Chapter 11

Complications of Circumcision

All medical procedures, especially those involving surgery, can and do result in complications. Circumcision is certainly no exception.

Parents rarely know even the simplest details about infant circumcision; much less often do they have any awareness that the operation can have complications. Even doctors are frequently unaware of the many complications that can result from circumcision. Commonly doctors pronounce infant circumcision a “simple operation with few risks.” The procedure is easy to perform. However, the risks are many and can be devastating and tragic.

Many of the complications listed herein are admittedly rare. Some are obscure enough to be medical curiosities. A doctor practicing over an entire lifetime, performing or seeing the results of thousands of circumcisions may never see or hear of some of these complications.

Meatal ulceration, the first condition discussed in this chapter, results from ammoniacal urine burns on the unprotected glans of the circumcised infant. This is extremely common among circumcised infants during the diaper wearing period. Possibly over half of all circumcised infants develop this.

The other listed complications are uncommon. All of these put together probably involve 5-10% of all circumcisions. (It is difficult to accurately document the precise rates of circumcision complications because some difficulties are either never reported or are never attributed to circumcision.) Therefore a parent having one’s son circumcised can be assured of an approximate 90-95% chance that the wound will heal normally without undue bleeding or infection, and that the outcome will be a “normal” circumcised penis.

Some of the complications of circumcision are easily resolved. Others have resulted in disastrous consequences — pain, trauma, psychological ill effects, prolonged hospitalization, tremendous expenses, lifelong-mutilation, and death. When viewed in terms of percentages — the fact that some of these complications occur in one out of several hundred or thousand infant circumcisions — the risks seem insignificant. But when viewed in terms of individuals and families involved in these tragic events –particularly when the operation is unnecessary – the risks are quite significant.

with baby

© Suzanne Arms

Parents who give birth in hospitals often do not change diapers or see their babies’ bodies during the entire hospital stay. Therefore, the circumcision wound may be nearly healed by the time they see the baby’s penis. Some complications arise during the first few days in the hospital of which the parents are never aware.

Sylvia Topp points out:

“One doctor says that on his daily hospital rounds in New York he frequently finds babies with ugly granulating wounds and others requiring surgical treatment to stop bleeding. Many of these results are remedied by the hospital staff without ever bringing them to the attention of the babies’ parents.”1

Interestingly, some doctors, upon reviewing the complications of circumcision, merely conclude by calling for greater skill and care upon operating rather than questioning this unnecessary operation. Perhaps they are too conditioned by society to think of foreskins as having any purpose other than being something to cut off. Or perhaps they feel that it would be overly idealistic to try to change the situation.

Upon reviewing the literature, nearly all from medical publications, I have discovered 28 different complications that can result from circumcision. Some of these interrelate or cause other complications. They are listed here in approximate order of frequency:

Meatal Ulceration

Many infants and toddlers in diapers develop “urine burns” from contact with ammonia in urine-soaked diapers. This is unquestionably painful for the child. The glans consists of sensitive, delicate tissue, and is intended to be protected by the thicker, less sensitive foreskin. The destruction of the foreskin creates an abnormal state in which the glans is exposed and in constant contact with outer clothing, and for the infant, with urine soaked diapers. Ammonia burns on the glans, especially around the urinary opening, which is known as the meatus, can be a particularly troublesome problem for the circumcised male infant.

Meatal ulceraction

Meatal Ulceration. Photograph contributed by John C. Glaspey, M.D.

Two of my own three sons had this problem during infancy. When Jason was around 8 months old he developed blisters in his diaper area and a whitish, eroded area around the urinary opening of his glans. As time went on it became crusty. Several nurses at a local “well-baby-clinic” were unable to identify the condition. The doctor (who had delivered and circumcised him) gave it little concern, prescribed a topical ointment, and apparently was unaware that this was a complication of circumcision. Likewise, a relative who is a family doctor, when shown the condition, remarked that this was a fairly common problem that baby boys had, and had little concern or awareness about it. The problem persisted until Jason was completely out of diapers. By the time he was three his glans was thick and leathery in appearance. This is skin which is supposed to be like the delicate tissue inside the mouth!

Later, Ryan also developed meatal ulceration. His was not nearly as severe as Jason’s had been. By this time the research for this book was underway and I readily recognized the condition.

Meatal ulceration is clinically described as follows:

“…The lesion manifests itself as a rather superficial ulceration about the meatus. From what we know about the development of similar ulcers in the diaper region due to the same cause, it is probably preceded by a vesicle [blister]…. At times the ulcer becomes deep and extensive, up to 2 mm. in depth and more than 5 mm. in width. Usually it is more or less covered by a crust which is very firmly attached over a considerable area. Surrounding the ulcer there is often an area of inflammation which involves both the adjacent surface of the glans and extends into the urethral opening with consequent narrowing. In the severer cases there are commonly present at the same time erythema [redness], vesication [blistering), and ulceration of the glans, scrotum, and the rest of the diaper region wherever the diaper is in intimate contact with the skin.”2

“Many children have this ammoniacal diaper [condition] for weeks and months without any unpleasant symptoms. Usually it produces at least a local redness and subsequent desquamation of a large part of the diaper region. In severer cases there is scattered vesication and ulceration. These ulcers often remain denuded for a long time, often they heal over but remain as discrete nodules during the whole time that the ammoniacal condition persists. Often the exposed meatus is the only seat of a deeper lesion; rarely it escapes; as a rule, it is involved with the rest of the diaper region…. The male meatus is peculiarly [?] exposed to such contact, and the delicate mucous membrane is the most vulnerable spot; the female meatus is well protected and is apparently rarely if ever involved.”3

Meatal Ulceration

Meatal Ulceration. Photograph contributed by John C. Glaspey, MD.

The incidence of meatal ulceration among circumcised infants is very common. Kaplan estimates an incidence of between 8 and 31 % .4

Mackenzie found an incidence of 20% meatal ulceration upon following up 140 infants whom he had circumcised, and then examined within the next few weeks. He commented that:

“Several of the mothers whose infants were seen later reported that ulceration had been present and had healed. Such cases were not included since the ulceration had not been observed by me …”5

The true incidence of meatal ulceration is undoubtedly much higher than reported. Many cases are undoubtedly treated by the parents with over-the-counter ointments and are never brought to the doctor’s attention. Meatal ulceration appears to become more troublesome as the infant becomes older. The urine of a newborn, totally breastfed infant is quite mild, but as his diet becomes more varied more ammonia is produced. Older babies and toddlers are not taken to the doctor as frequently as are newborns. Additionally, some doctors see instances of meatal ulceration but fail to recognize or note the condition.

Since meatal ulceration usually does not manifest itself during the immediate aftermath of circumcision, many authorities have failed to recognize it as a complication of circumcision.

Mackenzie comments:

“Ulceration of the meatus is generally not recognized by obstetricians as a complication of neonatal circumcision. Speert failed to mention it in a series of 10,802. Hovsepian reported 1,844 circumcisions without tabulating the number of infants who developed meatal ulceration. Moeller and Moss evaluated the results in 2,400 circumcisions as uniformly excellent. Manson claimed no complications in a series of 387 circumcisions…. Pediatricians have recognized the greater incidence of meatal ulceration in circumcised boys than in uncircumcised, but have not related it to the immediate postoperative period, thereby more closely establishing circumcision as the cause.”5

Ironically, parents upon contemplating circumcision are frequently warned about the supposed “problems” that the child will have if he keeps his foreskin and are given the erroneous advice that the penis of the circumcised child requires no care. Many doctors who regularly treat the sore, eroded, and encrusted glans of the circumcised child apparently lack awareness that the protective foreskin would have prevented this.

The foreskin of the intact infant can occasionally become reddened and swollen. Some doctors believe that this is an indication for immediate circumcision. Others believe that all infant males should be deprived of their foreskins to prevent this occurrence. In actuality the swollen, red foreskin is performing its function of protecting the sensitive glans from more painful and troublesome irritation.

Meatitis

-Meatitis in an 11 -month old child.

Kaplan, ‘George W., “Circumcision -An Overview,” Current Problems in Pediatrics, Vol. 7, No. 5, March 1977 p. 23.

 

 

Hutchings comments:

“Now this condition of a red swollen prepuce is, in fact, a very good reason for not having the operation done.

“…One of the main constituents of urine is a substance known as urea. Certain germs from the bowel can alter urea to form ammonia, and the red area … is a small burn caused by the action of ammonia….

“If circumcision is performed, the ammonia can now burn the meatus instead of the prepuce and thus produce a small ulcer. When this ulcer heals a tiny scar forms, resulting in a slight constriction at the meatus.

“The logical treatment of such an ammonia burn is not to circumcise the child, but to attack the cause, i.e., the ammonia itself.”6

Treatment for ammonia burns varies. The child’s diet appears to contribute to the development of ammonia. Yet another advantage of breastfeeding is hereby discovered. According to Brenneman: “It is almost unknown in the nursing baby.” (I presume that he means the totally nursing baby. My two sons were both still nursing — although eating many other foods-when they developed meatal ulceration.)

