Saudi Journal of Medicine & Medical Sciences | Vol. 2 | Issue 2 | May-Aug 2014 | 86-8986

Complications of Circumcision

Nisar A. Bhat, Hamid Raashid, Kumar A. RashidDepartment of Paediatric Surgery, SKIMS, Soura, Srinager, Jammu and Kashmir, India

Correspondence: Dr. Raashid Hamid, Married Doctors Hostel, A-Block, Room No. S-2, SKIMS, Soura, Srinager - 190 011,Jammu and Kashmir, India. E-mail: drraashidhamid@gmail.com

INTRODUCTION

Circumcision is the most frequently performed elective procedure in males.[1] Approximately one in three men are circumcised globally.[2] Middle East due to its cultural

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DOI:10.4103/1658-631X.136990

A B S T R A C T

Objective: Circumcision is one of the most frequently performed elective procedures in male. In general, post circumcision complications are minor and treatable but complications requiring expert intervention are seen when the circumcision is perrformed by inexperienced/untrained person and in non-sterile setting and inadequate equipments.

Materials and Methods: From March 2008 to May 2012, 59 patients with circumcision related complications were received at age range of 6 months to 5 years with a mean age of 2.4 years. The most common complication was urethra–cutaneous fi stulae in 18 patients, followed by meatal stenosis in 9, bleeding in 6, incomplete circumcision in 6, buried penis in 5, glanular injury in 4, skin bridge in 4, complete amputation of phallus 3, hole in the prepuce in 3 patients and one patient with coronal constriction and fi stula.

Results: Urethral fi stulae were closed in all 18 patients with recurrence in 16%. Two patients with extensive bleeding required blood transfusion and all 6 children required hematoma evacuation under general anesthesia in the operating room. The circumcision was revised in those with an incomplete procedure, a hole in prepuce, burried penis and residual skin bridge. Meatotomy was the procedure of choice in 6 of 9 patients with meatal stenosis, but in the remainder meatal dilatation was efffective. Glanular injuries were managed conservatively. A short residual after glanular injury needed grafting.

Conclusion: Circumcision is considered a simple and minor surgical procedure, yet it needs to be performed competently by only medically qualifi ed and trained personnel and with a great care.

Key words: Circumcision, complications, education and training, personnel

ملخص البحث:تعتبر عملية الختان أكثر العمليات غير الطارئة لدى الذكور. وبشكل عام فإن المضاعفات بعد هذه العلمية قليله ويمكن التعامل معها، ولكن

المضاعفات الخطيرة تحتاج لتدخل الخبراء، خاصة عندما تجرى عملية الختان بواسطة شخص غير مدرب أو قليل التجربة وفي حالة عدم توفر األجهزة المالئمة والمكان المناسب.

تبين هذه الدراسة المستقبلية التي شملت ۹٥ مريًضا، بعض المضاعفات التي حدثت بعد عملية الختان والتي تم التعامل معها جراحيًا. وتخلص هذه الدراسة أن عملية الختان بسيطة ولتالفي المضاعفات الممكنة يجب أن تجرى هذه العلمية بواسطة العاملين المؤهلين والمدربين وبعناية فائقة.

ORIGINAL ARTICLE

and religious settings presently has the largest circumcised population. A number of techniques are used to perform this procedure with an overall complication rate of 2-5% respectively;[3-5] the severe complications are often related to general anesthesia, age at circumcision, and the method used besides the experience of the surgeon. On an average test the common complications of circumcision include; hemorrhage (35%) wound infection (10%), meatal injuries (8-20%), and urinary tract injury (2%). Open wound, insuffi cient removal of foreskin, residual skin bridges, Inclusion cysts, amputations of the glans and body of penis, gross sepsis and buried penis are rarely seen[1,6] [Table 1].

