Urologic Clinics of North America, Volume 10, Issue 3: Pages 543-549, August 1983.
Circumcision is unquestionably the operation most frequently performed on males in the United States. The exact prevalence of the circumcised state in this country is unknown but must exceed 90 per cent of males based on the incidence of circumcision reported in some newborn series and on the fact that some circumcisions are medically required during childhood and in adult life.5,29,50. It is of interest that neonatal or prophylactic circumcision is much less common in other well-developed Western countries.22,39,43 In as much as there is little difference in medical practice in these various countries, one must assume that there are some cultural differences that cause these disparities. It has been suggested that economic factors may affect the practice of circumcision, but recent studies on parental attitudes would tend to refute this hypothesis.27,54
It is important to review the normal development of the phallus to better understand both the circumcised and uncircumcised state. During the third month of intrauterine development (when the fetus is about 65 mm in size), a fold of skin develops at the base of the glans and begins to grow distally. This fold eventually becomes the prepuce. The dorsal aspect of the fold grows more rapidly than the ventral, so initially only the dorsum is covered. As the glanular urethra closes, so does the ventral prepuce. The resultant ventral fusion of the prepuce is marked by the frenulum. Preputial formation is usually complete by the fifth month of intrauterine life (fetus about 100mm).2 Once the glans is completely covered, the inner surface of the prepuce and epithelium of the glans itself, both of which are stratified squamous in type, fuse. Later in gestation, presumably under the presence of androgens,10 the squamous cells begin to keratinize and to arrange themselves in whorls.16 The whorled cells then degenerate so that clefts appear between the prepuce and the glans. These clefts increase in size and fuse with each other, as a result of which the inner preputial epithelium and the epithelium of the glans eventually are separated one from the other. This separation is usually incomplete at birth and continues through childhood.37 In infants and toddlers a mild, transient inflammatory reaction may occur at somestages of this separation process.
At birth the prepuce is retractable in only 4 per cent of boys. In almost half of newborn boys it cannot be retracted sufficiently to permit one to visualize even the external urethral meatus. By six months of age, the prepuce can be retracted in only 20 per cent of boys; by three years of age 10 per cent of boys still have an unretractable foreskin.37 However, the foreskin is completely retractable in almost all boys by 17 years of age. Complete separation of the foreskin from the underlying glans, even if the prepuce is partially retractable, has occurred in only 37 per cent of six-year-old boys.52 Smegma can be found in the preputial cavity in one per cent of uncircumcised six-year-old boys, but the presence of smegma increases so that it is demonstrable in about 8 per cent of uncircumcised 16-year-old boys.
Because most males in the United States are circumcised, there is little opportunity to observe the natural history of the uncircumcised penis; several errors have crept into American medical practice as a result. For example, if one defines phimosis as only the inability to retract the foreskin, then obviously almost all males have phimosis. However, phimosis as so defined is a physiologic entity is of no pathologic consequence. If instead one were to redefine phimosis as the inability to retract the foreskin which result is balanoposthitis or obstructive uropathy, the incidence of phimosis at birth would be practically nil. Another error occurs when one attempts to examine the uncircumcised penis by drawing the skin of the shaft proximally (toward the penile base; a pinpoint opening is frequently noted, which would lead one to think that there was a true pathologic phimosis. However, if one were to draw the prepuce distally instead, one would see that the preputial opening is quite wide and could in no way interfere with voiding.
Some physicians who have been denied the opportunity to observe the development of the uncircumcised penis are convince that the prepuce must be retractable at an early age. This leads to another error whereby the prepuce is forcibly freed from the glans in infancy.51 This maneuver usually results in pain and bleeding, and occasionally in paraphimosis. Forcibly retraction is completely unnecessary because separation will occur physiologically without such maneuvers. In addition, these manipulations usually are fruitless unless they are repeated because the glans and the prepuce will rapidly adhere to each other if the glans is not sufficiently epithelialized. It cannot be emphasized too strongly that no special care is required for the uncircumcised penis. It is not necessary to retract the prepuce on any routine basis to promote retractability or to hasten physiologic separation. Once the prepuce has separated from the glans, the child should be encouraged to cleanse the area under his prepuce just as he is encouraged to wash behind his ears.