Brenneman cites the following theory:

“…based on the work of Keller and others that in certain nutritional disturbances due to the ingestion of cow’s milk fat beyond the infant’s tolerance there is produced a relative acidosis of enteric origin which manifests itself in the urine in the excretion of a hypernormal amount of ammonium salts ….”8

Mild topical ointments are usually recommended for meatal ulceration and other urine burns. Petroleum jelly, or petroleum-based germ killing substances containing antibiotics are often prescribed. The parent should consult their child’s doctor about the appropriate ointment to use.

Some authorities emphasize careful washing of cloth diapers, as ammonia residues can build up in diapers if they are not thoroughly rinsed and washed. Boiling diapers, use of non-detergent soaps, several rinse cycles, and adding vinegar to the final rinse have all been advised.9

Frequent, conscientious diaper changing is especially important if the child is irritated by ammonia burns. However, if he takes long naps or sleeps through the night, his skin is still in contact with urine-soaked diapers for several hours.

Out of personal experience I have found that either disposable diapers or diaper liners, both of which draw urine away from the baby’s skin, help to protect him from contact with ammonia. (Author’s update: Today use of cloth diapers is far less common than it was in the 1970’s and 80’s. I would be curious to know whether or not meatal ulceration and ammonia irritation is more or less common today with nearly universal use of disposable diapers in the United States. – R.R.)

Meatal Stricture

Meatal stricture results from prolonged or repeated episodes of meatal ulceration. The repeatedly irritated meatus becomes narrowed. This results in pain and difficulty with urination. In extreme cases this can result in infections and kidney problems.

Brenneman describes this:

“The urethral opening is nearly always narrowed, often so much that the urinary stream is threadlike and the urine can be expelled only with evident effort…. [He describes a] scab that forms on the ulcerated area. This is very adherent and can hardly be removed without tearing and bleeding of the denuded and adjacent portion of the glans. This is practically always accompanied by a narrowing of the meatus, and it is at times impossible to tell whether the occlusion is due chiefly to the scab or to the narrowing of the urethra itself.”7

One doctor claims that different types of circumcision devices result in varying degrees of “pinpoint meatus,” stating that the Plasti-bell results in more incidence of narrowed meatus.10

Berry and Cross calibrated the urethral meatuses of 100 circumcised and 100 intact adult males, and did a similar study of 100 each of intact and circumcised infants. In both groups the urethral meatuses were significantly narrower among the circumcised individuals than among the intact individuals. Men undergoing circumcision early in life showed a higher incidence of meatal narrowing than did those circumcised later.

The results among infants were not as marked, indicating that narrowing of the meatus develops over time.11

The authors conclude:

“The results of this study suggest a relationship between meatal narrowing and circumcision, particularly when the procedure is done early in life. It is during that period that the meatus would be most vulnerable to irritation and trauma if not protected by the prepuce. A breakdown of the delicate mucosa of the urethral meatus, whether resulting from acute ulceration or low-grade inflammation, could result in eventual secondary stenosis of varying degree in many cases.”11

Meatal Stenosis-Meatal stenosis from recurrent meatitis in a 13-month old child.
Kaplan, George W., “Circumcision -An Overview,” Current Problems in Pediatrics, Vol. 7, No. 5, March 1977 p. 24.

Some authors believe meatal stricture to be hereditary, pointing to a familial pattern. What they may actually be observing is more likely a familial tradition of circumcised males.

Difficulty in urination is frequently a problem that results from urethral stricture. Campbell describes this:

“…straining to void, small stream, urination intermittent and painful. Mucoid discharge may be noted. Hernia may result from excessive straining. Enuresis [inability to control urine, bedwetting] may be present. Progressive renal [kidney] injury by urinary back-pressure with or without complicating infection, the systemic manifestations of urinary toxemia appear chiefly as gastrointestinal disturbances, anorexia [lack of appetite], or failure to grow. Hyperirritability or sluggishness may result from toxic effects on the central nervous system. With the advent of infection there may be a fever; the diagnosis of ‘pyelitis’ [kidney infection] is made.”12

The most common treatment for the condition is “meatotomy”-a snipping of the urinary meatus to enlarge the opening.

Linshaw describes two infants who suffered from this condition:

“I have personally cared for two male infants under a year of age who had obstructive renal disease on the basis of meatal stenosis. One infant was irritable and fussy on urination, had occasional intermittency of his urinary stream, and had a palpable left kidney. The other infant presented with hematuria [blood in the urine]. Both infants had been circumcised and also had a tiny meatal opening…. A tiny pinpoint external meatus should warn the physician that obstructive renal disease is a real possibility.”13

The incidence of enuresis (bedwetting, inability to control urine) caused by meatal stricture, resulting from the exposed, irritated glans due to lack of protective foreskin, is of particular interest in light of the earlier arguments given in favor of circumcision. Remondino and other turn-of-the-century writers listed enuresis among the alleged “dangers” of the foreskin. Evidence now indicates that the opposite is true. The absence of foreskin by exposing the glans to trauma and the urethra to stricture appears to be a cause of enuresis.

Hemorrhage

Hemorrhage is defined as excessive bleeding. It can result from any event that ruptures blood vessels, including any cut or surgical procedure. Hemorrhage is a fairly common complication of circumcision.

Shulman, Ben-Hur, & Newman list it as the most common (immediate) complication, and estimate that 2% of all circumcisions result in hemorrhage. They state that bleeding may be caused by inadequate hemostasis (compressing of blood vessels), by abnormalities of blood coagulation, or by anomalous vessels.14

The Plasti-bell device, in which a ring of plastic and remaining stump of foreskin are tied with a string, after which the foreskin atrophies and falls off, has been purported to prevent hemorrhage. However, one recent study evaluated 59 newborns who experienced hemorrhage following circumcision (out of 5,882 subjects) and noted that 29 of these had been circumcised with the Gomco clamp and 30 with the Plasti-bell.  Apparently the Plasti-bell string was improperly tied.

Fortunately most cases of hemorrhage, if promptly treated, have been easily resolved. Treatments include application of adrenaline-soaked gauze sponge to the bleeding site, ligature (tying off) of a blood vessel, Gelfoam (chemical foam to stop bleeding), silver nitrate stick, or topically applied thrombin, retying of Plasti-bell string, and administration of cryoprecipitate.15

Occasionally babies have required blood transfusions as a result of post-circumcision hemorrhage. One doctor tells of his experience:

“… I spent a considerable portion of one evening transfusing an infant circumcised by an expert Rabbi. The hemorrhage had to be controlled in the operating-room and the baby was hospitalized for two days…. I know of other cases needing transfusion under the same conditions and I have seen several babies considerably anemic owing to the insidious loss of blood which is easily overlooked for several hours.”16

Modern clamp type devices seal the cut edges of skin. Normally infant circumcision is followed by very little bleeding. Today most doctors and mohelim use such devices. However, the Orthodox Jewish circumcisors do not use clamps. The incidences of hemorrhages resulting from such ritual circumcisions may be a result of not using a clamp device, rather than the skill of the operator.

Babies have died from post-circumcision hemorrhage. Since Biblical times the Jews have had a law that if two sons of the same mother bled to death following circumcision, any future sons were exempt from the ritual. This indicates that hemorrhage has always been a complication of circumcision. I have found no record of deaths from post-circumcision hemorrhage in the modern literature that I have reviewed. Obviously in past ages when blood transfusions and modern methods of treatment did not exist, such tragedies were more frequent.

Finally, undetected hemophilia can produce drastic results if such an infant is circumcised. Occasionally hemophilia is discovered when the infant undergoes circumcision and subsequently hemorrhages:

“Brian’s birth … was routine-until it came time for his circumcision. When it didn’t heal properly, a hematologist was called in for consultation. Four days after Brian was born a physician told his parents [that he had hemophilia].”17

While it is hoped that in the future all parents will choose against circumcision, it must be emphasized that any parents who carry the genes for hemophilia should definitely not have their sons circumcised. Even parents who are convinced that their son’s foreskin must be cut off, should have preliminary blood tests performed to rule out the defect. The hemophiliac infant must be left intact. The difference may mean life instead of death, or at least will prevent a drastic bleeding problem. Additionally the child’s foreskin must be left alone until it is fully loosened of its own accord. Forceful retraction should not be done even to a normal child as it is painful and leads to problems. In the hemophiliac child this is especially important, because forceful retraction often results in slight bleeding, and even a slight injury can produce a severe hemorrhage for a hemophiliac.

Infection

Infection of the fresh circumcision wound has been a fairly common complication. I have found more reports of this incidence than of any other complication. Infection has occasionally been accompanied with disastrous results, including death. Some of the other complications described elsewhere in this chapter, such as loss of penile skin, have resulted from infection of the circumcision wound.

