Circumcision Injuries

Newborn circumcision is the most common surgical procedure performed in the United States. Over 61 % of newborn boys underwent circumcision in 2000 and the incidence continues to increase (Nelson et al. 2005). Although some lay people and professionals alike still question the need for circumcision, it has become apparent that it does afford a number of recognized medical benefits. Firstly, the risk of UTI in male infants is reduced in those who undergo circumcision, from 1 % to 0.1% (Singh-Grewal et al. 2005). Furthermore, boys with recurrent UTIs or identified genitourinary pathol-

Glans Amputation Circumcision

Fig. 8.35. Intraoperative photograph of an 8-day-old the day following partial glans amputation at the time of ritual circumcision. This was successfully reattached and healed without meatal stenosis or urethral fistula

Table 8.5. Potential complications following circumcision

Fig. 8.35. Intraoperative photograph of an 8-day-old the day following partial glans amputation at the time of ritual circumcision. This was successfully reattached and healed without meatal stenosis or urethral fistula ogy such as PUV, high-grade VUR or hydronephrosis, are at an even greater likelihood of risk reduction (Singh-Grewal et al. 2005; Herndon et al. 1999). Sexually transmitted diseases and HIV transmission are also greatly reduced in circumcised men (Baeten et al. 2005). Finally, early circumcision prevents conditions and diseases associated with an intact prepuce such as phimosis, paraphimosis, penile cancer, and recurrent balanitis (Busby and Pettaway 2005; Daling et al. 2005). However, it should not be considered lightly, as increased complications have been noted in children who undergo circumcision by untrained vs licensed practitioners (Aitkeler et al. 2005).

Although the majority of complications are minor, significant morbidity and even death has been reported following circumcision (Sullivan 2002). Strict adherence to technique including sterility, hemostasis, protection of the glans, removal of appropriate amounts of penile and preputial skin, and early recognition of complications will decrease potentially adverse outcomes (Davenport 1996). Complications are best managed by the immediate evaluation and treatment under subspecialist supervision. Bleeding is usually controlled by hematoma evacuation and suture ligation while partial or complete glans amputation requires emergent repair using fine absorbable suture and urinary diversion, if necessary (Fig. 8.35).

Finally, prevention is obviously the best tool to avoid potential complications. Circumcision should be delayed in premature infants or those with severe comor-bid disease or coagulopathy. Additionally, boys with an underlying congenital anomaly of the phallus, such as hypospadias or buried penis, should not undergo circumcision until thoroughly evaluated by a pediatric urologist. Table 8.5 lists acute complications and their respective treatments.

Table 8.5. Potential complications following circumcision

Complication

Treatment

Prevention

Bleeding

Temporary pressure dressing, suture ligation

Careful use of Plastibell devices

Infection

Broad-spectrum antibiotics

Sterile technique, use of antibiotic ointment after circumcision

Amputation

Emergent reattachment

Careful placement of clamp at time of circumcision

Excessive skin loss

Wound care, gradual re-epi-thelization

Careful placement of clamp, appropriate marking of coronal sulcus

Penile necrosis

Conservative treatment, debridement if necessary

Judicious use of cautery

Buried penis

Operative phalloplasty

Recognition of the abnormality, circumcision at time of phalloplasty

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