Circumcision For Children
Circumcision is one of the most commonly performed surgical procedures globally, with a history spanning thousands of years. This procedure involves the surgical removal of the foreskin, the retractable fold of skin covering the glans penis, to fully expose the head of the penis. It is typically a quick outpatient procedure, often performed under local anesthesia in infants or with additional sedation in older children, depending on the setting and patient needs.
Globally, the World Health Organization (WHO) estimates that 30-38% of males are circumcised, with significant regional variation. In Asia, circumcision rates differ widely due to cultural and religious influences. For example, in Muslim-majority countries like Indonesia and Malaysia, the prevalence exceeds 90%, driven by Islamic tradition. South Korea stands out with a rate of about 75-80% among younger males (ages 14-29), despite lacking religious roots. In contrast, countries like Japan and Thailand show much lower rates, typically below 10%, as circumcision is not a widespread tradition. In India, the rate varies by community, with Muslims (about 13% of the population) commonly practicing it, while the Hindu majority (around 1-2%) rarely does unless medically indicated.
Medically, circumcision may be recommended to address conditions like recurrent urinary tract infections, phimosis (non-retractable foreskin), or to reduce future risks of certain infections, though decisions often hinge on individual family values.
Why Should Circumcision be Performed?
Circumcision in children is commonly undertaken for medical, religious, or cultural reasons, with decisions often guided by a blend of clinical evidence and personal values.
Medically, the procedure addresses specific conditions that may compromise health or hygiene, while for many families, it fulfills deeply held spiritual or societal traditions.
Medical Indications:
- Phimosis: Phimosis is a condition where the foreskin cannot be retracted over the glans penis. In infants, toddlers, and preschool-aged children, the foreskin is often physiologically non-retractable due to natural adhesions, a normal developmental stage that resolves in most cases. Studies, such as those cited by the American Academy of Pediatrics (AAP), indicate that by adolescence, 98-99% of males can fully retract their foreskin without intervention. However, severe phimosis – characterized by ballooning of the foreskin during urination, pain, or significant hygiene challenges – warrants circumcision. Though rare, affecting less than 1% of boys beyond early childhood, this condition can lead to chronic irritation or infection if untreated, making circumcision a definitive solution.
- Paraphimosis: Paraphimosis occurs when a retracted foreskin cannot be returned to its natural position over the glans, potentially restricting blood flow. This urologic emergency, while uncommon (incidence estimated at <0.1% in uncircumcised males), can lead to ischemia or tissue loss if not addressed promptly. Immediate manual reduction is required, often followed by elective circumcision to prevent recurrence. The procedure eliminates this risk by removing the foreskin entirely.
- Balanitis and Posthitis: Balanitis (inflammation of the glans) and posthitis (inflammation of the foreskin) are infections often linked to poor hygiene or bacterial growth beneath the foreskin. Affecting approximately 3-11% of uncircumcised boys at some point in childhood, these conditions typically resolve with antibiotics, topical treatments, and warm baths. However, in recurrent cases – estimated at 1-2% of affected boys – circumcision is recommended as a preventive measure, significantly reducing reinfection rates.
- Recurrent Urinary Tract Infections (UTIs): Uncircumcised boys face a higher risk of UTIs, particularly in infancy. The AAP reports that uncircumcised male infants have a UTI incidence of 1-2%, up to 10 times higher than the 0.1-0.2% rate in circumcised peers. Repeated infections due to recurrent UTI can cause impaired kidney function. Therefore, in the setting of recurrent UTIs circumcision is justified as it reduces bacterial colonization under the foreskin.
Religious and Cultural Reasons
Beyond medical necessity, circumcision holds profound significance in many traditions. In Judaism, the brit milah – performed on the eighth day of life – symbolizes a covenant with God, rooted in Genesis, and is observed by nearly 100% of Jewish males globally. In Islam, circumcision is a widespread Sunnah, typically performed in childhood, reflecting a tradition of cleanliness and faith. These practices highlight circumcision’s deep cultural and spiritual resonance across communities.
When Should Childhood Circumcision be Avoided?
Circumcision should be avoided in cases of certain medical conditions or anatomical anomalies. These contraindications include prematurity, penile abnormalities such as chordee (curvature of the penis), hypospadias, epispadias, concealed or buried penis, micropenis, webbed penis, and ambiguous genitalia.
Advantages of Childhood Circumcision Over Adult Circumcision
Performing circumcision in childhood offers several potential benefits compared to adulthood, including the following:
- Reduced Risk of UTI: In infancy and childhood, uncircumcised boys face a higher risk of urinary tract infections (UTIs)—1-2% compared to 0.1-0.2% in circumcised peers. Early circumcision can prevent recurrent UTIs, which may lead to complications like renal scarring.
- Lower Complication Rates: Circumcision in infancy or early childhood typically has a lower complication rate (0.2-0.6%) than in adulthood (1-4%) as the procedure is simpler in younger patients due to less developed tissue and smaller anatomy.
- Prevention Over Time: Early circumcision reduces the lifetime risk of penile infections (e.g., balanitis) and, though rare, penile cancer. It also lowers HIV transmission risk by 50-60% in adulthood.
- Faster Healing: Children, especially infants, heal more quickly, typically within 7-10 days as compared to adults, who may need 2-4 weeks. Younger tissues regenerate faster, and there’s less disruption to daily life, with no need to pause work or sexual activity.
How Is Childhood Circumcision Performed?
Childhood circumcision is typically performed using numbing cream and local anesthesia, avoiding the need for general anesthesia. Sedation may be provided to ease anxiety during the procedure. At the Clifford Clinic, two modern techniques are employed: Shang Ring circumcision and Stapler circumcision.