Any open area of skin is a potential avenue for infection. Because the freshly circumcised infant penis is in constant contact with wet and/or soiled diapers, this area cannot be kept sterile. Therefore it is unusually in danger of infection.

An infection would be accompanied by fever, pus, redness, and swelling.

Kaplan cites a post-circumcision infection rate as high as 8%.18  While Rosner cites an extremely low rate of only one out of 10,802.19  Gee & Ansell reported 23 infections out of 5,882 circumcised infants (0.4).15

Of the 23 occurrences of post circumcision infection reported by Gee & Ansell, 4 followed use of the Gomco clamp and 19 followed use of the Plasti-bell. Critics of the Plasti-bell device often cite a greater possibility of infection. The remaining piece of foreskin tied to the plastic ring and left to dry up and fall off is in contact with wet diapers and therefore cannot be kept dry. Obviously this is a great potential site for infections.

Particularly antibiotic-resistant strains of bacteria and other infectious agents abound in hospitals. Newborn infants are not as able to resist infection as are older individuals who have built up more immunities. It is not uncommon for newborns in busy hospital nurseries to develop infections, particularly Staphylococcus-based. Sometimes babies do not manifest symptoms of infections until they are home from the hospital.

A 1960s study, investigating the effectiveness of hexachlorophene-based detergents in reducing infections, reported 3.15% of male infants and 1.38% of female infants experiencing staph infections. They cited the umbilical stump and the freshly circumcised penis as the major sites of highest concentrations of Staphylococcus aureus to be found, saying “the blood on the cord and the circumcised penis provide an excellent media for growing bacteria.”20

A wide variety of different infections with the circumcision site as port of entry have been listed by different sources. Besides Staphylococcus aureus, other infections include Staphylococcus epidemidis, Klebsiella pneumoniae, Escherichia coli, and Proteus mirabilis.15

Scurlock and Pemberton report four cases of “fulminating neonatal sepsis with meningitis.” In other words, infection of the circumcision site resulted in infection of the spinal cord and brain. Each case describes the infants as feverish, irritable, crying, with a swollen infected circumcision wound, lethargic, and not feeding. Further symptoms included pallor or cyanosis, “fits,” apnea, bulging fontanelle, head retracted, and lumbar puncture revealing cloudy cerebral-spinal fluid containing the same bacteria present at the circumcision site. Two of the infants healed and recovered normally following treatment, one died, and one showed signs of cerebral palsy upon follow-up at 5 months.21

In another report Annunziato and Goldblum describe severe staphylococcus infections originating from the circumcision site which they call “scalded skin syndrome.” They describe three cases of infants with skin red and peeling, pustules, circumcised area red, swollen, and covered with profuse thick, yellow-green exudate. The infants were feverish, lethargic, cyanotic, and had diarrhea. After administration of antibiotics, two infants healed normally and one died.22

Sussman, Schiller, and Shashikumar describe a type of infection which they call “Fournier’s Syndrome.” They describe three cases of this condition, one resulting from a burn, and two from infected neonatal circumcision. Their descriptions include extensive gangrenous ulcerations around the base of the scrotum, tip of the penis, and in the perineum, with the skin sloughing off. The infants healed following treatment with antibiotics, but scarring remained.23

Sauer reports a fatal staph infection following ritual circumcision. On the 13th day the infant exhibited fever, pallor, and lack of appetite. The circumcision blade had cut away a slight amount of the glans, which appeared to be the center of the infection. Antibiotics were given. On the 18th day of life several cc. of blood and mucus were vomited spontaneously and the infant expired before medical aid arrived.  Autopsy revealed 6ver 50 gray abscesses in the lungs. The infecting agent was Staph Aureus. The circumcision wound was nearly healed at the time of death.24

Kirkpatrick and Eitzman describe two cases involving premature infants who developed infections after being circumcised with the Plasti-bell device. In one case:

“The circumcision site had frank pus around the plastic ring. Necrotic [dead] tissue was present in this area with incrustation of the glans and ulceration at the meatus.”

The infant healed normally following antibiotic therapy. In the other case:

“Pus was noted at the base of glans adjacent to the plastic ring. Gross hematuria [blood in the urine] was present. Blood transfusion was given. Condition remained critical until age two weeks…. Pneumonia and congestive heart failure which were major problems during the recovery period responded to medical management. Infant eventually recovered normally.”25

Routine circumcision is often recommended because of the possibility of “infection.” In truth any part of the body can become infected. Intact men and boys can develop infections of the foreskin. This type of infection is invariably mild and local in nature. It usually can be remedied easily with proper washing, without resort to any drastic measures. This minor type of infection does not begin to compare with the potentially disastrous consequences of an infection of a fresh circumcision wound. It appears that authorities have been concerned about the wrong kind of infection.

Retention of Plastic Bell Ring

If a Plasti-bell device is used to circumcise a baby, the remaining foreskin should dry up and fall off with the ring within about 10 days after the operation. A complication peculiar to this device occurs when the ring fails to fall off and instead becomes buried under the skin along the shaft of the penis. A piece of plastic imbedded in the skin is undoubtedly painful to an infant, and leaves undesirable cosmetic results in the form of a permanent ridge or groove along the shaft of the penis.

Rubenstein and Bason report the following:

“Three infants, two aged 3 weeks and one aged 4 weeks respectively have returned to our outpatient clinic with the plastic ring at midshaft of the penis. In the first of these cases, the infant was brought to the clinic because he was ‘always crying'; in the other two, the infant had no symptoms but the mother thought the penis ‘didn’t look right.’ Although there was marked swelling both [above and below] the ring, in no case was there interference with the urinary stream, and in all three cases, the penis appeared normal within three weeks of the removal of the ring with a ring cutter…. Although in our series of three cases no serious sequallae were noted, it is certainly conceivable that infection or necrosis of the head of the penis, or both, as well as the recognized complications of urethral stenosis could result from such prolonged midshaft constriction.”26

Datta and Zinner comment:

“Because the plastic material of the Plasti-bell has relatively rigid and sharp edges, there is compression damage and ulceration of the corona and portions of the proximal glans as well as that of the penile shaft. Edema and vascular congestion distal to the ring further complicate matters. All four infants [in their study] had extensive ulceration of the skin of the penile shaft…. Although we did not observe it, urinary retention and gangrene of the glans penis may occur and should be considered.”27

Johnsonbaugh, Meyer and Catalano comment on the ridge often left behind by this occurrence:

“Five days later [the infant] was again brought to the clinic with the complaint that the ridge had not disappeared … this constriction appears to be permanent.”28

Lawton hypothesizes that:

“…this complication is due to pushing the bell too far over the glans, perhaps further than the coronal sulcus, prior to tying the ligature.”29

Concealed Penis

An unusual complication occurs when the penile shaft, following circumcision, retreats into the surrounding skin and fatty area and cannot be seen. This problem must be corrected by surgery, and often skin grafting, to produce a normal penis.

Drs. Shulman, et al., describe this occurrence:

“…The penis is forced into a subcutaneous position by wound contraction following circumcision. This may be produced if there is a tendency of the penis to retract into the fatty mons pubis, and later the circular wound heals, contracts and holds the penis in a submerged position beneath the pubic skin.”

They describe the following case:

“On exam, the penis was palpated deep in the subcutaneous tissue of the pubic region. Over the scrotum, only a tag of penile skin was visible, in the center of which there was a sinus through which the child passed urine. After careful dissection of the skin ring, it was possible to pull the penile shaft outwards. The shaft was normal but was denuded and it was necessary to cover it with a skin graft.”30

Trier and Drach report two similar cases and offer their explanation for its occurrence:

“Failure to completely separate the inner surface of the prepuce from the glans penis. Circumcision, when correctly performed, eliminates the possibility of phimosis by excision of a sufficient portion of redundant prepuce in order to leave the glans penis exposed. Usually more of the inner preputial surface than the outer requires excision, so that very little penile skin need be discarded. If the inner surface of the prepuce is not adequately dissected from the surface of the glans penis, most or all of the inner surface of the prepuce remains. Penile skin is then pulled into the circumcision device and amputated immediately, or in a week’s time in the case of the plastic bell clamp. The circular wound contracts as it heals and confines the glans penis in a subcutaneous position.”31

Fig. 2 -Left, Concealed penis. Bulge of glans is seen under skin. Right, Glans exposed and held by traction suture. Suture line of inner surface prepuce and penile skin is visible. c. Trier, William C., M.D., & Drach, George W., M.D., "Concealed Penis," American Journal of Diseases of Children, Vol. 125, Feb. 1973, p. 277.

 

 

 

 

 

 

 

 

Penis repair

-Repair of concealed penis. The inner preputial epithelium has been folded back to provide skin cover.

Concealed penis after circumcision

-Concealed penis after circumcision

Kaplan, George W., “Circumcision – An Overview,” Current Problems in Pediatrics, Vol. 7, No. 5, March 1977 p. 18, 20.

