISION TO HELP YOU DECIDE

Medical Data

Beyond the social, cultural and religious reasons, the scientific consensus about MEDICAL BENEFITS of circumcision (personal hygiene and preventative health data) as reviewed by the American Academy of Pediatrics (AAP) is that “the health benefits of newborn male circumcision outweigh the risks.” However, the evidence is not strong enough to recommend routine circumcision of all newborn boys purely for medical reasons (see references below). Ultimately, the decision to circumcise a boy is a personal family decision that should take into consideration the known medical facts as well as the social, cultural and religious circumstances of the family. About 55% to 65% of all newborn boys are circumcised in the United States each year, though this rate varies by region (western states have the lowest rates and the north central region has the highest). The procedure is much more widespread in the United States and Africa, Canada, and the Middle East than in Asia, South America, Central America, and most of Europe, where it’s less common.

POTENTIAL HEALTH BENEFITS OF MALE CIRCUMCISION

Hygiene

Circumcision makes it simpler to care for and wash the penis. While washing inside the foreskin of an uncircumcised penis is generally requires pulling the foreskin back. Penile problems, such as irritation, inflammation, and infection, are more common in uncircumcised males. It’s easier to keep a circumcised penis clean, although uncircumcised boys can learn how to clean beneath the foreskin once the foreskin becomes retractable (usually some time before age 5).

Risk of infections around the head of the penis and urinary tract infections

UTIs are about 10 times more common in uncircumcised males than circumcised infants, particularly in the first year of life. However, the overall risk of urinary tract infections in all males is low (1% or less in uncircumcised males). Severe infections early in life can lead to kidney problems later on.

Risk of sexually transmitted infections

Studies have shown that circumcised men might have a lower risk of certain sexually transmitted infections, including HIV. Still, safe sexual practices remain essential.

Penile problems

Occasionally, the foreskin on an uncircumcised penis can be too tight (phimosis) making it difficult or impossible to pull back. When very tight, this may cause partial obstruction of urine flow, increase the risk of urinary tract infections or lead to inflammation of the foreskin or head of the penis resulting in adhesions forming.

Penile cancer

Although cancer of the penis is rare, it’s less common in circumcised men. In addition, cervical cancer is less common in the female sexual partners of circumcised men.

Fertility and sexual pleasure

Circumcision does not affect fertility. Some people claim that circumcision either lessens or heightens the sensitivity of the tip of the penis, decreasing or increasing sexual pleasure later in life, but none of these subjective findings are conclusive. There is no medical evidence that circumcision enhances or detracts from sexual pleasure for men or their partners. However, social and cultural circumstances may affect the perceptions of partners either way.

TIMING OF PROCEDURE, ANATOMICAL VARIATIONS, CONTRA-INDICATIONS AND OTHER CONSIDERATIONS

Timing

In our opinion, the best time for a circumcision is when your son is between 4-12 weeks of age (1-3 months old). During this time your son has made the transition from fetus to baby, you as a parent are more comfortable with his care and are getting to know his personality, and both parents and son should be in a relatively established routine. At the same time, pain control is very easy after the procedure while he will have no real memory of the procedure later in life.

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Buried Penis and Other Abnormalities of the Penis

Certainly if your son was born prematurely the risk of circumcision complications is greatly increased when done too early. Size does matter, but all penises grow! Premature babies should ideally wait until they are at least 1-2 months old before circumcision for the best results and lowest complication rates, especially when there are other medical concerns.

Should we have the procedure done in the hospital at birth?

Circumcisions may be done earlier in the first week of life for religious reasons and we are happy to accommodate these circumstances in the office. Some obstetricians and pediatricians prefer to do the circumcision while your son is still in the hospital after birth and there may be insurance coverage issues requiring circumcision in the hospital. However, in our experience, the RISK of complications is highest when routine circumcision is performed during the first 10 days (often within the first 48 hours).

Prematurity

Some babies have what is called a “Buried Penis”. This is a NORMAL condition often seen between 4-18 months of age when the fat pad above the penis enlarges before the babies start walking and the penis that is attached to the pelvic bone, sinks into the fat pad and may disappear or become buried in the pad. The penis is NORMAL. However, technically circumcision of a Buried Penis can be complicated if not performed by a pediatric surgeon with a great deal of experience. We are very comfortable with treating Buried Penises and have a great deal of experience. At the time of circumcision in our office, we will discuss the additional risks as well as the additional benefits to the procedure. However, post-operative follow-up is CRITICAL in these boys. Babies born with physical abnormalities of the penis that needed to be corrected surgically often aren’t circumcised because the foreskin may eventually be

needed as part of a reconstructive operation. When we see such conditions, we will discuss treatment in detail with you. Some babies have other medical conditions that may delay circumcision or require antibiotics for surgical procedures (such as heart anomalies). Circumcision may require special consideration if certain blood-clotting disorders are present, but this is not a contra-indication and the Plastibell technique is ideally suited to this condition. We take all of this into consideration when planning your son’s circumcision.

