How Circumcision Is Done: Newborn and Adult Methods

Circumcision in newborns and adults involves fundamentally different surgical approaches, driven by differences in anatomy, tissue size, and anesthesia requirements. Newborns are almost always circumcised using specialized clamp devices in a procedure that takes just a few minutes, while adults typically undergo a more involved surgical excision under local anesthesia, sometimes with sutures or staples to close the wound. The specific technique matters because it affects procedure time, pain control, complication rates, and cosmetic outcomes.

The Three Clamp Devices Used on Newborns

In clinical settings, neonatal circumcision relies on one of three clamp-based instruments: the Gomco clamp, the Mogen clamp, and the Plastibell device. All three work by crushing the foreskin to stop blood flow before the tissue is cut or allowed to fall off, but each does this differently.

The Gomco clamp uses a bell-shaped metal piece that fits over the glans beneath the foreskin. The foreskin is pulled up over the bell, and a flat plate and clamp mechanism compress the skin against it, cutting off circulation. A scalpel then trims away the crushed tissue. Training programs for the Gomco often use a structured step-by-step checklist because the device involves multiple components that must be assembled correctly.¹

The Mogen clamp is a simpler, reusable stainless steel device that looks a bit like a pair of flat-jawed pliers with a narrow slit. The foreskin is drawn through the slit, the clamp is locked to crush the tissue, and a scalpel cuts along the top. A fresh sterile blade is used for each procedure.² The Mogen tends to be among the fastest of the three devices because its mechanism is straightforward, but proper technique is essential to avoid trapping the glans in the slit.

The Plastibell works on a different principle. A plastic ring is placed over the glans under the foreskin, and a ligature (a string tied tightly around the outside) compresses the foreskin against the ring. The excess foreskin above the tie is trimmed, but the ring stays in place and falls off on its own after several days as the crushed tissue dies and separates. The Plastibell comes in seven sizes, from 1.1 cm to 1.7 cm in diameter, and choosing the right size matters. A ring that is too small can cause tissue death from excessive pressure, while one that is too large can migrate along the shaft or get stuck.³ Serious complications from this device have been linked to a ring that stays on too long and causes pressure damage.⁴

How Newborn Pain Is Managed

Circumcision without any pain relief causes measurable distress in newborns, including elevated heart rate, prolonged crying, and drops in blood oxygen levels. The two most studied interventions are dorsal penile nerve block (an injection of lidocaine at the base of the penis) and EMLA cream (a topical numbing cream applied to the skin beforehand). A Cochrane review of 35 trials involving nearly 2,000 newborns found that neither method eliminates pain completely, but both reduce it significantly compared to no treatment. The nerve block performed better than the cream: compared to placebo, it lowered heart rate by about 35 beats per minute during the procedure and reduced crying time by roughly half. EMLA also helped, cutting heart rate by about 15 beats per minute and reducing crying, but when the two were compared directly, the nerve block came out ahead.⁵

Some practitioners combine a nerve block with oral acetaminophen for longer-lasting relief after the procedure. One trial found that the nerve block gave better pain control during circumcision itself, but both approaches kept pain scores low an hour afterward, suggesting that combining the two could cover the immediate procedure and the recovery window together.⁶

Adult Surgical Techniques

Adults have thicker, more vascularized tissue than newborns, so clamp-only methods are generally not used. Instead, the standard approaches involve cutting and then closing the wound with stitches, staples, or other means. The two classic freehand techniques are the sleeve resection and the dorsal slit.

In a sleeve resection, the surgeon marks two circumferential incision lines on the penile shaft skin and removes the strip of tissue between them as a single “sleeve.” This gives precise control over how much skin is removed and tends to produce a clean, even scar line. Refinements to this method include using a test (sometimes called Horton’s test) to determine exactly where the inner incision should be placed, and using electro-dissection instruments to reduce bleeding.⁷

The dorsal slit method involves making a single cut along the top of the foreskin to open it up, then trimming the excess tissue around the circumference. It is widely used in medical programs across sub-Saharan Africa and other regions where circumcision is offered for HIV prevention. Compared to newer device-based methods, the dorsal slit tends to take longer and is associated with somewhat more bleeding and higher pain scores during the operation.⁸

Device-Based Methods for Adults

Several newer devices aim to simplify adult circumcision and shorten procedure time, which is especially relevant in large-scale public health programs.