Talarico and Jasaitis describe a similar case and conclude:

“The most common accepted theory is the tendency of the penile shaft to retract into a deep prepubertal fat pad. This disappearance, although temporary, can become more permanent by the reaction of the newly formed circular mucocutaneous union with cicatrization [scarring]. The puckering scar tissue builds up, closes over the retracted penis and completely entombs it in a pseudosac with a pinpoint for the egress of urine. Fortunately the glans around the meatus is not involved in this scarring process…. We suggest a more adequate disruption of adhesions and more aggressive followup in the case of newborn circumcision…. The mother should be instructed in cleansing the genital area and retracting the skin around the penis.” [emphasis mine]32

These instructions are interesting because expectant and new mothers are often urged to consent to circumcision of their sons on the belief that the circumcised infant’s penis “needs no particular care.”

Today “concealed penis” can be resolved by modern surgical procedures. Certainly this complication has also occurred throughout ancient times. One shudders to think of the lifelong difficulties suffered by such individuals in ages when surgical correction was not possible.

Urethral Fistula

A fistula is an abnormal opening in any part of the body. A urethral fistula is a hole going from the side of the male urethra to the outside of the penis. Usually the fistula occurs on the underside. This can develop as a result of circumcision. It results either from accidental crushing of the urethra by the circumcision clamp, an abnormality in the urethra, or from a stitch placed in the underside of the penis to control excessive bleeding at the site of the frenulum.

Urethrocutaneous fistula

-Urethrocutaneous fistula following circumcision.


Kaplan, George W., “Circumcision -An Overview,” Current Problems in Pediatrics, Vol. 7, No. 5, March 1977

p. 27.

Kaplan comments:

“This complication presumably occurs either because the urethra is pulled into and crushed by the Gomco clamp or because the urethra actually is incised, either with a knife or a suture placed for hemostasis. The prevention of this complication results from being able to visualize exactly what is being done in the course of the circumcision and … can be accomplished by marking the level of skin to be excised and by completely freeing the preputial sac from the glans penis. Additionally, if any penile abnormality is uncovered in the course of freeing the preputial sac, I would strongly recommend desisting and referral at that point .”33

Limaye and Hancock describe such a case, its repair, and its probable cause:

“[A 7 year old child] voided in two streams…. One stream came from the tip of the penis and was directed forward; the other, a little larger, emerged from the underside of the penis and was directed downward. The child had undergone circumcision on the third day of life … there was bleeding [after the circumcision] in the area of the frenum. This was controlled with some difficulty with a suture. [The defect was repaired as follows:] A circular incision was made 3 mm. from the margin of the fistula and a skin cuff raised. The fistula was closed by inverting the margins of this incision…. [Subsequent healing was normal and the fistula closed.] … 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.”34

Byars & Trier describe a similar case:

“…a 10 year old boy who was circumcised soon after birth: A complete segment of urethra was destroyed, resulting in a large defect of the urethra and chordee [painful downward curvature of the penis on erection] secondary to scar contracture. This was corrected by a two stage repair.”35

Shiraki describes an unusual cause of such a fistula. A newborn baby boy was born with an abnormally enlarged urethra which instead of being a normal narrow tube, formed a “pocket” in the underside of his penis. This was termed “congenital megalourethra.” It became distended with urine and the condition was mistaken for phimosis with urine filling the preputial- glandular space. Circumcision was performed with a plastic bell clamp at age four days. Afterwards his urinary stream was poor with a tendency to spray. Circumcision had created a fistula on the underside of his penis where the large urethral pocket had been cut open. This was corrected by plastic surgery to close the hole and make a normal stream.36

Phimosis of Remaining Foreskin

Phimosis refers to any condition in which the foreskin cannot be retracted. This condition is normal in the intact infant, and is not true phimosis. Occasionally the older intact male may have a tight foreskin that is difficult to retract. This condition can usually be resolved by simple methods, and does not need to be corrected by circumcision. One of the purported arguments in favor of routine neonatal circumcision is that the operation will supposedly prevent phimosis. This is proven untrue, for occasionally the remaining piece of foreskin becomes tightly attached to the sides of the glans and the infant then must undergo a painful loosening procedure or possibly a second circumcision.

Browne describes this occurrence:

“Removal of too little mucosa … allows the circular wound to slip forwards over the end of the penis, where it contracts rapidly and completely, so that urination may be very difficult. The resultant problem is far from easy to solve if approached in the wrong way. The trick in untangling this is to make a circular cut through the skin just proximal to the ring of scar tissue and retract this so as to leave only mucosa covering the glans. This mucosa is then torn through cautiously with forceps and, once the corona is exposed, the situation is clear.”37

Kaplan comments:

“…Insufficient skin has been removed from the shaft of the penis and, in addition, insufficient inner preputial epithelium has been removed. As healing progresses there is contraction of the preputial ring so that true phimosis is produced. This can, at times, be quite severe and result in urinary obstruction. The prevention of this complication lies in the suggestion made to mark the area of the coronal sulcus on the shaft skin with ink and to be sure that the inner preputial epithelium has been completely freed from the underlying glans penis prior to removing the prepuce … the treatment for this complication is a repeat circumcision.”38

In Mothering magazine a young mother writes of her experience with her child who had this complication:

“I … was unaware of what a horrible thing circumcision is, and allowed my son to be circumcised the same day he was born…. When he was 15 months old … the doctor discovered that a half-inch of skin had grown back to the head of Jared’s penis.

“Our pediatrician referred us to a urologist who assured us that he could sedate Jared and simply ‘pull’ the adhesion apart; that there shouldn’t be much discomfort to Jared.

“Jared was given a sedative. He was then put on a table where a nurse held him down while the doctor pulled on the adhesion. Jared woke up crying immediately. The doctor injected a local anesthetic into Jared’s penis to prepare it for surgery. Jared struggled with all he had to free himself from the nurse’s hold.

“As the nurse and doctor prepared the surgical room, I held and nursed my son. He was so upset that his little body convulsed with sobs the whole time he nursed. His penis had swollen to double its normal size!

“I insisted on accompanying my son into the surgical room. Jared began to cry as soon as they laid him on the table. I held down the upper half of his body while the nurse held his lower half and kept his legs spread. Even though he was sedated, Jared was like a wild animal…. The doctor inserted the hemostat into one opening of the adhesion, and pushed it through to the other side, pulling up on the hemostat as he cut. After the cut was made, the doctor had to cauterize the wound to stop it from bleeding.

“I was beyond myself, hearing and seeing my son scream for his life…. I am so sorry I was ignorant about circumcision. Had I witnessed a circumcision first, I never would have consented to having my son circumcised.

“…If you decide to circumcise your son, prevent growth-back adhesions: bathe the baby and gently pull the skin back as he soaks in the water. Also apply Vaseline to the penis when you change him.”39

Urinary Retention

Occasionally a baby will not urinate for several hours following circumcision. Sometimes the cause is an overly tight bandage wrapped around the wound. In other instances the cause is less clear.

No special dressing was applied to my own babies’ penises following circumcision except for a tiny, loosely applied petroleum jelly coated gauze strip. However, some operators, particularly ritual circumcisers, apply a tightly wrapped bandage around the end of the infant’s freshly circumcised penis. Most doctors today would agree that this is not necessary.

A group of doctors report the following:

“Performers of ritual circumcision in Israel wrap the circumcised penis with a firm, circular bandage for hemostasis. The three newborn infants we saw were brought to the emergency room about a day after the procedure because of restlessness, refusal to eat and occasional vomiting. One of the mothers noticed blue discoloration of her child’s legs. On examination, cyanosis of both lower extremities and a huge bladder were found in all three infants. In each case after removal of the bandage, a large quantity of urine was passed and the cyanosis disappeared. The babies became quiet and began to drink avidly. It is conceivable that the tight bandage constricted the urethra giving rise to a distended bladder. This in turn led to the discomfort and restlessness of the infant and caused compression of the iliac veins interfering with venous return from the legs and producing cyanosis.40

Horwitz, Schussheim, and Scalettar report a similar case:

“An 18 day old infant was brought to us with a ten hour history of mild, green, watery diarrhea and refusal to eat. There was no fever or vomiting, and on close questioning it was learned that he had been voiding normally. Over this period of time he refused to take any milk or liquids and it was this feature that had the parents particularly concerned.

“On examination, he was found to be in a state of shock, mildly dehydrated, with grunting respiration, and with a hugely distended abdomen. There had been a ritual circumcision two days previously (somewhat delayed because of prematurity) and the penis was still covered by a tightly bound circular bandage. The tip of the penis was red and looked necrotic. While being examined he voided in a weak stream. After we released the bandage he voided a tremendous amount of urine…. The abnormal distention rapidly diminished and the grunting respiration improved but he was still obviously in shock. In fact, he appeared to be temporarily worse immediately after the release of the gauze.