THE PROCEDURE

For babies from birth to two years of age, the procedure is generally done in the office under local anesthesia and usually takes 5-8 minutes. The procedure may be performed in the operating room after age 6 months with the baby under general anesthesia, but this is more costly, takes longer and adds the risk of general anesthesia which, while low in an otherwise healthy baby, remains higher than using local anesthesia only. Discomfort, memory and emotional trauma, risk of post-operative complications and aftercare is no different when done in the office or operating room. We allow up to two parents or adult relatives to be in the procedure room with your sons while the procedure is being performed in the office. Of course, it is also fine to step out of the room if you prefer. Your son will be secured in a papoose to reduce movement and keep him safe and secure. You may hold his hands if you choose.

Anesthesia

We ALWAYS use local anesthesia. After cleaning the skin with antiseptic prep, the base of the penis is injected with a mixture of two types of local anesthesia. Lidocaine works very quickly but only lasts about 45 minutes, while Bupivicaine which takes longer to start working lasts about 4-6 hours. If performed in the hospital or surgicenter we use general anesthesia but the child is breathing spontaneously. The procedure is very safe in this regard. Even when done in the operating room we still also inject local anesthesia for afterwards. We are able to perform circumcision using several different techniques, but the most reliable and lowest complication rate in our hands is using a Plastibell. We will select the technique most suited to your son at the time of the procedure. Plastibell circumcisions require a greater degree of skill than most other forms of circumcision, but in our experience of over 10 000 circumcisions, give us the most control and the best overall cosmetic result with the lowest complication rates. Aftercare is also most simple after Plastibell circumcision. A small plastic ring is inserted between the head of the penis and the foreskin and a string is tied around the outside in an exact and controlled manner to give the best cosmetic result. The redundant foreskin is cut away. Just like the umbilical cord healed under the clamp that was placed during the birthing process, the string and plastic ring remain in place for approximately 7-10 days while the inside and outside skin of the foreskin grow together. Once the skin is sealed, the plastic ring and string separate from the penis and the circumcised foreskin is left healed.

AFTER CARE

Apart from the best cosmetic results and lowest risk of complications, Plastibell circumcisions are the easiest to care for and we keep it very simple. You may handle and treat your son in exactly the same way as you did before the procedure. You will be provided a detailed list of aftercare instructions at the time of the procedure.

Bathing

You may bathe your son exactly the same way you did before the circumcision. It is important to keep the area as clean as possible. You may use the same soap and you may get the site under water. All you have to do is dry the site by dabbing it with a towel. Wet wipes are fine when changing diapers, diapers are placed no differently than before. The Plastibell protects the opening at the tip of the penis and prevents meatal stenosis. For babies 6-8 months and older, we will give you a prescription for stronger pain medication and give you specific instructions on how to use the medication as needed.

Ointments

After the procedure, there may occasionally be some bleeding from the injection site or the inside of the Plastibell. This is not unusual and will stop. Don’t panic. Call the office anytime if you have concerns. While the Plastibell is in place your son may spray when he urinates. This is OK. Once the Plastibell falls off, his stream will be normal. The local anesthetic injection and the circumcision will cause the penis to swell up and become bruised. THIS IS NORMAL. The penis will be swollen, may turn red and even have some mucus or crustiness at the tip. It is not infected. This is all part of the normal healing process. Don’t panic. If you have any concerns, call the office any time. Once the Plastibell falls off the swelling goes down but the skin may stick up slightly. This is OK. There is NO NEED for you to try to pull the skin back. Let it heal. It may look ugly or abnormal, but this is part of the healing process. Leave it alone. We will take care of this at the follow-up visit and show you how to care for it then.

Pain Control

For babies under 6-8 months of age we ask that you use Tylenol or a generic equivalent alternating with Motrin or a generic equivalent. There is a risk of overdosing small babies if you only use one medication, but by alternating them you reduce the risk of overdose while maintaining good pain control. The surgeon will direct you in the proper and safe use of pain medication. Fortunately most babies in this age group really do not experience a great deal of pain after Plastibell circumcision with local anesthesia since the technique crushes the nerve endings similar to when you fall asleep on your arm and it goes numb. Only give your son medication as needed. For babies 6-8 months and older, we will give you a prescription for stronger pain medication and give you specific instructions on how to use the medication as needed.