There are definite indications for circumcision but none of these are present in the newborn. True phimosis or paraphimosis are both indications for circumcision;70 however, the physiologic phimosis seen in the newborn and in the infant is not. Recurrent episodes of balanitis, one again, are an indication for circumcision, but posthitis alone is only a relative indication. Mild episodes of posthitis are often seen in infants and toddlers. While the child is in diapers, the prepuce may actually protect the glans from inflammation. In adults, the uncircumcised state is thought to promote the presence of cutaneous yeast but a recent study refutes this.13
Carcinoma of the penis can be largely prevented by neonatal circumcision;39 however the incidence of penile carcinoma in uncircumcised males is extremely low in most Western countries.73 Using a life-table analysis Kochen and McCurdy have estimated the risk in uncircumcised males to be 1 in 600,35 Certainly neonatal circumcision is not totally protective as penile carcinoma has been reported in men who have been known to have been circumcised as infants.9,40 Because circumcision in the newborn is a prophylactic procedure, as one examines the arguments favoring circumcision one must conclude, as did the American Academy of Pediatrics, that "there are no valid medical indications for circumcision in the neonate."67
There are some definite contraindications to newborn circumcision. Any abnormality of the penis, in my opinion, is a definite contraindication until plans for treatment of the abnormality have been formulated. Such abnormalities would include hypospadias, epispadias, megalourethra, webbed penis, and any other condition in which prior circumcision renders treatment more difficult. Despite this, 36 per cent of newborn males with hypospadias were inadvertantly circumcised according to one recent study.23 Another contra-indication is any other illness in the newborn in which good medical judgement indicates that circumcision should be delayed, e.g. prematurity, bleeding diathesis, myelomeningocele, or imperforate anus.
There are many methods of circumcision employed in modern practice. the goal of each is the same: to remove enough shaft skin and inner preputial epithelium that the glans is sufficiently uncovered to prevent or treat phimosis and to render the development of paraphimosis impossible. It is important to understand the principles common to all forms of circumcision in order to prevent complications, regardless of the method employed. Additionally, it is important to recognize the pitfalls of each individual method. Although many of the methods are not employed in urologic practice, I describe them herein because the urologist often will be faced with their complications.
There are four principles common to all forms of circumcision, and it is the compliance with these principles that allows for circumcision without complications. These principles are asepsis, adequate but not excessive excision of outer and inner preputial layers, hemostasis, and cosmesis. Strict asepsis is a principle that is almost uniformly adhered to in theory. However in practice it probably is violated frequently, especially in neonatal circumcision. Because inoculated wounds only occasionally become frankly infected, violation of this principle often results in no harm. The likelihood that adequate amounts of outer and inner preputial layers will be excised varies according to the method chosen. Circumcision methods can be classified into one of four types or combinations thereof: dorsal slit, shield, clamp, and excision.
Dorsal slit is common to many techniques and occasionally is used alone, especially in the presence of acute inflammation. Dorsal slit prevents both phimosis and paraphimosis but usually is cosmetically unacceptable.
A shield is used routinely in ritual circumcision. In this technique the glans is forced down by a grooved shield that is placed over the stretched prepuce. The excess prepuce is excised and hemostasis is secured. The inner preputial layer must then be folded back off the glans to ensure full exposure of the glans after healing. The Mogen clamp uses this principle.
Other clamps have been developed primarily for use in neonatal circumcision.24 The Gomco clamp and the Plastibell are the most widely used. When such clamps are employed, a dorsal slit usually is performed and the glans is freed from the inner preputial lining. A bell is placed over the glans and the prepuce is drawn through a ring. Hemostasis is secured by pressure between the ring and the bell. Excess prepuce is excised and the bell is removed.