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Bhat, et al.: Complications of circumcision

87Saudi Journal of Medicine & Medical Sciences | Vol. 2 | Issue 2 | May-Aug 2014

MATERIALS AND METHODS

From March 2008 to May 2011, 59 patients with circumcision related complications were referred from peripheral to the Department of Pediatric Surgery a tertiary care center in the region. The age range of these children varied from 6 months to 5 years with a mean of 2.4 years. Most of these procedures were carried out by non-medically trained personnel with suboptimal facilities. However all three patients with phallic loss were operated upon by medically trained personnel. One of the patient had undergone circumcision outside the country, the procedure in the second patient was performed by a medical assistant who applied electric cautery that caused necrosis and sloughing of penis and in the third patient a surgeon at a peripheral hospital applied a very tight dressing to control the bleeding resulting in infection and loss of the penis.

RESULTS

In patients with urethro-cutaneous fi stulae the distal urthra was patent, they underwent repair of the fi stulae with a recurrence rate of 16%. The patients with meatal stenosis were initially dilated over a period, but ultimately all of them required meatotomy due to their late presentation. Blood transfusion was given in 2 of the 6 patients with bleeding, all of whom require emergency evacuation of hematoma and re-suturing of the prepuce. The revised circumcision was enough in all of the patients with inadequate circumcision, buried penis, a hole in the prepuce and skin bridge. Glanular injuries were managed conservatively on indwelling catheters, antibiotics, analgesics and dressings. Patients with the loss of phallus allowed complete healing after which remaining stump 1-2 cms grafted. Table 1 summarizes the management of these patients [Figures 1-5].

DISCUSSION

Circumcision is an old surgical procedure with a history of 15,000 years, and has been performed for 5000 years in South Africa.[1] The proportion of circumcised males varies from place to place according to race, religion, culture, medical reason as well as the choice of the parents in case of children. The Middle East has per capita the most dominant circumcised population where infant and child circumcision is universal,[2] as is our part of world due to its large Muslim population. Potential benefi ts of decreased incidence of urinary tract infection and carcinoma of the penis has been acknowledged by the American Academy of Pediatrics.[3,7,8]

Various methods of circumcision employed in modern practice aim at removal of shaft skin and the inner prepucial epithelium enough to uncover the glans so as to prevent phimosis and the development of paraphimosis. In children, besides the classical surgical methods, three different circumcision clamps; Gomco clamp, Plastibell and Morgan clamps can be used.[9,10] The Gomco clamp is one of the most commonly used instruments for neonatal circumcision in the United States and elsewhere.[11]

In a review article, a total of 1349 published papers were identifi ed, of which 52 studies from 21 countries met the inclusion criteria. The Arab world literature search identifi ed 46 potential relevant papers, of which 6 were included. The median frequency of any complication was 1.5% (range: 0-16%). Only two studies reported severe adverse event with a frequency of 2%. Serious complications include death from excessive bleeding and amputation of glans penis.[12-16] The complications were substantially more common when circumcision had been performed freehand (27% excluding incomplete circumcision) than by using Plastibell (8%) or performed by midwives (19%) than by doctors (7%). Interestingly

Table 1: Complications of circumcisionType of complication No. of patients Circumcisionist ManagementUrethrocutaneous fi stulae 17 13*, 4** Repair (recurrence=3)Meatal stenosis 9 7*, 2** MeatotomyBleeding 6 5*, 1* Evacuation of hematoma (blood transfusion=2)Inadequate circumcision 6 4*, 2** Re-do circumcisionBurried penis 5 4*, 1** Re-do circumcisionGlanular injury 4 3*, 1* Conservative treatmentSkin bridge 4 2*, 2* Re-do circumcisionLoss of phallus 3 3** Grafting of stumpHole in prepuce 3 2*, 1** Re-do circumcisionCoronal constriction with fi stula 1 1* Repair with excision of fi brotic bandSevere wound infection 1 1* Conservative managementTotal no. of patients 59 45*, 14**NMTR – Non-medically trained personnel; MTP – Medically trained personnel

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Saudi Journal of Medicine & Medical Sciences | Vol. 2 | Issue 2 | May-Aug 201488

among doctors, the frequency of complications at University Teaching Hospital was 1.6% compared with 20% at private hospitals.

