Your son is in good hands.

The Plastibell is a well-recognized approach to infant circumcision that has been successfully used since the 1950s. It is safe, simple and produces a consistently high quality, cosmetically satisfactory result. It has the advantages of an even circumcision line, minimal post-operative blood loss and protection of the glans (head of the penis) during the procedure.

Advantages

The advantages of this circumcision method are multiple. For one, the glans is protected from injury due to the plastic ring that is placed during the procedure. Moreover, due to the ligature that is placed around the ring (over the foreskin), hemostasis (control of bleeding) is typically excellent and of minimal concern upon discharge home. Thirdly, the cosmetic result is predictable due to the straight line of the ligature that causes the wound. Once mastered, it is a quick procedure for the physician to perform. Finally, no bandage is required and care and maintenance of the surgical site at home are straightforward. Cosmetically, there is generally no circumcision scar, though as usual with any of the methods, there will be a colour change where the (formerly) inner and outer layers of foreskin meet.

Disadvantages

The major disadvantage I always counsel parents about is that because healing occurs only after the ring falls off, the glans of the penis may swell and cause the plastic ring to become trapped behind it. I have encountered this FOUR times in now over 3000 infants. Each time was due to an infection that required oral antibiotics, close follow up and manual removal of the Plastibell ring by myself. To prevent this from happening, it is so important to keep the area very clean, to allow lots of diaper-free time and to contact my office (phone, email) should you think your son is becoming tender in the area. He truly should not care about his circumcision by the day after his procedure. If you think he is becoming increasingly irritable, this may be an early warning sign that he needs to be re-assessed.

• One study of 2000 Plastibell circumcisions reported a complication rate of 1.8%.

• There also is a report of impetigo caused by Staphylococcus aureus when using the Plastibell.

• There have been a number of cases reported of children developing necrotizing fasciitis following circumcision with the Plastibell method. (I have never seen this.)

• There have been cases of necrosis of the glans penis following circumcision with the Plastibell instrument. (I have yet to see this.)

• The need for blood transfusion has been quoted at a rate of 1 procedure in 30 000. (I have not encountered this.) It is humbly sometimes during a neonatal circumcision that a previously undiagnosed bleeding disorder is discovered.

• Death has been reported as a result of neonatal circumcision but I am aware of no such cases.

There are many reasons to consider circumcision for your newborn son. Some of these are cultural, ethical and religious in nature. There is now also mounting evidence regarding the medical benefits of circumcision. The American Academy of Pediatrics released a statement in September 2012 that the benefits of neonatal circumcision outweigh the potential risks. See Circumcision Policy Statement. Ultimately it is a personal decision based on personal reasons. Once the decision to circumcise has been made, the procedure is best performed by an expert and experienced operator.

Benefits begin in infancy and continue lifelong:

• Easy to care for and to keep clean

• Lower incidence of Urinary Tract Infection (UTI)

• Circumcision lowers the risk of balanitis (yeast infection)

• Avoids the possibility of circumcision at an older age which is more complicated and painful. This occurs in approximately 6% of uncircumcised males for medical reasons such as phimosis, a painful condition where the foreskin becomes tight and non-retractable.

• Circumcision lowers the risk of STDs (sexually transmitted diseases) including HIV (AIDS), HSV (Herpes Simplex Virus), HPV (Human Papilloma Virus) and most others

• Circumcision reduces the risk of cancer of the cervix in the female partners of circumcised males

As with any surgical procedure, the two most common complications are bleeding and infection.

• Bleeding usually amounts to spotting for the first several diaper changes and is usually very minimal. The Plastibell's major advantage is the lower risk of bleeding overall compared to some of the other techniques available. Very rarely, an undiagnosed bleeding disorder will present with excessive bleeding at the time of the procedure. Should there be a family history of bleeding disorders that is known, I would defer the procedure to a hospital-based provider following consultation with a pediatrician.

• Infection is uncommon. With over 3000 procedures performed, I can count on one hand how many infections I have encountered. When an infection does occur, it can look like a more irritable infant accompanied by swelling and tenderness around the site of the Plastibel. A later sign of an infection would present as a Plastibell ring that appears to be constricting your son's penis. This is rare but very important to recognize. It requires careful follow up, oral antibiotics and sometimes manual removal of the Plastibel.

• Cosmetic concerns are possible, but again, not common. These are more likely if the infant has a short penile shaft to start with, or if the infant’s heritage provides him with a darker skin tone, increasing the possibility of keloid (excessive scarring) formation.

• More serious complications are almost unheard of in the hands of an experienced operator.

• I encourage the parents of all of my infant patients to email us with any concerns, send us pictures along with those questions in the days after their son's procedure. My only caveat to this is that should a concern arise on a weekend or holiday, my office nor I will be checking email until the following business day. Should a concern arise over a holiday, I strongly encourage you to go to your local Emergency room. This, over 14 years of performing infant circumcisions, has rarely occurred.