Surgical excision can be accomplished either by dorsal slit and excision of all tissue distal to the coronal sulcus or by a sleeve technique in which a sleeve of tissue is removed distal to the corona. These methods are the only ones in which sutures are routinely used to coapt skin edges and ensure primary wound healing.
The exact incidence of complications is unknown. In one series of consecutive circumcisions, 9.5 per cent of patients had repeated circumcisions for inadequately performed initial operations.39 In that same series, 38 per cent of patients sustained complications.39 In three series surveyed retrospectively, the incidence of complications ranged from 1.5 per cent to 5 per cent.21,43 and some patients required readmission to hospital for treatment of their complications or for repeat operations. One per cent of all circumcisions in McCarthy's series required repetition because they were inadequate.43 Additionally, Fredman mentions two deaths as a direct result of sepsis from neonatal circumcision during a 10-year period.22 Deaths under similar circumstances have been noted as isolated case reports elsewhere in the literature12,37,60. Suffice to say that circumcision, like any other surgical procedure, is accompanied by both morbidity and mortality that should be considered when risks and benefits of the operation are discussed.
Bleeding. A complication inherent in any surgical procedure is bleeding. The reported incidence of bleeding after circumcision varies from 0.1 per cent to 35 per cent.21-23,29,55,62 It is most unusual for bleeding to be of significant magnitude to require transfusion. Ancillary pharmacologic means that have been utilized to control bleeding after circumcision include the topical application of thrombin, silver nitrate, or epinephrine,23 as well as the injection of epinephrine into the wound. Epinephrine, if used should be in an extremely dilute solution (e.g., 1:100,000) as it can be absorbed from the open wound and produce marked cardiovascular effects: additionally, more concentrated solutions of epinephrine may produce local tissue ischemia.6
Removal of Tissue. Circumcision lends itself to errors of omission and commission in that both insufficient and excess tissue can be removed. Several different problems may result depending on which combination of circumstances is extant. The simplest problem is cosmetic only. When insufficient skin and inner preputial epithelium are removed and the new preputial orifice does not fibrose, the cosmetic appearance is such that the penis does not appear to have been circumcised.74 Although this result poses no medical threat, the affected individuals parents often are quite upset with the result. In one study, 39 per cent of men who stated that they were circumcised, on examination had had, in the opinion of the examiners, an incomplete circumcision.17
If insufficient skin and insufficient inner preputial epithelium have been removed, and in addition, there is contraction or fibrosis of the preputial ring, true phimosis can be produced. This occurred in 2 per cent of patients in one series.21 This complication often can be severe and may result in urinary obstruction.58
Another variation of these complications of omission and commission is the concealed penis.11,41,62,66,69 In this instance, an excess of skin is removed from the penile shaft while not enough of the inner preputial epithelium has been removed. The new preputial orifice is distal to the tip of the penis and it fibroses so that as healing occurs, the penile shaft is forced into the suprapubic fat and the stenotic preputial ring that results lies at, or just above, the abdominal skin level. If excess skin is excised from the shaft and a proper amount of inner preputial epithelium is excised, the resultant penis may be foreshortened and require skin grafting at a later date.23 If there is sufficient tension on the wound, it may separate.23 In my opinion, the wound is best left to heal by secondary intent as the result usually is cosmetically and functionally normal. However, a short penis may result and, if so, skin grafting may be required as as a secondary procedure.
Prevention of all of these errors of omission and commission is best achieved by marking the site of the corona on the skin surface prior to any incision and by completely freeing the inner preputial epithelium from the glans and thereby visualizing completely the coronal sulcus before before applying any clamp or excising any tissue. Treatment of any problems that result because insufficient prepuce has been excised requires repeat circumcision. When phimosis exists with a concealed penis, the initial incision for this circumcision should be circumferential and at the preputial ring so that the excess inner preputial epithelium can be used in the repair. By using this type of incision rather than a dorsal slit, one may be able to avoid the need to use skin grafts for coverage of the penile shaft.31 In the treatment of those cases in which excess skin has been excised and skin grafts are necessary, the use of free full thickness grafts of hairless skin or split thickness skin grafts68 is preferable to burying the penile shaft in the scrotum or under the abdominal wall with delayed removal71 and use of scrotal skin because the former technique produces superior cosmesis.
