Circumcision removes the foreskin for religious, cultural or medical reasons, in babies, boys and adults. With a trained surgeon and proper pain relief, complications are rare and lowest in the first year of life. This guide covers the reasons, the best age, pain relief, techniques, health effects from the main studies, healing and the short stay in Istanbul.
About This Department
Pediatric Surgery
Circumcision is one of the oldest and most common operations in the world, chosen for religious, cultural and medical reasons. Done by trained hands with proper pain relief, complications are rare, and they are rarest in the first year of life.
Circumcision removes the foreskin, the fold of skin that covers the head of the penis. For many families it is a religious or cultural step, and for others a medical one, to treat a foreskin too tight to pull back, repeated infections or urinary infections linked to kidney reflux. In a review of 1.4 million circumcisions in American medical settings, problems occurred in fewer than 0.5 percent, rising tenfold to twentyfold when the operation was done after infancy. The American Academy of Pediatrics concluded that the health benefits of newborn circumcision outweigh the risks and leaves the decision to parents. Send us your son's age and any medical history, or your own if you are an adult, and a pediatric surgeon or urologist will explain the options and how long to plan.
Under 0.5%
Adverse events in 1.4 million circumcisions
10 to 20 times
Higher complication rate after infancy than before age one
Families come to circumcision for different reasons, and each deserves respect.
Religious and cultural practice, the reason for most circumcisions worldwide.
Phimosis, a foreskin too tight to retract after early childhood, that does not respond to steroid cream.
Repeated balanitis, infection of the head of the penis and foreskin.
Urinary infections in boys with kidney reflux or other urinary tract problems.
Gather accurate, balanced information about benefits and risks.
Make sure the baby is healthy and stable, and that any genital abnormality such as hypospadias has been excluded, since the foreskin may be needed for its repair.
Choose a trained surgeon working with sterile technique.
Insist on effective pain relief, a nerve block or anesthesia, at every age.
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Health effects of circumcision in the main studies
Outcome
Study
Finding
Urinary infection in boys
Meta-analysis of 12 studies, 402,908 children
Risk reduced by close to nine tenths
HIV infection in young men
Randomized trial, South Africa, 3,274 men
60 percent protection
HIV infection in young men
Randomized trial, Kenya, 2,784 men
53 percent reduction, 60 percent adjusted for adherence
Tight foreskin in adolescents and men, including scarring from lichen sclerosus.
Paraphimosis, a retracted foreskin stuck behind the head of the penis, once treated.
Recurrent infections or tears during intercourse.
Age and safety
Why age matters
A large American study of 1,400,920 circumcisions between 2001 and 2010 found adverse events in slightly under 0.5 percent overall. Compared with boys circumcised before their first birthday, boys circumcised between one and nine years had twenty times the rate of probable complications, and those aged ten or older ten times. Older children and adults have more blood vessels in the foreskin, need general anesthesia and heal more slowly.
1
Newborns and young infants
A short procedure under a local nerve block, with a clamp or plastic ring device, and feeding straight afterward.
2
Older boys
Under a short general anesthetic with a nerve block, the foreskin is removed and the edges stitched with dissolving stitches. Home the same day.
3
Adolescents and men
Under local or general anesthesia, the same stitched technique, 30 to 45 minutes, home the same day.
Pain relief
Every child feels pain, including newborns.
The American task force found that sugar water, positioning and cuddling help as additions. Alone they fall short, and the task force recommended a proper anesthetic at every age, a nerve block at the base of the penis in babies and a nerve block with a short general anesthetic in older boys. Given this way, the block keeps the area numb for several hours after the procedure, long enough for the child to feed or eat, sleep and settle at home before ordinary pain relief by mouth takes over for the next two or three days.
Warning signs after circumcision
Bleeding that soaks through a dressing or does not stop with ten minutes of gentle pressure, no urine for more than eight hours in a baby or twelve in an older child, spreading redness, fever or pus need the surgeon the same day.
What the American study found
Of 41 possible problems the researchers examined, 16 were probably related to circumcision. The commonest were a second procedure to complete an incomplete circumcision, at 703 per million, and minor issues such as adhesions. Serious complications were rare. The authors concluded that the overall rate is low, lowest of all in the first year.
Techniques
Clamps and plastic ring devices suit newborns and young infants, whose skin is thin and heals fast. Older children need stitches. From toddler age onward, surgeons prefer the freehand technique with dissolving stitches, which controls bleeding precisely and gives a neat, even line, and laser or thermal devices add nothing to safety, since the experience of the surgeon matters more than the instrument.
Circumcision in adults
Adult circumcision and HIV
Two randomized trials in Africa found that circumcision protected young men against HIV. In South Africa, 3,274 men aged 18 to 24 were randomized, and the trial stopped early when circumcised men had 60 percent fewer infections. In Kenya, 2,784 men had a 53 percent lower risk, 60 percent after adjusting for adherence, and adverse events in 1.5 percent of circumcised men resolved quickly. Circumcision lowers the risk of acquiring HIV through heterosexual sex. It is one layer of protection and never a replacement for condoms.
