To cut or not to cut with anesthesia

Dear Dr. G,

I am the proud father of a five-year-old boy.

As a tradition, all boys in the family were circumcised for hygiene purposes and I think it is time for my boy to have the cut.

However, I remember that I had a really tough time during and after my operation as I could feel every cut during the procedure, which haunts me right up to today.

The pain was particularly bad two weeks after the surgery, especially when I had morning erections.

That said, I think anaesthesia was not offered to me because it was not available back then.

Recently, I took my son to see a doctor who suggested that general anaesthesia be used for safety reasons.

However, my wife and I are a bit doubtful and would like to put Dr. G on the spot for his opinion.

I understand in the United States, most circumcisions are done within a few days of birth without anesthesia. Is that true?

Also, is it true that young children experience no pain at all during the operation?

Lastly, is general anesthesia safe for a five-year old?

I really need your help.

Warmest regards

Painful Pete

A circumcision is the surgical removal of the skin covering the glans of the penis, which has been practiced since ancient times, with an origin in religious rites.

Clearly, no anesthesia was applied in those days but today many parents decide to have their sons circumcised for religious and medical reasons, and the issue of anesthesia for children is often a concern.

Anesthesia was not advocated for infant circumcision, as it was believed the procedure caused little or no pain to the child. It is now known that infants do experience pain, and such experience may interfere with mother-infant interaction and even result in behavioral changes in adulthood. Therefore, the usage of analgesia and anaesthesia is generally encouraged.

“Pain” according to the dictionary is defined as “an unpleasant feeling that is conveyed to the brain by sensory neurons, the discomfort that signals actual or potential injury to the body.” Presumably, pain is part of evolution in order to prevent injury or potential harm from happening to our body.

The interesting question is whether we develop such physiological protection only after we mature into adulthood? Therefore, can we assume children don’t feel pain as much as adults?

With regards to pain, anaesthesia and its usage on infants during circumcision has long been debated and it is known that newborn babies have low pain scores compared to older infants. As such, in view of the pliability and tolerance of newborns, it has been argued that pain reactivity appears to be inhibited during fetal life. This has led to the suggestion that performing any invasive procedure within ninety days after birth will have a minimal impact on the child. The critics often argue it is cruel to put an infant through an operation with no anesthesia, reasoning that newborn babies experience pain but are just unable to convey the displeasure.

The utilization of anesthesia can be applied locally or in a general manner; the injection of lidocaine as a ring or dorsal block is simple and safe, even for premature low birth-weight newborn infants. Additionally, the use of an anesthetic cream on the foreskin before the operation, has also been shown to be effective.

General anaesthesia is another option for parents to consider, as the benefits of a steady child under the knife outweigh the negligible side effects.

Apart from the anesthesia during the circumcision, it is also crucial to ensure post-operative pain is minimized. Paracetamol and non-steroidal anti- inflammatories are generally adequate to manage post-operative pain. However, some children with complications such as bleeding and infection may need stronger painkillers such as opiates.

Despite the benefit and proven safety of anesthesia for infants undergoing a circumcision, a recent study in the United States revealed the non-usage of anesthesia ranges from 54-96%. Another study demonstrated only 71% of pediatricians, 56% of family practitioners and 25% of obstetricians offered anesthesia to infants when discussing the operation.

In conclusion, the poet Maya Angelou once said that “history, despite its wrenching pain, cannot be unlived, but if faced with courage, need not be lived again”. Although the age-old practice of circumcision without anesthesia dates back centuries, the marvel of modern medicine ensures the safety and benefits of such protection of vulnerable infants.

So, Dr. G’s advice is: “Have a heart, don’t let the pain you cause your son come back to haunt you!”