Plastibell Technique – Dr Carolyn Russell

---

One of the most important aspects of operating on an awake newborn is adequate pain relief. The penis can only be rendered completely numb after two local anaesthetic injections are administered – one above and one below the penis. These injections are as painful as those given for immunisation. Dr Russell uses an ultrasound when placing the injection to be confident that the anaesthetic is in the correct location. After waiting for 4-5 minutes ,the local anaesthetic has taken full effect and the penis is numb – the baby can be operated on without further discomfort.

During the operation (which takes 8-10 mins), the plastibell is placed between the foreskin and the head of the penis, protecting the head of penis during the procedure. A surgical string used to secure the plastibell device in the correct position and excess skin is removed. It is the string that gradually works its way through the layers of the foreskin, healing it as it goes. Once the string has completely cut through the layers of the foreskin, the plastibell ring and string will spontaneously separate from the penis and the ring will be found in the nappy.

• Your baby may require panadol for the first 24 hours. Instructions will be given at your appointment.
• At every nappy change for the first three days after the circumcision apply a smear of chloromycetin ointment (provided at the procedure) followed by petroleum jelly to the head of the penis. Petroleum jelly/Vaseline is easy to use if it is first applied to a cotton gauze/ tissue/ flat makeup remover pad then the gauze is placed on the head of the penis on top of the chloromycetin ointment.
• The baby should be given a bath every day from day two – use your usual product in the bath.
• After the first three days, chloromycetin ointment is no longer required – just use petroleum jelly on cotton pads every nappy change until the ring separates and falls off.
  About 36 hours before you find the ring free in the nappy you will notice some swelling and redness around the ring, this is normal and means the ring is about to completely separate.
• When the ring falls off and you find it free in the nappy you need to follow the directions below for the next month. After the ring has fallen off you should use a nappy wipe to push any skin off the head of the penis towards the abdomen. This needs to be done every nappy change for a month. The circumcised newborn penis looks different from an adult circumcised penis. In the newborn, there are three distinct colours. The head of the penis appears deep pink/purple, there is a cuff of shiny pink skin that encircles the base of the head of the penis, and finally the skin coloured shaft skin. With each nappy change, use a nappy wipe to push any pink skin or shaft skin off the head towards the abdomen and ensure you can clearly see each layer. Cover the entire penis with petroleum jelly every nappy change for a month. After this time, just push the skin completely off the penis once a day for the next two months – no petroleum jelly is needed during this time.

Every method of circumcision has risks associated with it. The main risks of the plastibell technique for circumcision are listed below, and in my experience, happen very rarely.

• Bleeding: It is extremely uncommon to have bleeding after leaving the rooms following the procedure. Please contact me directly if you notice any bleeding.
• Infection: Redness and swelling down the shaft of the penis towards the abdomen is also very uncommon and may represent infection. Infection itself is also very uncommon in my practice. Please contact me directly if you are concerned about the appearance of your baby’s penis. I will ask you if it seems painful when touched, if he has a temperature, if his behaviour isn’t normal for him. If I am concerned that he has an infection I will provide a script for antibiotics which will need to be administered as soon as possible.
• Head of the penis impacted/stuck in the ring: It is normal for part of the head of the penis to protrude through the ring. Newborn babies often have erections. Very rarely, the head of the penis protrudes through the ring during the erection and equally uncommonly may become stuck in the ring. The ring may act as a tight band around the penis which may block the flow of urine from the baby. With each nappy change ensure that the nappy is wet and inspect the penis to be sure that only a small portion of the head is poking through the ring and that it doesn’t seem to be “mushrooming” out of the ring. If you have any concerns about the appearance of your son’s penis please contact me directly. The most important aspect of circumcision is the care of the penis for the first month following the procedure – this will prevent almost all complications.

The plastibell system is designed to remove the correct amount of skin. Even so, concerns can arise that not enough skin has been removed. This is usually due to the pubic fat pad that develops at the base of the penis and pushes the shaft skin onto the head of the penis. The fat pad resolves around age 4. This is the best age to assess the length of residual skin and, if necessary, excess skin will be removed under general anaesthetic.