“Our impression was that he was in septic shock secondary to urinary obstruction and he was admitted immediately to a neonatal intensive care unit…. Eschericha coli was cultured from the blood, urine, throat, and tip of the penis…. A ventral meatotomy and urethral dilation were performed. The penis was intermittently soaked in warm saline for a few days, during which time improvement was seen…. The baby was also treated with antibiotics.”41

Kaplan tells of another case of post-circumcision urinary retention by a different cause:

“I once was consulted about a 72-hour old male who had failed to void. He had been circumcised immediately following delivery. On examination, his bladder was distended and his glans penis was covered by a brownish film that obscured his urethral meatus. As this film was teased away from his meatus, he voided a full stream and had no further difficulties. Subsequently, it was learned that this film was dried tincture of benzoin used as a circumcision dressing.”42

It is conceivable that similar urinary retention could result from an overly tight plastic bell ring. There have also been instances of infants failing to void for several hours following circumcision when no bandage or plastic ring was in place. This may be a psychological response on the infant’s part to the trauma of the operation.

Glans Necrosis

“Necrosis” refers to the death of body tissue. This has happened to the glans following circumcision due to an overly tight bandage or a Plasti-bell ring that is too small.

Kaplan describes this occurrence:

“On occasion, in an attempt at hemostasis, the circulation to the glans penis may be compromised, resulting in either cyanosis or necrosis of the glans penis. I was asked to see a child with cyanosis of the glans penis one day following circumcision. Many sutures were present. Additionally, an anaerobic streptococcus was cultured from the wound so that it was not clear whether the cyanosis was secondary to the sutures used or to an underlying infection. With removal of the sutures and use of antibiotics, this problem resolved without tissue loss.”43

When a baby is born in breech position frequently the lower extremities become swollen from the pressures of birth. Rosefsky reports of a case of glans necrosis in a breech baby who was circumcised with a Plasti-bell:

“A breech baby was circumcised 12 hours after birth with a Plasti-bell. At age 24 hours, the baby was observed to have a moderately edematous scrotum, leg edema, and a black necrotic-appearing glans. The ligature and the plastic ring were removed … following which the glans gradually became quite swollen and slightly moist over the following 12 hours. The urinary stream was narrow and forceful. By the 6th day the glans was moist and remained black. By day 7 the edema was almost gone. An outer black ‘crust’ of necrotic tissue, and part of the prepuce which had been distal to the ligature, began to slough. A reddish-purple, shiny glans underlay the old ‘crust.’ By the fifteenth hospital day the glans looked nearly normal. The patient was discharged and showed no evidence of urethral stenosis.

“Breech delivery was almost certainly the cause of the edema of the legs and scrotum. The size of the plastic bell was satisfactory at age 12 hours, but ‘became’ insufficient, suggesting that the penis became more edematous, whether as a continuing process secondary to the breech delivery, or as a consequence of the circumcision method.”41

Injury and Loss of Glans

Occasionally the glans can be injured or entirely cut off during circumcision. Usually a permanent deformity results. Both the Plasti-bell and the Gomco clamp employ the protective “bell” which covers the glans before the clamp or string is applied, thus precluding injury to the glans. Other methods not employing a “bell” pose greater risk of injuring the glans. The glans can also be injured before the bell is in place, during the dorsal slit procedure, or as the operator frees the foreskin from the glans.

Shulman, et al. describe two cases of injury to the glans during circumcision:

“[A two year old boy:] The glans was deformed in shape, divided by a deep transverse scar, and slightly edematous. The urethral meatus was not visible. There was also a post coronal stricture…. At operation, the clefts were excised and resutured, the stricture was opened, and the normal penile skin was rotated into the defect….

“A five year old boy sustained amputation of the glans penis during circumcision, with severe postoperative hemorrhage. Wound healing was uneventful but was followed by repeated urinary infection. On examination only a small part of the glans remained. The meatus was very small and the urinary stream exceedingly narrow … meatotomy was performed and … to produce a glans-like corona, a circumferential incision was made above the meatus, and the penile skin retracted proximally to give rise to a raw surface 1.5 cm. in width which was covered with split skin graft.”45

McGowan describes a different type of injury:

“…surgically bivalving either the dorsal or ventral half of the glans penis. This is caused by inadvertent placement of one limb of the scissors into the urethra rather than between the foreskin and the glans prior to performing either the dorsal or ventral slit in the prepuce…. Once the incision is made, the glans penis is bivalved and the urethra laid open. In effect, a first degree hypospadias or epispadius has been produced.”46

Excessive Skin Loss

A newborn baby’s penis is very tiny. Usually only about one-half inch of skin is amputated during circumcision. Some operators tend to take off more than others, consequently there are many “varieties” of circumcised penises. Some males have no remaining foreskin while others have a sizeable ring of skin left in place.

Considerable debate abounds over what is the “right” amount of foreskin to cut off. (Hopefully soon we will decide that the best answer is “none!”) Taking off a small amount of skin can result in phimosis of the remaining foreskin with possible need for repeat circumcision. However, devastating complications result from cutting off too much skin. The fact that the ultimate size of the penile shaft, proportionate to the foreskin, is not attained until later in life, further complicates the matter. A newborn’s foreskin usually extends far beyond the glans. It may appear overly long, but as he matures he will in effect “grow into it.” For this reason, some adult intact penises appear as if they have been circumcised. An advantage of delaying circumcision until adulthood (if desired or medically necessary) is that the individual has reached his full size and can have it “tailored to fit.”

Excessive skin loss can result from the operator severing too much foreskin, from infection of the wound resulting in tissue death, or from a burn caused by an electrocautery device. Sometimes the entire penile shaft becomes denuded and skin grafting is necessary. Other times the results are less drastic and the wound heals, but as the individual grows older his penile skin becomes too tight, causing discomfort on erection.

Van Duyn & Warr state:

“Reports of major losses of penile skin as a complication of circumcision are fairly common; the causes of such loss being usually either a complicating infection, the use of the electrocautery, or improper surgical technic (sic) … when these defects are allowed to heal without grafting, there may be ‘discomfort’ during adulthood, and a shortening of the future functioning (erectile) length of the organ. Theoretically, even a minor inadequacy of penile skin in the shaft would tend to result in a holding back of the subcutaneous part of the penis against the abdominal wall.”

They describe the following case:

“An infant male was circumcised on the third day of life with a Gomco clamp. The next morning the wound was pulled apart and it was apparent that an excess of penile skin had been removed leaving a gap of 1.0 cm underneath and 0.7 cm. above. Three days later plastic surgery was done. A split graft was cut from the left lower abdomen … and wrapped around the defect in the penis and covered with fine mesh gauze. On the fourth post-operative day the dressings were removed and left off. The baby’s hands and feet were restrained to keep him from disturbing the area. Ten days after the operation the patient was discharged from the hospital. The patient healed normally. The parents were told to look for evidence of constricting scar tissue at the juncture lines as this can result.”47

Wilson & Wilson describe another case:

“Child was circumcised one day after delivery. The guillotine method [!] of circumcision had been used and electrocautery employed. Mother and child left on the 6th day. One week later the physician examined the child and found the entire penis to be black and gangrenous. Two days later it had apparently sloughed off completely and there remained only a small scarred area at the base…. At age three weeks, the first stage procedure was begun. Scar tissue was excised and after removing dense adhesions, a completely denuded penis was exposed. There was complete loss of the glans, but about two-thirds of the penile shaft was intact. Two horizontal incisions were made an inch apart in the scrotum and the intervening skin undermined to create a subcutaneous tunnel. The penis was inserted under this bridge of full thickness skin and the distal incision sutured around the end of the penis leaving the amputated end exposed.

“The second stage was performed 6 weeks later (the baby being 9 weeks old). By this time the scrotal skin was adherent over the entire penis and the cut distal end of the penis completely epithelialized. The penis was freed from its subcutaneous bed along with adequate flaps of scrotal skin adherent to the sides and distal end. These three flaps were approximated without tension over the naked ventral surface and the scrotal incision closed vertically. A meatotomy was performed to insure an adequate urethral orifice. Recovery from this second procedure was also uneventful.”48

Skin Bridge

“Skin bridge” can result from circumcision. It is a complication in healing of the wound, by which a piece of skin from the shaft of the penis has become attached to the glans, or another point along the shaft, forming a “bridge” that must be surgically corrected.

Klauber & Boyle describe this condition:

“A small portion of the circumference of the shaft skin is found to be continuous with the epithelium of the glans penis, producing a bridge over the coronal sulcus. Retraction of the shaft skin, or erection may cause deviation of the glans with respect to the shaft of the penis. Smegma may accumulate under the skin bridge, causing infection…. [It is caused by) damage to a small area of the glans penis during separation of the prepuce from the glans penis. Divided skin edge of the penile shaft skin must come in contact with the damaged area on the glans and become adherent. Subsequently, healing with epithelial bridging between the coronal sulcus from the glans to the shaft skin occurs.”49

Skin Bridge

A. a patient with a skin bridge. B. a probe has been passed under the bridge,

Kaplan, George W., “Circumcision -An Overview,” Current Problems in Pediatrics, Vol. 7, No. 5, March 1977 p. 21.