Skin Bridge. Another adverse result of circumcision is the formation of a skin bridge between the penile shaft and the glans.34 Smegma often accumulates under those skin bridges. Additionally these bridges may either tether the erect penis, with resultant pain or penile curvature. The treatment of such bridges is simple surgical division. How such problems arise is not completely clear. Some investigators have suggested that injury to the glans at time of circumcision, with resultant fusion to the circumcision wound is the genesis of this problem. In my opinion there must be, in addition, incomplete separation of the inner preputial epithelium at the time of circumcision so that there is firm fusion of skin, inner preputial epithelium, and glans at one point. Later, there is spontaneous separation of the inner preputial epithelium from the glans as normally occurs in the uncircumcised penis, but because one point is fixed to the glans, a skin bridge results. If this thesis is correct, this complication could be avoided by completely freeing the inner preputial epithelium from the glans at the time of circumcision.
Infection. Infections occur after circumcision, as in any surgical procedure. The incidence of infection in one series of neonatal circumcisions was 0.4 per cent,23 while in a series of older boys it was as high as 10 per cent.21 Presumably, most of these infections are minor and of no consequence. However, major morbidity has been reported, including major skin loss,68 necrotizing fascitis,72 staphylococcal scalded skin syndrome,1 Fournier's gangrene,65 generalized sepsis,33 and meningitis.56 Some of these complications have resulted in severe permanent disability or death.12,60
Urinary retention. Urinary retention has been reported following circumcision, usually secondary to a tight circular bandage, and obviously is best treated by removal of the bandage.7,20,23,28,62 In addition, urinary retention secondary to a tight bandage presumably sets the stage for urosepsis in some of the reported cases of systemic infection following circumcision.28,47. When tincture of benzoin is used in or as a dressing for circumcision, it may occlude the urethral meatus and produce urinary retention.31 Hesitancy and dysuria are seen following circumcision in as many as 60 percent of older boys.21
Meatitis. Meatitis or meatal ulcer is a consequence of circumcision that may be considered a complication. The reported incidence of meatitis with or without ulcer varies between 8 and 31 per cent13,37,44,55 and usually occurs later in the first year of life, but while the child is still in diapers.
Meatitis and meatal ulcer are rarely, if ever, seen in the uncircumcised boy. Meatal stenosis is far more common in circumcised adult men than in uncircumcised adult men5 and is believed to result from meatitis in infancy.
Chordee. Chordee can be produced by circumcision, especially if the procedure is performed at the time of acute inflammation.31 This chordee usually is produced by a dense scar on the ventrum of the penis, and a Z-plasty often suffices for its resolution.
Cysts. Inclusion cysts in the circumcision line have been reported.31,62 These presumably are produced by the rolling in of epidermis at the time of circumcision or perhaps by the implantation of smegma in the circumcision wound. Some of these cysts may grow to rather large proportions. Even small cysts can become infected and prove a source of morbidity. The treatment is obviously surgical excision.
Lymphedema. Penile lymphedema may occur following circumcision especially if the wound separates or becomes infected.62 The treatment of this complication must be individualized, but skin grafting may be required for resolution.
Fistulas. Urethrocutaneous fistulas have been reported following circumcision.11,36,38,42,62 Most have occurred with a clamp or a Plastibell type of circumcision, but in many such instances sutures were also utilized in the area of the frenulum for control of hemorrhage. Presumably, these fistulas occur either because the urethra is actually pulled into and crushed by the circumcision clamp or because the urethra is actually incised either with a knife or as suture placed for hemostasis. The prevention of this complication lies in the operators visualizing exactly what is being done in the course of a circumcision. In a few patients an unrecognized congenital megalourethra has been directly incised resulting in fistula.61 Obviously, as was stated earlier, any penile abnormality is reason to delay circumcision; by heeding this caveat one can avoid creating a fistula in the patient with megolourethra.
