No-Needle Local Anesthesia for Adult Male Circumcision - report

We are planning to do "no needle anaesthesia for adult male circumcision" in future at Thornhill Clinic and Leyton Clinic , London. Please ask for the details from the clinic. We will use "the Comfort-in™ system - compact, spring-powered device"for no needle local anaesthesia for adult male circumcision.

Following report was published in Journal of Urology in 2010

Purpose: We used a local anesthetic jet injection technique for adult male circumcision. This method eliminates needle use and may decrease the fear of local anesthetic injection used for male circumcision.
Materials and Methods: We recruited 60 men seeking voluntary adult male circumcision into the study from June to September 2009. We used a MadaJet® Medical Injector to deliver a high pressure spray of 0.1 ml 2% plain lidocaine solution directly through the penile skin circumferentially around the proximal third of the penis. All men underwent circumcision using the Shang Ring and were evaluated for anesthetic safety, efficacy and acceptability. Pain was measured on a visual analog scale.

Results: The average volume of 2% lidocaine anesthetic solution delivered by jet injection was 0.1 ml with a mean total of 0.9 ml per circumcision procedure. More than 85% of men did not require supplemental anesthesia. Anesthetic onset required approximately 45 seconds from the time that injections were completed. Mean pain scores for immediate postoperative, 24-hour postoperative, ring removal and post-ring removal events were 0.1, 6.8, 2.2 and 0.9, respectively. In 4 patients (6.67%) mild urethral bleeding resolved with pressure, resulting in technique modification.

Conclusions: No-needle jet injection is safe and effective for adult MC. The technique efficiently delivers local anesthesia with rapid onset in men undergoing circumcision. This needle-free approach may enhance the popularity of adult male circumcision


Reference: DOI:

Certificate of Excellence 2018 to Dr. Khan by CEO & Founder of iWantGreatCare

Neil Bacon, MRCP (CEO & Founder iWantGreatCare) has recognised Dr. Khan's feedbacks from patients and parents.  Please see email below from Neil

 "Congratulations, you (Dr. Khan) have been awarded the Certificate of Excellence 2018

I am delighted to contact you with this news, as you are one of only a handful of UK clinicians to receive this powerful endorsement of the way in which you deliver care to all your patients.

Certificates are only awarded to those clinicians whose patients consistently rate them as delivering great care. You truly deserve to be acknowledged for this fantastic achievement.

You will shortly receive your Certificate of Excellence in the post. In the meantime, please click the attached link for more information about your award, what it means and how to share this news.

Thank you for your support and please do contact me directly if you have any questions or ideas about how iWantGreatCare can improve the service provided to all clinicians and patients.

With best wishes,



Neil Bacon, MRCP

CEO & Founder iWantGreatCare "

The Use of Tissue Glue for Circumcision in Children: Systematic Review and Meta-Analysis Published 2018



Tissue glue has been used for circumcision in children with promising results. We aimed to evaluate the efficacy of tissue glue in pediatric circumcision.

Materials and Methods

A systematic review and meta-analysis of the English literature (1997-2017) was conducted according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement on children that underwent circumcision with tissue glue. Meta-analysis was conducted using RevMan 5.3, Comprehensive Meta-Analysis 2 and MedCalc 18. P values < 0.05 were considered significant.


The search returned 15 studies for a total 4567 circumcisions of which 3045 (66%) were performed with tissue glue. Systematic review: Overall complications rates were 4.3% (tissue glue) and 5.9% (sutures). Use of tissue glue was associated with reduced post-operative pain; better cosmetic results and reduced cost. Meta-analysis: There was no difference between the incidence of total post-operative complications (RR 0.86 [CI: 0.62 – 1.19]; p = 0.36]) and wound infection/dehiscence between the two groups (RR 0.95 [CI: 0.59 – 1.56]; p = 0.85). Post-operative bleeding/hematoma formation were reduced with the use of tissue glue (RR 0.55 [CI: 0.32 – 0.95]; p = 0.03). Tissue glue also significantly shorten the operative time (MD -0.22 [CI: -0.39 – -0.05]; p = 0.01).


