Complications of circumcision

INTRODUCTION — Circumcision in the male refers to the surgical removal of the foreskin (ie, prepuce) of the penis. The procedure is centuries old and continues to be performed for a variety of religious, cultural, and medical reasons. Debate continues as to the utility of circumcision. The 2012 American Academy of Pediatrics policy statement regarding newborn circumcision states that "preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure" but did not recommend it for all newborns, instead leaving the decision to the infant's caregivers [1].

Careful, meticulous attention to penile anatomy (figure 1) and the correct use of surgical equipment by trained clinicians can prevent most complications from circumcision. Most of these problems are readily treatable and cause no long-term effects. However, when complications occur, especially surgical complications, specialist referral may be required for evaluation and reoperation.

Complications of circumcision and their management will be reviewed here. Circumcision technique and its risks and benefits are discussed separately. (See "Neonatal circumcision: Techniques" and "Neonatal circumcision: Risks and benefits".)

FREQUENCY OF COMPLICATIONS — The rate of procedure-related complications during and after circumcision in the neonate is approximately 2 to 6 per 1000 [2-4]. This rate increases 20-fold for those who are circumcised between one and nine years of age and 10-fold for those circumcised after 10 years of age [3]. Inadequate training of clinicians contributes to complications as practitioners without formal training may not recognize congenital malformations (eg, congenital buried penis (picture 1) and penoscrotal webbing (picture 2)) that are more likely to result in poor results when using routine conventional methods [5]. Patients with these abnormalities should be referred to a pediatric urologist.

The most common complications of male circumcision are bleeding and local infection [2,6,7], followed by unsatisfactory cosmetic results (too little or too much skin removed) and surgical trauma or injury. Rare but significant complications include life-threatening sepsis and meningitis, buried penis due to cicatrix formation, amputation of the glans, and necrotizing fasciitis [7-9]. In a retrospective study at one institution, multivariant analysis identified birth weight >5.1 kg as a risk factor for bleeding requiring sutures and adhesions [10].

These points were supported by a large study that compared complication rates among 136,000 circumcised and uncircumcised male infants [2]. The frequency of complications and genitourinary problems during the first month of life among circumcised neonates was 0.19 percent, a figure comparable to the 0.24 percent rate of urinary tract infections (UTIs) in uncircumcised neonates. The benefit of circumcision in reducing UTI is discussed separately. (See "Neonatal circumcision: Risks and benefits", section on 'Reduction in urinary tract infection'.)

The following circumcision complications were noted in the 100,157 circumcised patients:

●Bleeding – 83 cases, including 31 patients who required ligature to stop the hemorrhage and 3 requiring transfusion

●Local infection – 62 cases

●Surgical trauma/injury – 25 cases

●UTIs – 20 cases

●Bacteremia – 8 cases

MEDICAL COMPLICATIONS

Bleeding — Bleeding is the most frequent complication following circumcision [2,11,12]. It occurs from injury either to the frenular artery or dermal cut edges. The risk of severe bleeding is higher if there is an underlying coagulopathy. Therefore, neonatal petechiae or a family history of bleeding diathesis should prompt further evaluation before the procedure is undertaken. (See "Treatment of bleeding and perioperative management in hemophilia A and B".)

There appears to be no difference in the risk of bleeding based on the technique chosen to perform the circumcision. This was illustrated in a randomized trial between Plastibell device circumcision and traditional sleeve technique circumcision that did not find any significant differences in hemorrhage rate [13]. Some authors have reported that a worn Gomco clamp may predispose the infant to bleeding after circumcision due to inadequate crushing mechanisms. Therefore, the Gomco clamp should be carefully checked prior to each circumcision to ensure that there is no visible light between the bell and baseplate and no stripped threads and screws [11]. There should be a minimum distance of 0.085 inches between the arm and the base plate prior to tightening. (See "Neonatal circumcision: Techniques", section on 'Techniques'.)

Most commonly, bleeding after circumcision is a technical issue. Hemostasis is typically achieved by manual pressure. In cases with modest and/or persistent bleeding, a compressive wrap and topical hemostatic agents are used. For infants with excessive persistent bleeding, fine absorbable sutures are used. For any of the hemostatic methods, cautions should be used in the region over the urethra to prevent inadvertent injury to the urethra. (See "Neonatal circumcision: Techniques", section on 'Hemostasis'.)