In 1970, Leitch sustained complication in 38% of his patients.[17] In 2006, an article from Nigeria reported very high complication rate of circumcision in 20.2% and suggested training workshop to retrain all their practitioners of circumcision in the safest available methods.[16] In this geographical area, we do not know the exact incidence of complication rate following circumcision since the minor problems are managed locally and only complications that require specialized treatment are referred to us.

CONCLUSION

In summary, there are multiple complications that can occur after circumcision, ranging from the insignifi cant to the tragic. These complications are commonly seen when the procedure is undertaken by inexperienced operators, in a non-sterile setting and with inadequate equipment. These can be prevented with improved training of providers and provision of sterile equipments.

Figure 1: Total penile necrosis due to application of high voltage electric cautery

Figure 2: Pregangrenous changes in glans penis

Figure 3: Urethrocutaneous fi stula formationFigure 4: Trapped penis

Figure 5: Partially amputated glans

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Bhat, et al.: Complications of circumcision

89Saudi Journal of Medicine & Medical Sciences | Vol. 2 | Issue 2 | May-Aug 2014

How to cite this article: Bhat NA, Raashid H, Rashid KA. Complications of Circumcision. Saudi J Med Med Sci 2014;2:86-9.

Source of Support: Nil, Confl ict of Interest: None declared.

REFERENCES1. Burgu B, Aydogdu O, Tangal S, Soygur T. Circumcision: Pros and

cons. Indian J Urol 2010;26:12-5.

2. Weiss HA, Larke N, Halperin D, Schenker I. Complications of circumcision in male neonates, infants and children: A systematic review. BMC Urol 2010;10:2.

3. Wiswell TE, Tencer HL, Welch CA, Chamberlain JL. Circumcision in children beyond the neonatal period. Pediatrics 1993;92:791-3.

4. Gee WF, Ansell JS. Neonatal circumcision: A ten-year overview: With comparison of the Gomco clamp and the Plastibell device. Pediatrics 1976;58:824-7.

5. Kaplan GW. Complications of circumcision. Urol Clin North Am 1983;10:543-9.

6. Flaherty JA. Circumcision and schizophrenia. J Clin Psychiatry 1980;41:96-8.

7. Pryles CV. Percutaneous bladder aspiration and other methods of urine collection for bacteriologic study. Pediatrics 1965;36:128-31.

8. Circumcision policy statement. American Academy of Pediatrics. Task Force on Circumcision. Pediatrics 1999;103:686-93.

9. Griffi ths DM, Atwell JD, Freeman NV. A prospective survey of the indications and morbidity of circumcision in children. Eur Urol 1985;11:184-7.

10. Baskin LS, Canning DA, Snyder HM, Duckett JW. Treating complications of circumcision. Pediatr Emerg Care 1996;12:62-8.

11. Horowitz M, Gershbein AB. Gomco circumcision: When is it safe? J Pediatr Surg 2001;36:1047-9.

12. Gluckman GR, Stoller ML, Jacobs MM, Kogan BA. Newborn penile glans amputation during circumcision and successful reattachment. J Urol 1995;153:778-9.

13. Shenfeld OZ, Ad-El D. Penile reconstruction after complete glans amputation during ritual circumcision. Harefuah 2000;139:352-4, 407.

14. Ahmed A, Mbibi NH, Dawam D, Kalayi GD. Complications of traditional male circumcision. Ann Trop Paediatr 1999;19:113-7.

15. Strimling BS. Partial amputation of glans penis during Mogen clamp circumcision. Pediatrics 1996;97:906-7.

16. Okeke LI, Asinobi AA, Ikuerowo OS. Epidemiology of complications of male circumcision in Ibadan, Nigeria. BMC Urol 2006;6:21.

17. Leitch IO. Circumcision. A continuing enigma. Aust Paediatr J 1970;6:59-65.

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