Necrosis. Necrosis and slough of the glans or even entire penis has been reported following circumcision. Distal ischemia producing such tissue loss may result from infection,15 from the use of solutions containing epinephine, from vigorous attempts at hemostasis with suture or cautery,49 from the prolonged use of a tourniquet, or from a tight bandage.63 Necrosis is particularly likely to result if cautery is applied directly to a circumcision clamp (e.g., the Gomco). When the entire penis is lost following such a misadventure, it usually is best to change the child's sex of rearing to female. Such changes are particularly successful when accomplished before 18 months of age.49 Surgical reconstruction along female lines is far simpler and eminently more satisfactory in such circumstances than is reconstruction of a phallus.
Hypospadias and Epispadias. Both hypospadias and epispadias have inadvertently been produced during circumcision by splitting the glans penis at the time of dorsal or ventral split preparatory to actual excision of the prepuce.46 The operator can prevent this complication by visualizing what is done rather than by performing some aspect of the procedure blindly. On rare occasions the penile or scrotal skin has been inadvertently lacerated.23,47 These lacerations probably result from carelessness but rarely are of any consequence. On occasion, the tip of the glans has been excised, usually when the operator was using a blind technique.
Complications of Plastibell. When the Plastibell is utilized, the ring of the bell may migrate and by pressure necrosis produce a set of problems unique to this technique. If the ring may migrate and by pressure necrosis produce a set of problems unique to this technique. If the ring is too large it may migrate proximally and produce a groove in the shaft itself.14,23,30,45,59,73 To avoid such complications, any retained Plastibell ring should be removed after several days if it has not fallen off spontaneously.
Impotence. Impotence has been reported following circumcision in adults.26,64. In two instances this complication was caused by injection of anesthetic agent into the corpora.53
Psychosocial issues. Circumcision in the adult may precipitate, or be a part of, psychotic delusional behavior.4,19 One may detect such psychiatric problems preoperatively by carefully scrutinizing the motives leading the a.symptomatic adult to seek circumcision.
It recently has been reported that a subset of the homosexual male population is greatly disturbed by the state of being circumcised, to the extent that they have requested and actually have undergone, uncircumcision.48 Just as with undiversion, the trend away from routine neonatal circumcision may result in even fewer uncircumcisions than are currently performed. Uncircumcision is not a new operation but has been present since antiquity, its purpose usually being to obliterate signsof religious identifications.
Anesthetic Complications. Lastly, the anesthetic or lack thereof, may produce complications. General anesthesia led to deaths related to circumcision in at least one study.37 Caudal anesthesia is currently being employed in some centers,32 and its use, like the use of all regional anesthetics has its own inherent complications. When local anesthetic agents are injected into the corpora cavernosa, they can injure the tissues, producing impotence as previously noted.53 Additionally, idiosyncratic reactions and overdosages can occur. Solutions containing epinephrine may produce local tissue problems or systemic toxicity.6 The performance of neonatal circumcision without anesthesia produces decreased Po,2,57 increased serum cortisol, and withdrawal,25 all indirect evidence of pain. Additionally, circumcision without anesthesia in a newborn has precipitated a pneumothorax.3
In summary, there are multiple complications that can occur following circumcision, ranging from the insignificant to the tragic. Virtually all of these complications are preventable with only a modicum of care. Unfortunately, most such complications occur at the hands of inexperienced operators who are neither urologists nor surgeons. However, it usually will fall to the urologist to consult in the management of these complications and to repair such problems as they arise.
For a more recent (1993) survey of circumcision complications see Williams and Kapila.
*Clinical Professor of Surgery/Urology and Pediatrics, School of Medicine, University of California, San Diego and Senior Staff Children's Hospital and Health Center, San Diego, California.
Division of Urology H-897, University Hospital, University of California Medical Center, San Diego, 225 Dickinson Street, San Diego, California 92103
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