The Shang Ring is a disposable device consisting of two concentric plastic rings. The inner ring fits over the glans under the foreskin, the outer ring snaps over it to clamp the foreskin in place, and the excess tissue is trimmed. The ring stays on for a week or more while the wound heals underneath, then it is removed at a follow-up visit. In a proof-of-concept study in Kenya, the average procedure took under five minutes, and ring removal about four minutes. Most men were back at work within two days.⁹ A review of clinical trials across Africa confirmed that the Shang Ring has a safety profile comparable to conventional surgery while offering a procedure time of roughly three to six minutes and eliminating the need for suturing, which makes it easier for non-physician providers to learn and perform.¹⁰ One trade-off is that swelling around the ring can persist for a couple of weeks after the device is removed, though it typically resolves within a month.⁸

Another device gaining use, primarily in China, is the circular stapler. It consists of an inner bell that protects the glans and an outer bell containing a circular blade and a ring of tiny staples. The surgeon places the inner bell under the foreskin, positions the outer bell over it, and triggers the mechanism, which simultaneously cuts the foreskin and staples the wound edges closed. In cases of severe phimosis where the foreskin cannot be retracted, a preliminary dorsal slit is made to position the device correctly.¹¹ The staples are typically removed at a follow-up visit once the wound has healed enough to hold together on its own.

Anesthesia for Adult Circumcision

Adults receive local anesthesia, and the specific technique influences how reliably the procedure stays pain-free. A randomized study of 250 adults compared five different nerve block approaches. The two simplest single-injection techniques had high failure rates, with over 40 out of 50 patients in each group experiencing inadequate numbness. By contrast, a subcutaneous ring block (injecting anesthetic in a ring around the base of the penis) and combination approaches that added frenulum infiltration to a dorsal nerve block had failure rates in the single digits. All five techniques provided similar duration of post-procedure pain relief when they worked.¹²

For men with needle anxiety, a needle-free jet injector (the MadaJet) has been tested as an alternative. It delivers a high-pressure spray of lidocaine directly through the penile skin in a ring pattern around the shaft, avoiding needles entirely.¹³ Researchers have also explored whether lower concentrations of the standard lidocaine-bupivacaine mix can work just as well. A study of over 200 men found that a more diluted mixture actually provided better pain control at 60 minutes post-procedure while using about 70% less lidocaine and 90% less bupivacaine than the standard formula, staying well within safe dosing limits.¹⁴

Wound Closure Alternatives

The traditional approach to closing the circumcision wound in adults is absorbable sutures, either running continuously or placed as individual interrupted stitches. But suturing takes time and leaves marks, so tissue glue (cyanoacrylate) has been studied as an alternative. In one trial, tissue glue cut procedure time by roughly ten minutes compared to sutures (about 14 versus 24 minutes) while producing a cosmetically superior result with no visible suture marks.¹⁵ A separate trial found a similar time savings, with comparable complication rates and better cosmetic appearance in the glue group.¹⁶

However, glue alone may not hold up well in adult tissue, which is under more tension than a child’s. A trial of 2-octyl cyanoacrylate combined with a few interrupted sutures in adults found that while cosmetic satisfaction and procedure time were favorable, wound dehiscence (the edges pulling apart) occurred in half of the glue-plus-suture cases, and the study was stopped early. The authors concluded that this particular combination does not support routine use in adult circumcision.¹⁷ Tissue glue seems to work well for pediatric circumcisions, where wound tension is low, but its role in adults remains limited.

Complications and How They Differ by Age

The most common immediate complication of circumcision at any age is bleeding. In one cohort study, bleeding was the most frequent early problem in both neonates and older children, occurring in about 1 to 3 percent of cases.¹⁸ A separate study of neonatal circumcisions at a dedicated clinic found that roughly 6.5% of patients required sutures for bleeding during the procedure, though serious post-operative bleeding requiring an emergency visit was rare.¹⁹

Age at circumcision significantly affects overall complication risk. A large U.S. study spanning 2001 to 2010 found that the overall adverse event rate was slightly less than half a percent when circumcision was performed in infancy. For boys circumcised between ages one and nine, the complication rate was roughly 20 times higher than for those circumcised before their first birthday. For males circumcised at age ten or older, the rate was about ten-fold higher than the infant baseline.²⁰ The one-to-nine age window being the highest-risk period partly reflects the fact that these children often need general anesthesia and that the tissue is big enough to bleed more than a newborn’s but the child is not cooperative enough for a local-anesthesia approach.