Incidence of post-operative bleeding/hematoma formation in pediatric circumcision is reduced with the use of tissue glue. Tissue glue has reduced operative time; furthermore, it might be associated with reduced post-operative pain, less overall cost and superior cosmetic results.


circumcision; children; tissue glue


Cosmetic appearance of penis in children before or after circumcision

Before the circumcision in infants and children, every child anatomy is different, and their shape or size of penis and foreskin are also different. Penis is sometimes  rotated, bended  or buried in pubic areas. When  parents arrange a circumcision,  they may have in mind that the child will look like the father or head of the penis may not be completely exposed as religious or cultural requirements, but this is definitely not the case in some children. Children develops differently as well. Degree of buried penis can change as child grows older.

Hypospadias describes an anatomical variant where the wee hole (external mental opening) did not complete its development and did not close fully to the tip of the penis leaving an opening along the underside of the penis. Opening could be present away from tip of the penis to scrotum or perineum. This also requires hypospadias repair under general anaesthesia and the foreskin may be helpful for this purpose, so circumcision must not be done until the hypospadias repair is done. In most of the cases, you can recognise as foreskin is hooded. In some cases, hypospadias may be present on intact foreskin and described as megameastus or glandular hypospadias.  This can only recognised after retracting the foreskin and circumcision should be postponed until hypospadias repair is done. 

Some babies, infants and children have long and skinny penis and others short and fat penis. Some have showed bending to the left or to the right before or after circumcision. Some children penis is buried into the abdominal fat. Some are more bent than others, even more to 90 degrees. This markedly bent penis is described as a penile chordee and requires paediatric urology to straighten, and the foreskin is useful for this procedure in these cases, so should not have circumcision until the corrective operation of penile chordee is done under general anaesthesia in the hospital.

Buried penis is very common now a days. In most of the cases, it is mild form which may not require any further corrective surgery and it is possible to do circumcision. Many boys have loose attachment of the skin to the shaft of the penis. In these children, there may be a high insertion of the scrotal skin along the underside of the shaft of the penis, or there may be a pad of “puppy fat” in front of the pubic bone pushing the skin forward and away from the penis which is anchored at its internal base to the pubic bone. The penis appears to disappear behind the skin, and this is sometimes referred to as the “Disappearing Penis Syndrome”. It is also referred to as a “buried penis”,  "hidden penis" or "inconspicuous penis"

It is primarily an issue of loose attachment of the skin and it is usual for the penis to “reappear” by the time the child is about 1-6 years of age, with the reduction in this pubic fat and the growth of the child. However, some few older children or adults retain this appearance at rest; yet, it looks and performs perfectly adequately in sexual situations.

This anatomical variant, however, causes the parents concern after a circumcision, because as the skin moves forward over the head of the penis, it appears that not enough skin has been removed. This is not the case. The paediatric urologist ( Mr A R Khan) has to estimate the length of skin to leave in order that when the child is grown, there will be enough skin to cover the erect penis and not leave too much area that will be covered by scar tissue. It is only in the infant years, then, that the child may appear to have been inadequately circumcised.

It is very important in such boys, that the parents retract the cut foreskin regularly to prevent the cut edge healing and attaching to the head of the penis after 3 days of separation of the ring circumcision and creating a cosmetic result that is not desired. Therefore, if you notice that the skin of the penis is falling forward covering the head of the penis at any time after the operation, even up to a few years later, ( such that it looks like not enough skin was removed), then please have the child reviewed at our clinic by Dr. Khan. He will explain to you how to manage the skin so as not to form permanent attachments to the head of the penis, and he may have to separate the skin from head (glans) of penis for you at times or referral to the GP for further managamnet at tertiary centre in UK..

 The content on the our website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice from Dr. Khan regarding any medical questions or conditions developed after circumcision.