 

Kaplan comments:

“When present, these often result in accumulations of smegma or infection. Additionally, they tend to tether the erect penis, with resultant pain or curvature. Their treatment is simple surgical division. However, there must be preparation for hemostasis, as they often contain many vessels that can bleed vigorously. Some authors have stated that they arise by injury to the glans at the time of circumcision, with resultant fusion of the circumcision line thereto. It is my belief that there is yet another dimension in genesis; namely incomplete separation of the inner preputial epithelium at the time of circumcision. Consequently, there is firm fusion of skin, inner preputial epithelium and glans at this point, with later separation of the inner preputial epithelium from the glans, resulting in a skin bridge.”50

Vomiting, Apneic Spells

Apnea (British spelling apnoea) means cessation of breathing, usually for a short period of time. Sometimes normal healthy infants have spells of apnea during sleep and it is of no consequence. However, sometimes this event can be life-threatening.

Fleiss and Douglass report:

“A healthy 1-week-old infant had a circumcision done by a well-trained and experienced physician without any anaesthetic. The infant tolerated the procedure well except for excessive crying, which began at the time of the operation. The mother, attempting to soothe her distressed infant, resumed breast feeding after the operation. An episode of vomiting followed the feeding. An apnoeic spell followed the emesis. The infant was taken to a local emergency room and subsequently transferred to [a children's hospital]. He received a complete septic workup, intravenous antibiotics and hospitalization for five days of observation until the cultures were negative and sepsis was ruled out. The infant was discharged from the hospital six days after circumcision doing very well.

“Infants do feel the pain of the surgical removal of the foreskin performed without any anaesthetic, and they respond to the pain by crying. That crying may be excessive. Air may be swallowed. Mothers do soothe their infants by feeding them. Vomiting may follow the feeding. Apnoea may follow vomiting ….”51

Sewing of Penile Skin to the Glans

Stitches are not normally required following neonatal. circumcision, so presumably this bizarre complication has resulted from circumcision performed on older individuals.

Browne mentions:

“Sewing the skin edge to the glans, with consequent burying of the corona. This mistake arises from not retracting the mucosa fully. It entails a tedious little dissection.”37

Laceration of Penile or Scrotal Skin

Circumcision jokes often center around “What if the knife slips?!” This feared event has happened.

Shulman, Ben- Hur, & Newman report:

“Accidental laceration of the penile skin and scrotum following circumcision has been seen in 2 cases…. [In one case] the Mohel slipped during the performance of the operation, and the knife opened the ventral surface of the penis and scrotum and exposed both testes. The skin was sutured under general anesthesia six hours after the accident and healing was uneventful.”52

Undetected Hypospadias

Hypospadias is a congenital deformity in which a fistula naturally occurs in the underside of the penis. This is corrected by plastic surgery. The foreskin provides an easily available piece of tissue for use in skin grafting. (Thereafter, the individual is essentially circumcised, but at least the foreskin has provided a correction for the defect.) If an infant with hypospadias is routinely circumcised, this potentially useful piece of skin has been destroyed and the operator must resort to more complicated types of skin grafts to reconstruct the penis.

According to Gee & AnseII:

“In 5,882 live births, there were 22 patients with a hypospadias…. In 13 patients, the hypospadias was recognized and circumcision was not done; in 6 the hypospadias was not recognized and circumcision was done; in 2 the hypospadias was noted but circumcision was done anyway; and in one patient hypospadias was recognized after the dorsal slit was made, and the incision was then reapproximated with fine chromic gut.”15

Preputial Cysts

A cyst is an abnormal, closed pocket of body tissue which contains fluid or solid material. Occasionally cysts develop along the remaining edge of foreskin at the site where the skin was severed.

Kaplan discusses this:

“These occur either by rolling in epidermis at the time of circumcision, or perhaps by implanting smegma in the circumcision wound. These inclusion cysts may grow to rather large proportions…. Even those that remain small can become infected…. Obviously the treatment is surgical excision.”53

Preputial inclusin cyst

-Preputial inclusion cyst following circumcision. A. lateral view. B. ventral view of the same patient.

Kaplan, George W., “Circumcision -An Overview,” Current Problems in Pediatrics, Vol. 7 No. 5, March 1977 p. 25.

Complications of Anesthesia

Complications can ensue from use of any type of anesthesia for any medical procedure, including circumcision. Kaplan states:

“Over the period 1942-1947 in England there were 16 deaths per year related to anesthetics used for circumcision. It is presumed that anesthetic techniques today have greatly reduced this incidence. This once again, however, reaffirms the observation that no general anesthetic is used lightly and without due consideration of the risks and benefits therefrom.”18

Critics of infant circumcision frequently express outrage that newborn infants are usually given no anesthesia for an operation considered painful enough to warrant anesthesia for an older child or an adult. However, administration of such drugs to newborn infants is riskier than anesthetizing an older individual. Certainly if all newborn infants undergoing circumcision were being given general anesthesia for the operation we would see many more cases of death or difficulty from the anesthetic.

Tuberculosis and other Diseases from Mezizah

Mezizah is the third step of the Jewish ritual circumcision ceremony, in which the mohel applies his mouth to the fresh circumcision wound. Diseases have been spread due to this practice. Today, few ritual circumcisors practice it.

According to Bromley:

“A few years ago [19291 one of our leading medical journals published an account of an infected operator, who, during the third stage of the operation [mezizah] had infected seven children with tuberculosis and it proved fatal to all within a short time after this religious rite. . . .”54

(Please see Ch. 3 – Judaism, for additional discussion of this practice.)

Strangulation of the Glans by Hair

Medical reports have described cases of small boys who have, either accidentally or intentionally, had long strands of human hair tightly wrapped around the coronal sulcus (the indentation beyond the outer rim of the glans). This can be considered an indirect complication of circumcision, because the intact penis with the foreskin covering the glans has one smooth continuous surface and the glans and the coronal sulcus are not exposed.

Singh, Kim, & Wax describe three cases:

“A four year old boy presented discoloration of the glans with swelling due to an encircling hair. The hair was cut free … the child recovered fully with no complications.

“A three year old boy presented a history of dysuria [painful urination]. He had an excoriated [abraded, traumatized] glans. A hair was wrapped around the glans which was cutting into the tissue. The hair was removed and the infection was treated with antibiotics. He recovered fully with no complications.

“A five year old boy was voiding through an opening on the underside of the penis. He had had an infection around the urethral meatus for six months which did not clear on local antibiotic therapy. Examination revealed a urethral fistula located ventrally in the line of a deep groove which completely encircled the penis just proximal to the glans. Ten months later the fistula was repaired. Six months later he experienced a three day history of discoloration at the tip of his penis. A hair was removed from the groove proximal to the glans. His glans was black and dry. Two days later the glans sloughed off leaving a clean, dry, proximal urethra. The healing was normal.”55

Recurrence of Pneumothorax

A pneumothorax is a collection of air or gas in the membranes that surround the lungs or pleural cavity. Auerbach & Scanlon tell of a case involving an infant who developed a. pneumothorax as a result of mechanical assistance with breathing for severe respiratory distress at birth. After it was treated the infant was circumcised. His excessive crying from the pain of the operation caused the pneumothorax to recur:

“A baby was delivered after spontaneous labor at 35 weeks’ gestation. He weighed 2.51 kg. [about 4 1/2 lbs.] His Apgar scores were 5 at 1 minute, and 9 at 5 minutes. He was given oxygen. The infant developed severe respiratory distress syndrome documented by chest x-ray and clinical course. Assisted ventilation was required via an endotracheal tube. At 15 hours of age a right-sided tension pneumothorax was noted, followed in three hours by a left-sided leak. Assisted ventilation was discontinued on the fifth day…. On the fifteenth day he was electively circumcised prior to anticipated discharge. Circumcision was complicated by moderate bleeding, which required several pressure dressings. After the procedure the baby had circumoral cyanosis [blueness around the mouth) and tachypnea [abnormally rapid breathing] that persisted. The infant was … irritable and frequently crying. A right sided pneumothorax was diagnosed on the seventeenth day of life and necessitated chest tube insertion and drainage. The infant required an additional 19 days of hospitalization for this problem…. Circumcision and subsequent bleeding with frequent dressing, resulted in crying and sobbing sufficient to raise intrapulmonary pressures and rerepture a previously weakened site.”56

Pulmonary Embolism

A pulmonary embolism is a clot of blood which travels through the circulatory system and becomes lodged in one of the blood vessels in the lungs. This causes severe breathing difficulties and can result in death. This is a small but potential risk of any surgery.