What does the evidence show?
Large studies, and one balanced conclusion.
The American Academy of Pediatrics review
A task force of pediatricians, family doctors, obstetricians and the Centers for Disease Control and Prevention reviewed the evidence in 2012. They found benefits for the prevention of urinary infections, HIV, some sexually transmitted infections and penile cancer, no adverse effect on sexual function, sensitivity or satisfaction, and rare significant complications. They judged that the benefits outweigh the risks, enough to justify access for families who choose it, without recommending circumcision for every newborn.
Parents, they wrote, should weigh the health benefits and risks against their own religious, cultural and personal preferences, since the medical benefits alone may not decide the matter for every family.
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Probable complications by age at circumcision, 1.4 million procedures
Age at circumcision
Rate compared with under one year
Under 1 year
Reference, lowest
1 to 9 years
20 times higher
10 years or older
10 times higher
Trained hands matter
The task force found that untrained providers have more complications than trained ones, whether they are doctors, nurses or traditional religious providers. Sterile technique, effective pain relief and the skill to manage bleeding or an unusual anatomy are what make circumcision safe.
Urinary infections in boys
A meta-analysis of 402,908 children found circumcision reduced the risk of urinary infection to around a seventh, with the same result in every type of study. For a healthy boy with a one percent risk, 111 circumcisions prevent one infection. For boys with recurrent infections or high-grade reflux, with risks of 10 and 30 percent, the numbers fall to 11 and 4. Bleeding and infection after circumcision occurred in 2 percent, so the authors concluded the clear medical benefit lies in boys at high risk.
What is recovery like, and how long is the stay?
Healing is quick.
Care at home
Petroleum jelly on the dressing or diaper prevents sticking. Baths can start after 24 to 48 hours. Swelling and a yellowish crust on the head of the penis in the first week are normal parts of healing. Paracetamol and ibuprofen control pain. Older boys avoid bicycles and rough play for two weeks, and adults avoid sexual activity for four to six weeks.
Days, cost and the trip
Plan one to three days in Istanbul. Babies and children have the procedure on the first or second day, with a wound check before the family travels. Adults go home the same day and can fly the next, after a short check of the wound and a conversation with the surgeon on care at home, dressings, bathing and the first few days of discomfort, all of which a family or an adult traveling alone handles easily once they know what is normal. Cost depends on the age, the anesthesia and any related procedure. Your own figure follows the free review of your questions.
Our coordinator answers on WhatsApp from the first message and arranges the visa invitation letter ten days ahead, the transfer and a family hotel near the hospital. Both parents can stay with a child until the anesthetic takes effect. The team works in seven languages, halal, vegetarian and diabetic meals are served, and a prayer room is on site. Back home, a photograph sent at one week lets the surgeon confirm healing.
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Healing after circumcision
Time
What to expect
First 2 days
Swelling, a small amount of oozing, dressing or petroleum jelly
Days 3 to 10
Yellowish crust, normal healing, dissolving stitches start to fall
Weeks 2 to 3
Healed in children
Weeks 4 to 6
Healed in adults, sexual activity can resume
Circumcision FAQ
What is the best age for circumcision?
Complications are lowest in the first year of life. They were twenty times higher at one to nine years and ten times higher at ten or older in a study of 1.4 million procedures.
Is circumcision painful for a baby?
Not with proper pain relief. A nerve block or anesthesia is used at every age, and sugar solutions alone are not enough.
Does circumcision have health benefits?
It lowers the risk of urinary infections in boys, HIV in men through heterosexual sex, some sexually transmitted infections and penile cancer, and does not affect sexual function.
Can adults be circumcised?
Yes, under local or general anesthesia as a day case. Healing takes four to six weeks.
How long do we stay in Istanbul?
One to three days, including a wound check before travel.
Can both parents be with the child?
Yes. Both parents can stay until the child is asleep, and one parent stays throughout.
References
American Academy of Pediatrics Task Force on Circumcision. Male circumcision. Pediatrics. 2012;130(3):e756-e785.
El Bcheraoui C, Zhang X, Cooper CS, et al. Rates of adverse events associated with male circumcision in U.S. medical settings, 2001 to 2010. JAMA Pediatrics. 2014;168(7):625-634.
Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Archives of Disease in Childhood. 2005;90(8):853-858.
Auvert B, Taljaard D, Lagarde E, et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Medicine. 2005;2(11):e298.
Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet. 2007;369(9562):643-656.
Editor's note
Written by the Biruni Hospital medical editorial team. Reviewed by Prof. Dr. Hilmi APAK, Pediatric Hematology and Oncology.