Meatal Stenosis After Newborn Circumcision

The most common late complication following newborn circumcision is meatal stenosis, a narrowing of the urethral opening at the tip of the penis. In one cohort, it was found in about 4% of circumcised neonates on long-term follow-up.¹⁸ The proposed explanation is that after circumcision, the now-exposed urethral opening is subject to irritation from diaper contact and urine, and the frenular artery that supplies blood to that area may be damaged during surgery. Both factors can lead to scarring and narrowing over time.²¹

Interestingly, some cases that look like meatal stenosis turn out to be a ventral web (a small band of tissue that deflects the urine stream upward) rather than a true narrowing. In a series of 13 boys who had been diagnosed with meatal stenosis and scheduled for corrective surgery, examination during the procedure revealed that a small catheter could pass easily through the opening despite its pinpoint appearance. The actual problem was the web, not a blockage.²² This distinction matters because the treatments differ, and true stenosis may be over-diagnosed.

Healing and Recovery Timelines

Newborn circumcision wounds heal quickly, often within a week to ten days, partly because neonatal tissue regenerates rapidly and the wound is small. In the days immediately after, parents typically see some swelling, a yellowish crust at the incision site (which is normal granulation tissue, not infection), and mild fussiness.

Adult healing takes longer and varies by method. A prospective study of wound healing in Kenya found that the forceps-guided surgical method and the Shang Ring had comparable healing times, while the PrePex device (which works by cutting off blood flow and letting tissue die before removal) required a longer healing period because it relies on secondary wound healing, meaning the wound closes from the edges inward rather than from a sutured incision line.²³ Most adult methods require avoiding sexual activity for about six weeks to allow complete healing and reduce infection risk.

Revision Surgery for Unsatisfactory Results

When the initial circumcision leaves an unsatisfactory result, revision surgery can address a range of problems. A study of adult revision cases categorized the most common issues as hypertrophic (raised, thickened) scarring, scar wrinkling, incomplete removal of foreskin, and paraphimosis (foreskin stuck behind the glans). Scar problems were managed by excising the scar tissue, while incomplete circumcisions and paraphimosis were treated by performing a full sleeve resection and removing the old scar at the same time.²⁴

In rare and severe cases, a badly performed circumcision can cause a buried penis, where too much shaft skin is removed and the surrounding tissue contracts to conceal the penile shaft. Reconstructing this requires a multidisciplinary approach: the surgeon releases the buried shaft, anchors the base to the pubic bone for stability, and grafts new skin, sometimes taken from the excised suprapubic tissue, to cover the exposed shaft.²⁵

What Pathologists Find in Removed Foreskin Tissue

When foreskin tissue is sent for pathological analysis after adult circumcision, the most common finding is inflammation, which showed up in about 58% of samples in one review. In that same review, one unsuspected case of squamous cell carcinoma in situ was identified among 147 circumcisions, in a patient who had HIV. The finding was early-stage and would likely have gone undetected without the tissue being examined.²⁶

In children circumcised for a suspected skin condition called lichen sclerosus (a chronic inflammatory disorder that causes whitish, hardened patches on the foreskin), pathology confirms the clinical suspicion about three-quarters of the time. A review of 64 pediatric cases found that the clinical diagnosis was correct in roughly 74% of them.²⁷ Whether routine pathology is worthwhile for every circumcision specimen remains debated, but it can occasionally catch something that no one was looking for.

Sensation and Sexual Function After Circumcision

One of the most common questions men have about circumcision concerns its effect on sexual sensation. A large survey-based study found that men circumcised before puberty and those circumcised later reported somewhat different experiences. Men who were circumcised during adolescence or adulthood reported less sexual pleasure at the glans and were more likely to describe discomfort, pain, or unusual sensations along the penile shaft compared to those circumcised earlier in life.²⁸ This could reflect differences in how the nervous tissue adapts depending on age at surgery, or it could be influenced by the fact that men circumcised as adults have a pre-circumcision baseline to compare against, while those circumcised as infants do not. The evidence in this area is heavily shaped by study design, and self-reported sensation data is inherently difficult to standardize. The research does not paint a clean, universal picture, and anyone weighing this question should expect nuance rather than a definitive answer.