Fig. 22.28 A clinical photograph showing the foreskin being cut

22.8Complications of Circumcision

•Neonatal circumcision is generally safe when done by an experienced practitioner.

•The most common acute complications are bleeding, infection and the removal of either too much or too little foreskin.

•These complications occur in approximately 0.12 % of procedures.

•Minor complications are reported to occur in 3 % of procedures.

•Complication rates are greater when the procedure is performed by an inexperienced operator, in unsterile conditions, or when the child is at an older age.

•Significant acute complications happen rarely, occurring in about 1 in 500 newborn procedures.

•Severe to catastrophic complications are sufficiently rare that they are reported only as individual case reports.

•Other possible complications include buried penis, chordee, phimosis, skin bridges, urethral fistulas, and meatal stenosis.

•These complications may be avoided with proper technique.

•The circumcision procedure may carry the risks of heightened pain response for newborns and dissatisfaction with the result.

•Newborns that experience pain due to being circumcised have different responses to vaccines given afterwards, with higher pain scores observed.

•There are several complications known to be associated with neonatal circumcision.

•These complications include:

–Bleeding is the most common early complication (Fig. 22.46)

•This is commonly from the frenulum blood vessels but can be also from the cut edges of the foreskin or the dorsal vessels.

•This is usually controlled with local hemostatic measures, such as pressure dressings.

Figs. 22.31 and 22.32 Photographs showing small portable cautery which can be used to control bleeding at the time of circumcision

•Surgicele or other hemostatic agents can be applied also. A small piece of surgicele can be inserted in the grove between the glans penis and the plastibel to control bleeding.

•If these measures fail, the patient must be taken to the operating room for surgical hemostasis and hematoma evacuation.

–Infection is the second most common early postoperative complication, but usually is minor and easily managed with oral and topical antibiotics.

–The most common long-term complication seen after circumcision is meatal stenosis (Figs. 22.47 and 22.48).

•Other complications described include the followings:

–Recurrent phimosis

–Wound separation

–Penile torsion

–Concealed penis (Figs. 22.49 and 22.50)

– Unsatisfactory cosmetic appearance (Figs. 22.51, 22.52, 22.53, and 22.54)

–Skin bridges (Figs. 22.55, 22.56, and 22.57)

–Urinary retention

–Meatitis

–Skin chordee (due to removal of excessive skin) (Fig. 22.58)

–Inclusion cysts

–Retained Plastibel devices (Fig. 22.59)

–Incomplete circumcision (Fig. 22.60)

–Scalded skin syndrome

–Necrotizing fasciitis

–Sepsis

–Meningitis

–Urethral fistula

–Penile necrosis

–Amputation of a portion of the glans penis

–Gangrene of the glans penis (Fig. 22.61)

–Urethral fistula (Fig. 22.62)

•Sexual effects:

–Circumcision does not appear to decrease the sensitivity of the penis, harm sexual function or reduce sexual satisfaction.

–A 2013 systematic review found that circumcision did not appear to adversely affect sexual desire, pain with intercourse,

Fig. 22.35 and 22.36 Clinical photographs showing the plastibel circumcision. Note the plastibel falling down

premature ejaculation, time until ejaculation, erectile dysfunction or difficulties with orgasm.

–Another 2013 systematic review reported no adverse effects of circumcision on sexual function, sensitivity, sensation or satisfaction.

Fig. 22.38 A photograph showing circumplast

•Psychological effects:

–Behavioral effects have been observed following circumcision including changes in sleep patterns, irritability, changes in feeding, and parental bonding.

–Some men who were involuntarily circumcised described their feelings about the procedure using the terms “violation, torture, mutilation and sexual assault”.