If these hemostatic maneuvers fail, a pediatric urology consult should be requested as formal operative exploration may be required. In addition, or if the bleeding seems to be generalized, the patient should be evaluated for a coagulopathy, including a complete blood count, platelet count, prothrombin time, activated partial thromboplastin time, and fibrinogen level, which will detect most of the major bleeding disorders. (See "Approach to the child with bleeding symptoms", section on 'Diagnostic approach'.)

Infection — Wound infection infrequently occurs after circumcision [2,7]. It is usually mild and manifested by local inflammatory changes, which typically resolve with local topical triple antibiotic ointment [11,14]. However, ulceration, suppuration, and systemic infection (eg, sepsis and meningitis) can occur and may be associated with systemic symptoms, such as fever, irritability, lethargy, or poor feeding [7-9]. These cases require systemic antibiotics and surgical debridement.

Urinary tract infection (UTI) is not a complication of circumcision, but, rather, a reduced risk of UTI is a benefit of circumcision. A UTI can occur in circumcised male infants, although the frequency of UTI is significantly lower in circumcised infants compared with uncircumcised infants (0.02 versus 0.19 percent) [2]. (See "Urinary tract infections in children: Epidemiology and risk factors", section on 'Lack of circumcision'.)

SURGICAL COMPLICATIONS — Surgical complications include the following, some of which may require reoperation [15,16]:

●Urethral injuries

●Glans injury

●Removal of excessive skin

●Inadequate skin removal

●Epidermal inclusion cyst

●Abnormal scarring, resulting in adhesions, cicatrix, or penile curvature

●Anesthetic complications

Urethral complications — Urethral injury can occur if too much upward traction is placed on the foreskin prior to clamp application as it can cause entrapment of the glans in the clamp, possibly from incomplete separation of the glans or distal shaft skin from the inner prepuce.

Urethrocutaneous fistulas — Although urethrocutaneous fistula is most frequently associated with hypospadias correction, it may occur as a complication of circumcision (picture 3). If the skin at the coronal or distal penile shaft is inadvertently crushed in the Gomco clamp, this can cause an ischemic injury resulting in an urethrocutaneous fistula at the coronal margin (picture 3). This can be distinguished from hypospadias in that, with a fistula from circumcision injury, the glans is normal like with a conical shape and the meatus slit like with a normal caliber (approximately 12 French). To prevent urethral injury, the coronal sulcus should be clearly delineated prior to commencement of the circumcision and the Gomco clamp should be properly sized for the penis. (See "Neonatal circumcision: Techniques", section on 'Gomco clamp'.)

If urethral injury is suspected and the circumcision has not been completed at the time of injury, any prepuce should be left attached until the consultation as this tissue may be useful in the repair of the urethra. Circumcision fistula injury correction requires a second operation performed greater than six months after the initial procedure. These repairs are generally cosmetically and functionally successful [17].

Meatal stenosis — Urethral meatal stenosis is almost always a condition of circumcised males and is rare in uncircumcised individuals. It is thought that stenosis develops from irritation of the newly exposed meatus, which usually occurs on the ventral lip [11,14].

Typical presentations occur after toilet training and include an upward deflected urine stream, inability to direct the stream into the toilet, or small stream with prolonged voiding time. Often, males will push their penis between their legs to direct the upward-pointed urinary stream into the toilet. Other less common presentations include episodes of gross hematuria, dysuria, and urinary infection.

A typical appearance is scarring on the ventral aspect of the meatus (picture 4); however, visual inspection of the meatus alone does not make the diagnosis. These patients should seek an outpatient consultation with a pediatric urologist for further evaluation, including direct observation of voiding.

Treatment involves office or operating room meatotomy, where a few millimeters of the ventral lip of the meatus are divided. Sutures are then usually used to reapproximate the cut edges.

Glans injury — Glans injury, including penile amputation, can occur if the glans is inadequately protected at the time the foreskin is excised or if the glans is caught in the clamp apparatus when the foreskin is excised. These injuries have been described with Sheldon clamps [18] and Mogen clamps [19]. Gomco clamps and Plastibell devices should theoretically protect the glans via the bell attachment; however, such injuries can still occur if the bell is ill fitting or displaced or if the incision is made at the incorrect location on the device.