One medical report lists a case of pulmonary embolism following adult circumcision:

“The day before his discharge he felt vaguely unwell and lost his appetite. He awoke during the night and complained of back pains which radiated to his right shoulder and were aggravated on breathing…. Two days later he experienced severe pleural pain. He had difficulty breathing and was coughing up blood. He had at least two pulmonary emboli. He became seriously ill and was operated on. The recovery was satisfactory.”57

Keloid Formation:

A keloid is an abnormal development consisting of a raised, firm, thickened, red piece of scar tissue. Such a formation at the site of circumcision creates a grotesque deformation of the organ, with obstruction of its function.

Ecstein describes an extensive keloid scar which developed on a small boy 6 months after he was circumcised “without any good clinical indication.” The author concludes: — fortunately this complication is unusual.”58

Lymphedema or Elephantiasis of Skin

These terms refer to the swelling or obstruction of the lymph vessels. This can result from circumcision.

According to Shulman, et al.:

“A baby with lymphedema of the penis had been circumcised at 8 days. He was referred at age 10 months. Several days after circumcision the penis and scrotum had become swollen. On examination at 25 days it was found that a large portion of the prepuce remained and covered the glans. The penis and scrotum were edematous. Several weeks later the scrotal edema regressed but the penile skin of the ventral surface remained edematous. On admission, marked edema of the lower part of the penile skin was found…. At operation, the lymphedematous tissue was excised down to the penile fascia. The defect on the ventral surface was easily closed by the remaining dorsal flaps.”30

-Distal lymphadema following circumcision complicated by wound separation and infection.

Kaplan, George W., “Circumcision -An Overview,” Current Problems in Pediatrics, Vol. 7, No. 5, March 1977 p. 27.

Reaction of Older Sibling

Perhaps the following experience can be considered a complication of circumcision. A doctor reports:

“One Sunday afternoon I received an urgent call from a harassed mother who informed me that her two-year-old son had tried to amputate his penis and was bleeding profusely.

“He had a moderately deep laceration half-way around the base of the penis. The urethra was intact. The laceration was sutured and recovery was uneventful.

“The youngster had witnessed his baby brother’s ritual circumcision one week previously and had obviously been impressed by the procedure and all the attention his brother had received.”59

Cosmetic Problems

The Gomco clamp and Plasti-bell devices produce an even circular cut — although if applied crookedly can still result in cosmetic problems. Older methods such as smashing the skin with a hemostat and slicing it off present greater risk that an uneven cut will result. Browne uses the quaintly British expression: “Untidy tags of skin.”

Removal of only a tiny bit of foreskin can cause dissatisfaction on the part of parents who are conditioned to believe that the denuded state is preferable. Sometimes such parents will take their babies back to the doctor to have more foreskin cut off because they believe that his penis does not look circumcised “enough.”

Kaplan comments:

“An inconsequential but frequent source of parental dissatisfaction with the results of circumcision is the removal of insufficient skin and inner preputial epithelium. Often in such instances one is hard pressed to determine that circumcision has been performed. Obviously this is merely a cosmetic problem, but it is amazing how much time is required to convince the parents of these children that repeat circumcision is not necessary.”60

Loss of Penis:

I have purposely saved the most dramatic and devastating complication for last. There have been cases in which the penis has been lost due to circumcision, caused by mishandling of the operation, as a result of an infection, or by a burn from electrocautery technique. In some cases enough penile shaft remained so that after extensive operations a functional penis could be reconstructed. In other cases the child has been surgically made into a “girl.”

Hamm and Kanthak describe two infants who underwent penile reconstruction:

“Two cases of gangrene of the penis in newborn infants occurred following circumcision for which a high frequency cutting current was utilized. In each instance the procedure was done by the physician in this way for the first time and had been utilized in the hope that a simple, hemostatic method of circumcision would result. Each of these cases was attended by more or less complete sloughing of the external portion of the penis resulting, on spontaneous healing, in a flat, smooth area of skin continuous with the scrotum on which no evidence of penile projection was present. In each of these cases a satisfactory penis was reconstructed.

“… The penis has been reconstructed utilizing the remains of the corpora cavernosa penis and the corpus cavernosum urethrae with its enclosed urethra….

“Repair of the penis utilizing the remains of the penile stump by exteriorizing the deep portions of the corpora cavernosa and covering the newly formed shaft with a free skin graft provides a direct approach and a penis composed of more physiologically normal elements than is otherwise possible.”61

Penile slough

-Total penile slough due to electrical burn of penis during circumcision.


Kaplan,George W., “Circumcision — An Overview,”      Current Problems in Pediatrics, Vol. 7, No. 5, March 1977, p. 30.

There are documented cases of sex-change due to total loss of the penis following circumcision. A newspaper article reports the following:

“A boy injured so badly during a circumcision that specialists later advised a sex change operation, has been awarded $750,000in medical malpractice damages. Circumcision was performed when the child was five months old. According to testimony in the two-day trial, the baby’s genital area was burned so badly that specialists eventually recommended sex- change surgery which was performed … the child had undergone eight operations and that several more might be necessary. The parent-child relationship is affected. In future years they will look at certain of her activities and wonder if she’s beginning to revert to being male. She’s suffered severe surgical scarring. How will she look at herself as she grows older? Doctors testified that lifetime treatment with hormones would develop and maintain a feminine body, but she would never be able to bear children and would have only a 50-50chance of achieving orgasm.”62

Money has studied a number of cases of sex reassignment of male to female in infancy. (Occasionally this is also done because of congenitally defective, abnormally small genitals.) He describes a most interesting case example in which one of identical twin boys lost his penis during circumcision and was subsequently raised as a girl.63

“… The child was born a normal male and an identical twin, without genital malformation or sexual ambiguity … at the age of 7 months … the penis was ablated flush with the abdominal wall. The mishap occurred when a circumcision was being performed by means of electrocautery. The electrical current was too powerful and burned the entire tissue of the penis, which necrosed and sloughed off.

” …[The parents] implemented their decision [for sex-change] with a change of name, clothing, and hair style when the baby was 17 months old. Four months later the surgical step of genital reconstruction as a female was undertaken, the second step, vaginoplasty, being delayed until the body is fully grown. Pubertal growth and feminization will be regulated by means of hormonal replacement therapy with estrogen.””

“Concerning the status of her organs, the girl knows that she needs to apply finger pressure above the urethral opening to insure complete downward deflection of the urinary stream, and that she can request minor surgery to correct it when she is ready. She had recovered [!] from what in infancy was a terror of white-coated doctors, but is not yet ready for a voluntary hospitalization. She knows also that some girls are born without the baby canal properly opened, for which correction is possible in teenage years. Eventually she will be told about her medical history.”64

There is an old Freudian theory of “castration anxiety” and “penis envy” on the part of the small girl who, upon seeing a little boy’s penis believes that she once had one and lost it. While I consider such theory totally ridiculous, it is incredible to learn that such an event has happened in reality!

Being female is wonderful if one is born that way. But one can only begin to speculate the anxieties and identity problems that an unwittingly converted female will experience as “she” grows up. *

References:

