THE CIRCUMCISION REFERENCE LIBRARY
To the Editor:
The rare complication or urethral obstruction due to ritual circumcision (brit melah), so aptly described by Frand et al.1 is more often seen in Israel in general practice than in hospital practice. During a four-year period in the pediatric department of the same hospital no such complication were seen but subsequently, in 1968 while working in part-time pediatric practice, I saw two such cases. The signs and symptoms were very similar to those described, but very striking and worrisome to the parents was the fact that no urination had occurred since the time of the circumcision. Release of the circular bandage gave dramatic relief of all the sign and symptoms of urinary obstruction.
Weiss in his survey of ritual circumcision revealed that "accidents" frequently occur in the hands of mohalim (performers of ritual circumcision),2 but these are seldom reported in the medical literature or in Jewish sources. Stenosis of the meatus was included among "some recent bad results" that were reported to him.
A popular method of ritual circumcision still in use is the shield magen which, by clamping the prepuce, reduces the vascularity of the area where the incision is made. The natural clotting mechanism and temporary pressure applied in the area by the mohel usually causes adequate hemostasis. The vaseline-coated circular bandage is applied primarily as a protective covering to the circumcised area which remains red and tender for some days. If the infant is a "bleeder," the mohel will tighten this bandage to aid in hemostasis. The mohel is well aware that this bandage can constrict the urethra and will take care to prevent this. Unfortunately, at times this complication does occur. Parents who relate their infant's symptoms to the circumcision usually consult the mohel first, while others will see their pediatrician and some will visit the hospital emergency room.Wulfred Berman, M.D.
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