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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 2  |  Issue : 2  |  Page : 86-89

Complications of Circumcision


Department of Paediatric Surgery, SKIMS, Soura, Srinager, Jammu and Kashmir, India

Date of Web Publication18-Jul-2014

Correspondence Address:
Hamid Raashid
Married Doctors Hostel, A-Block, Room No. S-2, SKIMS, Soura, Srinager - 190 011, Jammu and Kashmir
India
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DOI: 10.4103/1658-631X.136990

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  Abstract 

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 fistulae 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 fistula.
Results: Urethral fistulae 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 qualified and trained personnel and with a great care.

  Abstract in Arabic 

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 الأجهزة الملائمة والمكان المناسب.
تبين هذه الدراسة المستقبلية التي شملت 59 مريضًا، بعض المضاعفات التي حدثت بعد عملية الختان والتي تم التعامل معها جراحيًا.
وتخلص هذه الدراسة أن عملية الختان بسيطة ولتلافي المضاعفات الممكنة يجب أن تجرى هذه العلمية بواسطة العاملين المؤهلين والمدربين وبعناية فائقة.

Keywords: Circumcision, complications, education and training, personnel


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

How to cite this URL:
Bhat NA, Raashid H, Rashid KA. Complications of Circumcision. Saudi J Med Med Sci [serial online] 2014 [cited 2017 Mar 26];2:86-9. Available from: http://www.sjmms.net/text.asp?2014/2/2/86/136990


  Introduction Top


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 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],[4],[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, insufficient 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].
Table 1: Complications of circumcision

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  Materials and methods Top


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 Top


In patients with urethro-cutaneous fistulae the distal urthra was patent, they underwent repair of the fistulae 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 [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5].
Figure 1: Total penile necrosis due to application of high voltage electric cautery

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Figure 2: Pregangrenous changes in glans penis

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Figure 3: Urethrocutaneous fi stula formation

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Figure 4: Trapped penis

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Figure 5: Partially amputated glans

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  Discussion Top


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 benefits 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 identified, of which 52 studies from 21 countries met the inclusion criteria. The Arab world literature search identified 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],[13],[14],[15],[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 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 Top


In summary, there are multiple complications that can occur after circumcision, ranging from the insignificant 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.

 
  References Top

1.Burgu B, Aydogdu O, Tangal S, Soygur T. Circumcision: Pros and cons. Indian J Urol 2010;26:12-5.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
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.  Back to cited text no. 2
    
3.Wiswell TE, Tencer HL, Welch CA, Chamberlain JL. Circumcision in children beyond the neonatal period. Pediatrics 1993;92:791-3.  Back to cited text no. 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.  Back to cited text no. 4
[PUBMED]    
5.Kaplan GW. Complications of circumcision. Urol Clin North Am 1983;10:543-9.  Back to cited text no. 5
[PUBMED]    
6.Flaherty JA. Circumcision and schizophrenia. J Clin Psychiatry 1980;41:96-8.  Back to cited text no. 6
[PUBMED]    
7.Pryles CV. Percutaneous bladder aspiration and other methods of urine collection for bacteriologic study. Pediatrics 1965;36:128-31.  Back to cited text no. 7
    
8.Circumcision policy statement. American Academy of Pediatrics. Task Force on Circumcision. Pediatrics 1999;103:686-93.  Back to cited text no. 8
[PUBMED]    
9.Griffiths DM, Atwell JD, Freeman NV. A prospective survey of the indications and morbidity of circumcision in children. Eur Urol 1985;11:184-7.  Back to cited text no. 9
[PUBMED]    
10.Baskin LS, Canning DA, Snyder HM, Duckett JW. Treating complications of circumcision. Pediatr Emerg Care 1996;12:62-8.  Back to cited text no. 10
    
11.Horowitz M, Gershbein AB. Gomco circumcision: When is it safe? J Pediatr Surg 2001;36:1047-9.  Back to cited text no. 11
    
12.Gluckman GR, Stoller ML, Jacobs MM, Kogan BA. Newborn penile glans amputation during circumcision and successful reattachment. J Urol 1995;153:778-9.  Back to cited text no. 12
    
13.Shenfeld OZ, Ad-El D. Penile reconstruction after complete glans amputation during ritual circumcision. Harefuah 2000;139:352-4, 407.  Back to cited text no. 13
    
14.Ahmed A, Mbibi NH, Dawam D, Kalayi GD. Complications of traditional male circumcision. Ann Trop Paediatr 1999;19:113-7.  Back to cited text no. 14
    
15.Strimling BS. Partial amputation of glans penis during Mogen clamp circumcision. Pediatrics 1996;97:906-7.  Back to cited text no. 15
[PUBMED]    
16.Okeke LI, Asinobi AA, Ikuerowo OS. Epidemiology of complications of male circumcision in Ibadan, Nigeria. BMC Urol 2006;6:21.  Back to cited text no. 16
    
17.Leitch IO. Circumcision. A continuing enigma. Aust Paediatr J 1970;6:59-65  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]



 

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