As with any surgical procedure, the 2 most common complications are bleeding and infection. Bleeding usually consists of a few drops of blood during the actual procedure. There may be pinnk noted in the diaper for the first few diaper changes. A red diaper or red thighs would be highly, HIGHLY unusual and if these are noted, you need to bring your infant back to me or to a local emergency room immediately. I can tell you that I have encountered a total of FOUR cases of bleeding of this caliber. All were managed in my office. A couple of these required a suture as part of the process of getting the bleeding managed. Sometimes a drop or two of blood is noted when the plastic ring ultimately falls off. Nothing other than gentle pressure is required in these cases. I have had a total of FOUR infections, requiring oral antibiotic use and manual removal of the plastic ring over a swollen glans. The last time one of my circumcisions became infected was in 2012.

More serious complications are almost unheard of in the hands of an experienced operator.

There is always the possibility of an imperfect cosmetic result, asymmetry of the tissues surrounding the glans or a result that looks different than the infant's brother (s). All boys are born with different shapes and sizes of penises. I do my very best to be as careful and symmetric in my procedures as possible. Even with careful attention to details during the procedure, variations and imperfections are part of the risks of removing tissue from a wiggly, dynamic organ like the penis!

The ideal age is between 2-21 days (0-3 weeks) of age and at most 42 days of age (6 weeks), provided he weighs no more than 12 lbs as we will have difficulty fitting him into the restraint system used. If the baby is unwell, this may require a minor delay until he has recovered. The younger the baby is, the easier it is on him, and the adage “the sooner, the better” certainly applies.

Each baby is different. We try to minimize any trauma and make every effort to keep your son maximally comforted. During the procedure, most babies do not like having their diaper removed and their diaper area wiped/cleaned. Neither do they like being placed in the Velcro arm and leg restraints, but they also do not like being taken out of them after the procedure is complete! Other than this, there is a lot of variability in terms of how each baby responds to the procedure. Most remain awake, with some simply looking around or with their eyes half closed as they suck on their soothers (dipped in sugar water for distraction). Some do in fact sleep through segments of the procedure but this is less common. Afterward, your baby may act very normally, sleeping and feeding as per usual. Some, though, are irritable in the hour or so after the procedure. As a general rule, I find that most babies are largely unaware of any discomfort by the evening of the day the procedure was performed.

• It is thought that a sucrose solution helps to minimize discomfort, so this is routinely used during our procedures.

• I also inject a lidocaine solution in a ring block around your son's penis before beginning.

• 0.5 ml of infant TEMPRA or TYLENOL may be given to your son immediately after the procedure is complete. This dose may be repeated in 4-6 hours. Sometimes, none is needed at all.

Because the surgery is deemed medically unnecessary, it is not covered by OHIP. As of March 1st, 2024, the cost of the procedure is $450 paid in full prior to the procedure.

Well, this is what I was trained in. But I also very much appreciate its advantages and I find that the cosmetic results are superior to results I have seen by other methods. One of the nice things about this technique is the bleeding risk is lower than, say, the Mogen technique. Because the plastic ring placed on your son's penis acts, along with a suture string, as a tourniquet, bleeding is less of a concern both during and after the procedure. We will only see a couple of drops of blood during the procedure and you, as a parent, should never have any active bleeding afterward. The other advantage is that by nature of the Plastibell's design, it is very difficult for me, as the operator, to damage the end of your son's penis. This is a possible risk of other techniques out there.

An adhesion is a scar. In relation to an infant circumcision, adhesions are common and can form in the weeks and months after a baby boy is circumcised. They can form up until toddlerhood. Typically these are tissue connections that develop between newly epithelialized shaft tissue and the now exposed head of the penis. Adhesions are subtle and often missed by anyone who does not routinely perform infant circumcisions. They are a cosmetic issue, not a functional one. Many men are walking around the Earth with penile adhesions they are not even aware of. Because I have performed your son's circumcision, I like to follow up a month after the procedure to assess for the development of these. You are welcome to call us, email us at any time after your child's circumcision and subsequent follow up appointment if you think there is a cosmetic concern that has developed. Adhesions generally are very easy to correct, so long as they are identified early.

Sometimes, a person's anatomy is inherently difficult. Things like a tight scrotum, thick or scarred scrotal skin, deeply located, hard to identify vas deferens make a vasectomy far more challenging and sometimes impossible, even with an open technique used by a urologist. I am usually able to determine whether you are a good candidate for an office-based no scalpel vasectomy by a short physical exam on the day of your consult. Obesity is another risk factor that could negatively impact whether you are a suitable candidate for the no-scalpel approach.