Shang Ring Circumcision
Shang Ring circumcision is a modern, sutureless that has gained popularity due to its safety, effectiveness, and superior cosmetic outcomes. This innovative method utilizes a specialized device, the Shang Ring, which is one of only two circumcision devices to achieve WHO Prequalification. It is also approved by the Health Authority of Singapore, underscoring its reliability and acceptance in medical practice. The Shang Ring offers a streamlined alternative to traditional circumcision, minimizing complications and enhancing patient satisfaction with its clean, aesthetically pleasing results.
The procedure begins with the application of local anesthesia and numbing cream to minimize discomfort. The inner ring of the Shang Ring is placed around the base of the glans penis, followed by the outer ring, which compresses the foreskin between them to prevent bleeding. The excess foreskin is then carefully trimmed away. The device remains in place for 3-4 weeks, allowing the tissue to heal naturally before detaching on its own. This suture-free approach eliminates the need for stitches, resulting in a smooth, healed circumcision with minimal scarring.
Stapler Circumcision
Stapler circumcision is an advanced technique developed by Chinese physicians, offering a streamlined approach to circumcision with notable benefits. This method uses a specialized stapler device, such as the 2nd-generation ZSR stapler, which is approved by the Health Authority of Singapore as a medical device. By simultaneously cutting and sealing the foreskin, the stapler reduces procedure time and enhances patient comfort, making it a promising innovation in circumcision. While still relatively new, its potential to improve outcomes has garnered attention in the medical field.
The Stapler circumcision procedure begins with local anesthesia and numbing cream to ensure minimal discomfort. The stapler device is positioned around the foreskin, allowing the surgeon to cut and seal the tissue in one motion. This process, which takes approximately 10 minutes, eliminates the need for sutures by using specialized staples to secure the trimmed edges. The staples naturally fall off after 1-2 weeks, leaving a clean, aesthetically pleasing result.
How does the above technique compare to conventional surgery?
The table shows a detailed comparison between conventional surgical circumcision and the techniques employed by the Clifford Clinic.
Conventional Circumcision | Shang Ring Circumcision | Stapler Circumcision | |
Anesthesia | General anesthesia would be required. | Local anesthesia and numbing cream | Local anesthesia and numbing cream |
Surgery Duration | 30min to 1hour | 5-10min | 5-10min |
Bleeding | Higher risk of bleeding | Minimal | Minimal |
Stitching required | Yes | No | No |
Pain | 1-2 weeks | ~1 week | ~3-5 days |
What are the potential complications of circumcision?
As with any surgical procedure, circumcision carries potential risks, including:
- Pain and Discomfort: Your child will experience some pain and discomfort after the procedure, this can be managed with regular analgesia.
- Infection: As with any surgical procedure there is a risk of infection at the circumcision site. This can be minimized with proper hygiene and careful post-operative care.
- Bleeding: Minor bleeding is normal, but excessive bleeding, though rare, requires prompt attention. Contact the clinic if this occurs.
What is the recovery like?
Analgesia will be provided post-procedure and should be taken regularly for pain relief. Normal daily activities can resume the next day, but strenuous activities should be avoided for one month. For Shang Ring circumcision, the plastic ring detaches after 2-3 weeks, with a follow-up at one month. For Stapler circumcision, the dressing is removed after 3 days, followed by a one-month review.
Shang Ring Circumcision at The Clifford Clinic
At The Clifford Clinic, the preferred method of circumcision is Shang Ring Circumcision, a modern, sutureless technique designed for minimal discomfort, faster healing, and superior cosmetic results. This innovative method utilizes the Shang Ring device, which has been rigorously tested and is one of only two male circumcision devices that have received WHO Prequalification for safety and efficacy.
Why Choose Shang Ring Circumcision?
Unlike conventional circumcision methods that require stitches, extensive surgical cutting, or long recovery periods, the Shang Ring technique offers a minimally invasive, quick, and virtually painless alternative.
Meet Our Specialised Doctor
Dr. Law Zhi Wei
Dr. Law Zhi Wei is a medical doctor with extensive experience in Shang Ring and ZSR Circumcision, sutureless and minimally invasive circumcision techniques. He graduated from the National University of Singapore with a Bachelor of Medicine and Surgery and later obtained membership in the Royal College of Surgeons (Edinburgh).
During his training in Tan Tock Seng Hospital’s Urology department, Dr. Law performed hundreds of circumcisions, refining his surgical precision and procedural expertise. His medical training also includes rotations in Urology, General Surgery, and Paediatric Surgery at KKH, SGH, and CGH, where he developed strong procedural skills applicable to circumcision and other minor surgical procedures.
His familiarity with Shang Ring Circumcision allows him to perform the procedure efficiently, while prioritizing patient comfort and recovery.
Beyond urological procedures, Dr. Law specialises in aesthetic and dermatological treatments and holds a Postgraduate Diploma in Practical Dermatology from Cardiff University. He regularly attends medical conferences to stay updated on advancements in surgical and aesthetic medicine.
FAQ
We recommend 1-2 weeks off school. Older children who can avoid strenuous activities may return after the Shang Ring or stapler detaches. Hospitalization leave or a memo can be provided for school if needed. Boys should refrain from sports like football, basketball, swimming, or running for 4-6 weeks.
Please call the clinic if you notice:
- Continuous bleeding from the wound.
- A fever of 38°C or higher.
- Persistent yellow fluid or coating on the penis tip after seven days.
- The Shang Ring or stapler not detaching after four weeks.
- Redness and swelling around the penis tip that persists or worsens after 3-5 days.