If the glans is amputated, the tissue should be wrapped in saline-soaked gauze and placed indirectly on ice for transport. The patient should be transferred immediately to a referral center as successful reattachment is possible if performed within eight hours of injury (picture 5) [14,18,19].

In utero tourniquet injury (presumed from hair) may also occur, leaving a permanent groove on the glans. In mild cases where urethra and corpora cavernosa are not injured, conservative management may be possible (picture 6).

Another possible mechanism of glans injury can occur with necrosis of the glans secondary to ischemia from a slipped Plastibell device ring. The Plastibell ring should ordinarily sit over the glans for approximately one week until excess skin sloughs and the ring falls off. If the ring is oversized, it can slip proximal to the glans onto the penile shaft, where it can cause constriction. If it cannot be removed easily, ring cutters found in emergency departments can be employed to cut the Plastibell ring off.

The glans can also be injured when electrocautery is used. Thermal injuries can cause devastating, irreversible destruction that can leave the penis unsalvageable [20]. For this reason, electrocautery should be used judiciously by experienced clinicians only or not at all.

Excessive skin removal — Too much penile shaft skin can be removed if upward traction on the prepuce is overly aggressive prior to excision or if the glans is inadequately separated from the inner prepuce (picture 7). Excessive skin removal may result in a denuded penile shaft (picture 8 and picture 5).

In many cases, conservative therapy consisting of wet to dry or antibiotic ointment dressings results in adequate healing by secondary intention [11,14].

More severe cases require pediatric urology referral. If primary reapproximation is to be attempted, it is imperative that the length of skin prior to closure is adequate for function including erection. If adequate inner prepuce is left, this can be primarily sutured to the penile shaft skin to provide coverage. This method will leave the penis with the slightly altered appearance inherent with inner preputial skin. For cases with inadequate skin for reapproximation, healing by secondary intention with local care with petroleum jelly may suffice. In rare cases, full-thickness skin grafting is performed [21].

Too little skin removed — If insufficient foreskin is removed, the penis may not appear to be circumcised or the result may appear asymmetric (picture 9), leading to a displeasing cosmetic appearance [11]. These cases should be referred to a pediatric urologist for further consultation to determine the need for circumcision revision, which is not usually medically mandated. At that time, the risks of a reoperation, including anesthetic sequelae, need to be weighed against the benefits of improved cosmetic appearance.

Epidermal inclusion cyst — Epidermal inclusion cyst occurs when an island of skin is left to heal underneath the skin of the penile shaft. Cysts usually are diagnosed by physical examination. Treatment consists of formal excision of the entire cyst (picture 10).

Scarring complications

Minor adhesions — Minor adhesions are commonly found after circumcisions [22] and consist of tiny areas of fusion between the foreskin and corona (picture 7). These adhesions usually resolve spontaneously with time [23]. If guardians or practitioners desire more rapid resolution, gentle retraction can be used to lyse the adhesion, followed by application of topical petroleum jelly or antibiotic ointment for one week to prevent new adhesions from developing. Alternatively, for those who do not want spontaneous resolution or manual retraction, betamethasone 0.05% ointment or other steroid creams, which are used to treat adhesions in patients with phimosis [24], may be tried but usually are not successful [25].

Most minor adhesions can be prevented by instructing the caregivers to retract and clean any skin covering the glans, beginning a day or two after circumcision when acute bleeding is unlikely and keratinization of the glans has begun.

Skin bridges — More complex fusion where the foreskin adheres higher up on the glans may result in dense adhesions, referred to as skin bridges (picture 11). As opposed to minor adhesions, skin bridges cannot be lysed with manual retraction or medicine but must be cut sharply to resolve.

Skin bridges can be visually displeasing and cause tethering of the penis. Children should be referred to a pediatric urologist for possible lysis of adhesions via scalpel after the application of a topical anesthetic [11,14]. This procedure may be performed in the office or in the operating room.