If you have concerns regarding the appearance of your son’s penis, please make an appointment to see Dr Russell.

In the few months following the circumcision, the layers of skin are trying to heal themselves and often the remaining inner layer of the foreskin will reattach to the head of the penis. This can be very easily separated with minor discomfort. Equally, the adhesions will undergo spontaneous separation and some stage in the future.

If you have concerns about adhesions, please contact the rooms for review by Dr Russell or one of our nurses.

A well known complication of newborn circumcision (regardless of method of circumcision) is urethral meatal stenosis – narrowing of the hole at the end of the penis. This is uncommon and usually noticed when the baby/child has an unusually forceful stream of urine. If meatal stenosis is diagnosed, an operation to widen the hole under a general anaesthetic will be arranged. This happens in around one in 1000 circumcisions.

If you have concerns about your son’s urinary stream please make an appointment to see Dr Russell.

One of the most important aspects of operating on an awake newborn is adequate pain relief. The penis can only be rendered completely numb after two local anaesthetic injections are administered – one above and one below the penis. These injections are as painful as those given for immunisation. Dr Dilley uses an ultrasound when placing the injection to be confident that the anaesthetic is in the correct location. After waiting for 4-5 minutes, the local anaesthetic has taken full effect and the penis is numb – the baby can be operated on without further discomfort.

During the operation (which takes approximately 3-4 mins) the foreskin is separated from the head of the penis, the clamp is then placed into position, and the foreskin is removed with a scalpel. A bandage is then applied.

• The morning following the circumcision is when the bandage is to be removed. Once this is done Vaseline is to be applied liberally to the penis each nappy change until the wound is fully healed. This usually takes 7-14 days.
• Your baby can be bathed as per your normal routine e.g. daily or every second day. You can use soap-free baby bath products in the bath.
• Your baby may require panadol in the first 24 hours or so (instructions will be given during your consultation).

Every method of circumcision has risks associated with it. The main post-procedure risks of the Surgical Cut Method are:

• Bleeding: Bleeding can occur during the first day or two. During the consultation, you will be given verbal and written information on what to do if this occurs.
• Infection: Infection can occur during the healing process. This happens in less than 1% of patients – if it does occur an oral antibiotic or ointment may be prescribed. During your consultation, Dr Dilley will discuss signs of infection with you.

The appearance of the penis will change with your son’s body shape. Newborns are often thin and have little fat over the pubic bone. They quickly become good at eating and develop substantial fat deposits, often over the pubic bone, in which case the fat pushes the skin forward along the penis, giving it a buried appearance. This buried appearance usually goes away when the rest of the puppy fat does, at around four years of age. If the penis becomes buried, ensure the penis is ‘popped out’ with each nappy change for cleaning.

Occasionally, the circumcision scar can shrink and trap the head of the penis (pseudophimosis) in the buried position – Dr Dilley can usually relieve this in his office, using a local anaesthetic cream. Often the buried appearance gives parents concern that there may be too much skin present, but this is in fact uncommon – approximately one in 500 boys have additional skin removed by Dr Dilley at a later date at the parents’ request.

If you have concerns regarding the appearance of your son’s penis, please make an appointment to see Dr Dilley.

In the few months following the circumcision, the layers of skin are trying to heal themselves and often the remaining inner layer of the foreskin will reattach to the head of the penis. This can be very easily separated with minor discomfort. Equally, the adhesions will undergo spontaneous separation and some stage in the future.

If you have concerns about adhesions, please contact the rooms for review by Dr Dilley or one of our nurses.

A well-known complication of newborn circumcision (regardless of the method of circumcision) is urethral meatal stenosis – narrowing of the hole at the end of the penis. This is uncommon and usually noticed when the baby/child has an unusually forceful stream of urine. If meatal stenosis is diagnosed, an operation to widen the hole under a general anaesthetic will be arranged. This happens in around one in 1000 circumcisions.

If you have concerns about your son’s urinary stream please make an appointment to see Dr Dilley.