Child Circumcision - Plastibell technique
The Plastibell circumcision device is a clear plastic ring with a deep groove running circumferentially designed for circumcising infant males. It was invented by Hollister Inc in 1950 and first reported on in 1953. The device works by providing a circumferential surface upon which to tie off the foreskin.
It has one of the longest track records of any device for circumcision and an excellent track record for safety.
The GOLD standard technique
We pride ourselves in providing excellent pain relief for babies undergoing circumcision in the form of a Penile Nerve Block using local anaesthetic (LA) infiltration. The penis can only be rendered completely numb after two LA injections are administered – one above and one below the penis at its base. These injections are no more painful to administer than childhood vaccination injections.
A 5-mins wait is mandatory to allow the LA to take full effect and to render the penis fully numb – the baby at this stage can be operated on without any discomfort.
Many clinics will not allow this wait and will proceed to surgery immediately after the LA administration. For the older child, we wait at least 7-8 mins.
During the operation (which takes 5 mins), the plastibell is placed between the foreskin and the head of the penis, protecting the head of the penis during the procedure. A surgical string is 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.
Pro's of the Plastibell
- The glans is protected during the procedure by the ring. Haemostasis (control of bleeding) is effective due to the ligature tie. Cosmetically, a predictable result is obtained due to the straight line of the ligature that causes the wound. It is a quick procedure for the physician to perform — once mastered.
- No bandage is required, allowing easy monitoring for infection.
- Healing occurs while the edges of the prepuce are secured in the ring, making skin bridges (where the foreskin's end heals to the glans' corona) unlikely.
- Cosmetically, there will be little to no circumcision scar, though as usual with any circumcision, there will be a colour change where the (formerly) inner and outer layers of foreskin meet.
Con's of Plastibell
These are very few – the main one that the literature alludes to is the migration of the device. In our clinic, we see this probably no more than once or twice a year. The key is in selecting the correct size Plastibell ring for the child. Older children that have the Plastibell method need monitoring and surveillance, which most clinics DO NOT do. Our routine practice is that anyone over the age of 3 Years will be followed up (FREE of charge).
We are also in the unique position to stock larger-size rings that ‘Plastibell’ do not manufacture. These are used preferentially on older children.
Post procedure care
- Your baby will require basic analgesia for the first 48 hours. Instructions will be given at your appointment.
- At every nappy change from Day 1 to the day the ring comes off apply Petroleum jelly/Vaseline to the front of the nappy.
- We advise that the scrotal skin is covered with a barrier cream such as a nappy rash cream of your choice (eg Sudocream) – this is to protect the scrotal skin.
- Numbing Gel that contains a local anaesthetic will be supplied to use as a topical agent on the head of the penis for pain relief.
- The baby should be given a bath every day from the next day – until the Plastibell ring falls off.
- The Plastibell ring usually takes anywhere from 3 days to 14 days to come off with an average of 7-10 days.
- As you approach ONE week there is some swelling and inflammation of the penis.
- At this point the ring starts to partially separate and will hang on a skin bridge for 1-2 days before the entire ring falls off.
- Once the ring comes off, you will notice that the surgical wound is not healed yet and there may be some ‘white’ or ‘yellowish’ exudate on the wound. This is all normal and will take a further two weeks to heal fully.
Long term concerns
Not enough skin removed
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 supra-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.
Adhesions
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.
Meatal Stenosis
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 may be necessary and this will need to be arranged through a GP referral through the NHS. This happens in around one in 1000 circumcisions. I have not seen this in my practice although the literature does cite it.
Procedures for children
Plastibell Technique
The Plastibell device is used as our 1st choice device for infant circumcisions. We have a 20 Year history of using this device with minimal to no complications. We are in a unique position where we stock larger size rings for the older child that other clinics will often not stock.
Circumplast
A relatively new device with little track or no track record. The range of sizes available is very limited and does not offer the full range of sizes to undertake safe circumcisions in this age group. The manufacturers of this device make strong claims about this device but these are not borne out in my experience who has been undertaking high-volume circumcisions for nearly 20 years. We, therefore, do not offer this technique. For older children, we have the Stapling device which is now the GOLD standard for that age group.