THE CIRCUMCISION REFERENCE LIBRARY
A case of urethra fistula following
circumcision and its repair are described.
Ramesh D. Limaye, M.D.* and
Reginald A. Hancock, M.D.**
P I T T S B U R G H, P A.
SINCE THE TURN of the century, the operation of circumcision has been performed more and more frequently in the United States. Prior to 1900, an estimated 6.8 per cent of male infants were circumcised.2 This number gradually increased to about 45 per cent through the 1940's2 According to a recent estimate, few male children born in this country are not circumcised during the neonatal period.4
In spite of the high rate of circumcision, complications are uncommon, but include bleeding, infection, and removal of too much skin. Removal of too little skin usually becomes apparent a few years after circumcision; at this stage, the redundant prepuce is thickened, irregular, often adherent to the glans, and cosmetically objectionable to the parents. Injury to the glans penis is uncommon.
Injury to the urethra during circumcision is very rare. Johnson3 reported a case of urethral fistula following circumcision. Byars and Trier1 reported 1 case of complete and 2 cases of partial urethral fistulae occurring following circumcision. A case of subglandular urethral fistula following neonatal circumcision is the basis for this report.
D.S., a 7-year old Caucasian male child, was brought to the Children's Hospital of Pittsburgh for "hypospadias." The parents stated that the child had voided in two streams ever since they remembered. One stream came from the tip of the penis and was directed forward; the other, a little larger, emerged from the under side of the penis and was directed downward. The child had undergone a circumcision on the third day of life. There was no history of any other surgery, injury, or illness. At birth no congenital abnormalities had been noted. The record of the circumcision states, "There was bleeding in the area of the frenum. This was controlled with some difficulty with a suture."
Physical examination revealed a normal male child except for the penis, which had a normally placed urethral meatus and another circular opening about 4 mm. in diameter at the site of the frenum. A probe was easily passed into the fistulous opening from the normal urethral opening (Fig. 1) Laboratory data and an intravenous pyelogram were normal.
A perineal urethrostomy was done. A circular incision was made 3 mm. from the margin of the fistular and a skin cuff raised. The fistula was closed by inverting the margins of this incision. A 1.5 cm. Incision was made on the anterior side of the scrotum and the margins of this were sutured to the margins of the raw area on the penis, in a Cecil fashion urethroplasty. Post-operatively, the child was given sulfsoxazole 0.5 Gm. twice daily The perineal urethrostomy tube was removed on the seventh postoperative day. On the ninth postoperative day the penis separated from the scotum for no apparent reason. The raw area on the under-surface of the penis was covered by a scab. The child was discharged. One month later the fistula was completely healed and the child was voiding in a single stream (Fig. 2).
The rarity of urethral injury during circumcision is probably due to the fact that this structure is situated in the midline ventrally, underlying only a small part of the circular operative field. Urethral injury seems more likely to occur when there is bleeding from the frenum and an attempt is made to control it with a suture. A suture placed too deeply may strangulate a part of the urethral wall, thus leading to the formation of a fistula.
In attempting to repair such a fistula, it should be borne in mind that in a circumcision, little free skin is available, particularly in the area of the frenum. The method chosen for repair should therefore be the safest. Urinary diversion and a repair without tension appear to be desirable. In our patient the fistula healed in spite of an unexpected penoscrotal separation. We believe this complete healing can be attributed only to the safety measures taken during the initial procedure.
From the Department of Urology, University of Pittsburgh Medical Center.
*Present address, Memorial Hospital for cancer and Allied Diseases, New York, N.Y.
**Address for reprints, 501 Jenkins Bldg., Pittsburg, Pa. 15222.
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