Things to be aware of

All we ask is that you apply a small dab of NEOSPORIN or similar TRIPLE ANTIBIOTIC OINTMENT to the tip of the penis after each diaper change as long as the Plastibell is in place. We will show you how to do this at the end of the procedure. Once it is off no aftercare is required. Please do not use any vaseline or other ointments or creams around the penis. None are required.

FOLLOW-UP

As part of the circumcision process, follow-up is critical to avoid complications later on. The follow-up visit will be scheduled for you at the time the procedure is performed and your son should be seen between 3-4 weeks after the circumcision. The follow-up visit is included in the payment for the circumcision and there are no extra charges. The visit is very brief but critically important. At the follow-up visit, the surgeon will examine the circumcision and show you how to pull the skin back at bath time for a few weeks until all the swelling is gone. Even if you think the circumcision looks fine, it is not unusual to see some of the skin sticking to the head of the penis. Infection may get into the groove and the skin may grow back onto the head of the penis. It is very easy to prevent these conditions if your son is seen at follow-up, but we never want to have to re-operate on one of our patients for a lack of follow-up. Particularly if you have a son with a “buried penis” follow-up is vital to prevent the foreskin shrinking over the head of the penis as it heals. Please make sure you do follow-up. In fact, one of the commonest procedures we do are revisions of circumcisions done by other doctors who did not see the babies back for follow-up.

RISKS AND COMPLICATIONS

Complications of circumcision are uncommon, occurring in less than 0.2% of cases in our practice and most commonly related to a lack of follow-up. The most common complications associated with circumcision are bleeding and local infection. Both of these are lowest after Plastibell circumcision. Follow-up is critical to prevent other complications especially if the remaining foreskin reattaches to the end of the penis. If not pushed back early, this may requiring surgical repair.

Problems from the procedure are rare, but all procedures have some risk like:

  • Infection – the penis will swell up and turn red and may even have some mucus on the tip. THIS IS NORMAL and is not an infection, however, if you are concerned, please call the doctor that did the circumcision rather than go to the ER, although if it is a true emergency, do go to the ER.
  • Bleeding – a little bleeding is not uncommon, but almost always stops. Call the doctor if you are concerned.
  • Reaction to drugs used for anesthesia.
  • You may not be happy with the appearance of penis after circumcision.
  • Damage or Tightening of the tip of the penis (meatal stenosis).
    This is very rare after Plastibell circumcision.

    Factors that may increase the risk of complications include:

  • Bleeding disorders.
  • Family history of bleeding disorders.

EMERGENCIES

For any emergencies related to the penis or circumcision, please call the office directly at any time to connect with the doctor. It is usually better to discuss the condition of concern with the doctor before taking him in to the ER or the family doctor. Pictures may describe your concerns better than words. If you think a picture would help the doctor assess the condition, you can text them to the doctor but be aware that this may affect patient confidentiality and information security since the privacy of such communication cannot be guaranteed. If it appears to be a life-threatening emergency please take your child to the emergency room or call 9-1-1, but also let the doctor know.

CIRCUMCISION IN BOYS OVER 2 YEARS OF AGE AND ADULTS AS WELL AS REVISIONAL SURGERY:

Circumcision in older boys, adults and most revisional surgeries are best done in the operating room under brief general anesthesia where the patient is asleep but unaware and breathing by themselves. These circumcisions are usually performed using a handsewn technique. The redundant foreskin is cut away, bleeding is controlled and stopped with cautery, and the inside and outside layers of the circumcised foreskin is sewn together using thin brown dissolvable sutures that melt away within 1-2 weeks of the surgery. Local anesthetic is injected around the base of the penis while the patient is asleep and an antiseptic ointment and bandage is applied. Complications are no different than described above and aftercare after the surgery is no different than described above. Follow-up at 3-4 weeks is critical.

FEMALE CIRCUMCISION

We do NOT perform any form of female circumcision and do not condone any form of ritual or other non-medically indicated form of female circumcision in any way shape or form on any female irrespective of age.

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CONTACT US

JUPITER LOCATION :

JSAPA
641 University Blvd. Suite 105
Jupiter, FL 33458
Tel: (561) 627-4107

JACKSONVILLE LOCATION:

JSAPA
8833 Perimeter Park Blvd. Suite 202
Jacksonville, FL 32216
Tel: (904) 410-3934