Cicatrix — A cicatrix is a circumferential scar that usually develops at the incision line. It is commonly associated with a hidden penis, in which the scar prevents the penis from being exposed (picture 12). Over time, this can result in trapping of urine, which causes more inflammation and worsening of the scar. In cases with a trapped penis by a cicatrix, outpatient referral to a pediatric urologist is necessary for assessment and intervention. Revision involves excision of the scar, with the use of excess coronal (inner preputial) skin to cover the defect and, in the rare case, skin flaps [14,26]. Topical steroid cream can sometimes play a role in less severe cases, especially if started within weeks of the circumcision [27].

Hidden penis due to a cicatrix needs to be distinguished from that commonly seen in overweight males with a large suprapubic fat pad. In overweight patients without any underlying pathology, the penis can be expressed simply by pushing under the pubic bone (picture 13). Circumcision in obese children or those with a relatively small phallus is generally discouraged during infancy because of the tendency for the penis to become buried [11,28]. If circumcision is performed, care must be taken to ensure that the caregivers expose the penis once or twice a day with application of antibiotic ointment until healing resolves to prevent cicatrix development.

Keloid — Keloids occur with excessive collagen disposition during scar healing (picture 14). Keloid formation is a rare but distressing complication of penile surgery, including circumcision. Surgical technique as well as genetic predisposition influence the development of this condition. The most common treatment options are topical application or intralesional injection of steroids, pressure therapy, and silicone sheets [29]. Because recurrence rates are high, proper technique in excision of the lesion and postoperative care are essential.

Skin pigment changes — A small fraction of patients may experience changes to the skin pigment, such as hyperpigmentation, hypopigmentation, or freckling. Surgical technique, as well as underlying predisposition, can influence the incidence of these complications. Tight postoperative dressings, bleeding, infection, and use of povidone-iodine preoperative cleansing may also influence the development of skin changes. Most commonly, a hyperpigmented scar can occur (picture 15). More cosmetically distressing lesions are also possible. Management may include reassurance, steroid creams, laser, or surgical resection, depending on the nature and severity of the pigment changes.

Anesthetic complications — In the United States, most neonatal circumcisions are performed in the nursery and not in an operating room setting. In this setting, the most commonly used anesthetics include penile nerve blocks and topical anesthesia. These analgesic measures and their potential complications are discussed separately. (See "Neonatal circumcision: Techniques", section on 'Pain control'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Neonatal circumcision".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Should I have my baby circumcised? (The Basics)")

●Beyond the Basics topic (see "Patient education: Circumcision in baby boys (Beyond the Basics)")

SUMMARY

●Frequency of complications – Circumcision is the most common surgery performed in the United States, and careful attention to penile anatomy (figure 1) and correct use of surgical equipment by trained clinicians can prevent most complications. The rate of procedure-related complications during and after circumcision is approximately 2 to 5 per 1000 cases. Most complications are readily treatable and cause no long-term effects, although some may require specialist referral. (See 'Frequency of complications' above.)

●Medical complications – The most common complications associated with circumcision are bleeding and infection. (See 'Medical complications' above.)

●Surgical complications – Surgical complications are less common and include the following:

•Urethral complications, including urethrocutaneous fistulas and urethral meatal stenosis (picture 3) (see 'Urethral complications' above)

•Glans injury including penile amputation (picture 5) (see 'Glans injury' above)

•Removal of excessive skin that may result in a denuded penile shaft (picture 8) (see 'Excessive skin removal' above)

•Inadequate skin removal that may result in an unsatisfactory cosmetic appearance (picture 9) (see 'Too little skin removed' above)

•Epidermal inclusion cyst (picture 10) (see 'Epidermal inclusion cyst' above)

•Adhesions can vary from mild adhesions of tiny areas of fusion between the foreskin and corona, which can be treated conservatively, to dense adhesions (also referred to as skin bridges) that may cause tethering of the penis and usually require surgical lysis (picture 7 and picture 11) (see 'Minor adhesions' above and 'Skin bridges' above)

•Cicatrix is a circumferential scar that usually develops at the incision line and is often associated with a hidden penis (picture 12) (see 'Cicatrix' above)

•Keloid formation is a rare but distressing complication of circumcision and requires care during revision to reduce the risk of recurrence (picture 14) (see 'Keloid' above)

•Changes to skin pigment (picture 15) (see 'Skin pigment changes' above)

●Anesthesia – Anesthetic complications of circumcision are reviewed separately. (See "Neonatal circumcision: Techniques", section on 'Pain control'.)