1. Topp, Sylvia “The Argument Over Circumcision – The Case Against” The Village Voice, June 16, 1975, p. 9.
2. Brennemann, Joseph, M.D. “The Ulcerated Urethral Meatus in the Circumcised Child” American Journal of Diseases of Children, Vol. 21, 1920, p. 39.
3. Ibid., p. 41.
4. Kaplan, George W. “Circumcision – An Overview” Current Problems in Pediatrics Year Book Medical Publishers, Inc., Chicago, IL., c. 1977, p. 23-24.
5. MacKenzie, A. Ranald, M.D. “Meatal Ulceration Following Neonatal Circumcision” Obstetrics and Gynecology, Vol. 28, No. 2, August 1966, p. 222.
6. Hutchings, Grame (Originally printed in the New Zealand Doctor. Later reprinted in the November 1964 Bulletin of the Federation of New Zealand Parents Centres.) “Notes on the Care of Uncircumcised Infants” – INTACT Educational Foundation reprint.
7. Brennemann, p. 42.
8. Ibid., p. 43.
9. Schlosberg, Charles, M.D. “Thirty Years of Ritual Circumcisions” Clinical Pediatrics, Vol. 10, No. 4, April 1971, p. 208.
10. Graves, John, M.D. “Pinpoint Meatus: Iatrogenic?” Pediatrics, Vol. 41, 1968, p. 1013.
11. Berry, Carl D., Jr., M.D. and Cross, Roland R., Jr., M.D. “Urethral Meatal Caliber in Circumcised and Uncircumcised Males” A.M.A. Journal of Diseases of Children, Vol. 107, Feb. 1961, p. 149.
12. Campbell, Meredith F., M.D. “Stricture of the Urethra in Children” Journal of Pediatrics, Vol. 35, 1949, p. 169.
13. Linshaw, Michael A., M.D. “Circumcision and Obstructive Renal Disease” Pediatrics, Vol. 59, No. 5, May 1977, p. 790.
14. Shulman, J., M.D.; Ben-Hur, N., M.D.; and Neuman, Z., M.D. (Israel) “Surgical Complications of Circumcision” American Journal of Diseases of Children, Vol. 107, Feb. 1961, p. 149.
15. Gee, William F., M.D., and Ansell, Julian S., M.D. “Neonatal Circumcision: A Ten-Year Overview” Pediatrics, Vol. 58, 1976, p. 827.
16. Banister, P.G. “Circumcision” The Lancet
17. Gottschalk, Earl C., Jr. “Living With Hemophilia” Family Circle, April 24, 1979, p. 14.
18. Kaplan, p. 29.
19. Rosner, Fred, M.D. “Circumcision – Attempt at Clearer Understanding” New York State Journal of Medicine, November 15, 1966, p. 2920-2921.
20. Kravitz, Harvey, M.D.; Murphy, John B., M.D.; Edadi, Kasem, M.D.; Rosetti, August, M.D.; & Ashraf, Hebatollah, M.D. “Effects of Hexachlorophene-Detergent Baths in a Newborn Nursery with Emphasis on the Care of Circumcisions” The Illinois Medical Journal, Vol. 122, No. 2, August 1962, p. 133-139.
21. Scurlock, Jacqueline M., M.B., B.S., & Pemberton, Patrick J., M.B. “Neonatal Meningitis and Circumcision” The Medical Journal of Australia, March 5, 1977, p. 332-333.
22. Annunziato, David, M.D., & Goldblum, Louis M., D.O. “Staphylococcal Scalded Skin Syndrome – A Complication of Circumcision” American Journal of Diseases of Children, Vol. 132, Dec. 1978, p. 1187-1188.
23. Sussman, Sidney J., M.D.; Schiller, Ruth P., M.D.; & Shashikumar, V.L., M.D. “Fournier’s Syndrome” American Journal of Diseases of Children, Vol. 132, Dec. 1978, p. 1189-1191.
24. Sauer, Louis W., M.D. “Fatal Staphylococcus Bronchopneumonia Following Ritual Circumcision” American Journal of Obstetrics, Vol. 1, No. 46, 1943, p. 583.
25. Kirkpatrick, Barry V., M.D., & Eitzman, Donald V., M.D. “Neonatal Septicemia After Circumcision” Clinical Pediatrics, Sept. 1974, Vol. 13, No. 9, p. 767-768.
26. Rubenstein, Mark M., LCDR, M.C., USNR, & Bason, William M., MC, USN. “Complication of Circumcision Done With a Plastic Bell Clamp” American Journal of Diseases of Children, Vol. 116, Oct. 1968, p. 381-382.
27. Datta, Nand S., M.D., & Zinner, Norman R., M.D. “Complication from Plastibell Circumcision Ring” Urology, Vol. 9, No. 1, January 1977, p. 57-58.
28. Johnsonbaugh, Roger E., LCDR, MC, USN; Meyer, Bruce P., LCDR, MC, USNR; & Catalano, Denis J., LCDR, MC, USNR. “Complication of a Circumcision Performed With a Plastic Bell Clamp American Journal of Diseases of Children, Vol. 118, No. 5, Nov. 1969, p. 781.
29. Lawton, Nora M. “Circumcision” (letters to editor) British Medical Journal, No. 2, August 14, 1965, p. 420.
30. Shulman et al., p. 152.
31. Trier, William C., M.D., & Drach, George W., M.D. “Concealed Penis” American Journal of Diseases of Children, Vol. 125, Feb. 1973, p. 276-277.
32. Talarico, Rudolph D., & Jasaitis, Joseph E. “Concealed Penis: A Complication of Neonatal Circumcision” The Journal of Urology, Vol. 110, Dec. 1973, p. 732-733.
33. Kaplan, p. 26-27.
34. Limaye, Ramesh D., M.D., & Hancock, Reginald A., M.D. “Penile Urethral Fistula as a Complication of Circumcision” The Journal of Pediatrics, Vol. 72, No. 1, Jan. 1968, p. 106.
35. Byars, Louis T., M.D., & Trier, William C., Lt. Comdr, U.S.N. “Some Complications of Circumcision and Their Surgical Repair” A.M.A. Archives of Surgery, Vol. 76, March 1958, p. 477-478.
36. Shiraki, Iwao William “Congenital Megalourethra with Urethrocutaneous Fistula Following Circumcision: A Case Report” The Journal of Urology, Vol. 109, No. 4, April 1973, p. 723-726.
37. Browne, Denis “Fate of the Foreskin” British Medical Journal, Jan. 21, 1950, p. 181.
38. Kaplan, p. 17-18.
39. Sexty, Lori “Jared’s Ordeal” Mothering, Vol. 12, Summer 1979, p. 84-85.
40. Frand, M.; Berant, N.; Brand, N.; & Rotem, Y. “Complications of Ritual Circumcision in Israel” Pediatrics, Vol. 54, No. 4, Oct. 1974, p. 521.
41. Horwitz, Jonathan, M.D.; Schussheim, Arnold, M.D.; & Scalettar, Howard E., M.D. “Abdominal Distension Following Ritual Circumcision” Pediatrics, Vol. 57, No. 4, April 1976, p. 579.
42. Kaplan, p. 22-23.
43. Ibid., p. 28.
44. Rosefsky, Jonathan B., M.D. “Glans Necrosis as a Complication of Circumcision” Pediatrics, Vol. 39, 1967, p. 744-745.
45. Shulman, et aL, p. 151.
46. McGowan, Andrew J., Jr., M.D.
“A Complication of Circumcision” J.A.M.A., March 17,1969, Vol. 207, No. 11, p. 2104-2105.
47. Van Duyn, John, M.D., & Warr, William S., M.D. “Excessive Penile Skin Loss From Circumcision” J.M.A. Georgia, Vol. 51, August 1962, p. 394-396.
48. Wilson, Carl L., M.D. & Wilson, Morton C., M.D. “Plastic Repair of the Denuded Penis” Southern Medical Journal, Vol. 52, March 1959, p. 288-290.
49. Klauber, George T., M.D., & Boyle, James, M.D. “Preputial Skin-Bridging — Complication of Circumcision” Urology, Vol. 3, No. 6, June 1974, p. 722-723.
50. Kaplan, p. 20.
51. Fleiss, Paul M., & Douglass, John “The Case Against Neonatal Circumcision” British Medical Journal, September 1979, p. 554.
52. Shulman, et aL, p. 150.
53. Kaplan, p. 26.
54. Bromley, R. Innis “Circumcision” Medical Journals and Records, August 21, 1929, p. 212-213.
55. Singh, Balbir, M.D.; Kim, Hong, M.D.; & Wax, Sandor, M.D. “Strangulation of Glans Penis by Hair” Urology, Vol. 11, No. 2, Feb. 1978, p. 170-172.
56. Auerbach, M. Richard, M.D.; & Scanlon, John W., M.D. “Recurrence of Pneumothorax as a Possible Complication of Elective Circumcision” Am. J. Obstet. Gynecol., Vol. 132, No. 5, p. 583.
57. Curtis, Pts. J.E.A., RAMC “Circumcision Complicated by Pulmonary Embolism” Nursing Mirror, Vol. 132, No. 25, June 18, 1971, p. 28-30.
58. Ecstein, Herbert B. “Minor Surgery in Infancy and Childhood” Update, January 15, 1979, p. 141, 144.
59. Lewin, Peter, M.D. “Ritual Circumcision Sequel” Clinical Pediatrics, October 1971, p. 583.
60. Kaplan, p. 21-22
61. Hamm, William G., M.D., & Kanthak, Frank F., M.D. “Gangrene of the Penis Following Circumcision With High Frequency Current” Southern Medical Journal, Vol. 42, No. 8, Aug. 1949, p. 657-659.
62. “Malpractice Leads to Sex Change” Philadelphia Inquirer, Friday, Oct. 31, 1975.
63. Money, John, Ph.D. “Ablatio Penis: Normal Male Infant Sex-Reassigned as a Girl” Archives of Sexual Behavior, Vol. 4, No. 1, 1975, p. 67.
64. Ibid., p. 71.

 

*This individual was never able to adjust to his reassigned female status and experienced severe emotional and adjustment difficulties during childhood and adolescence. Upon being informed at age 14 of his male origin and subsequent loss of his penis, he immediately chose to re-assume his male identity. He underwent surgical penile reconstruction, has married and had become an adoptive father to his wife’s children. Today, as a man in his 30’s, he has chosen to come forward with his story.

Circumcision had been recommended for the twin boys at age 7 months due to “phimosis.” Following the disastrous result of the first twin’s surgery, the other baby was sent home intact. His “phimosis” cleared up on its own within a few days – a poignant indication of the non-necessity of the surgery.

The entire story of this family’s horrendous, lifetime tragedy is related in detail in As Nature Made Him: The Boy Who Was Raised as a Girl, by John Colapinto, HarperCollins Publishers, Inc., c. 2000.

** “Just When You Think You’ve Heard it All!” I’ve received countless phone calls about circumcision related matters. During the mid-90’s I was contacted by an individual who was in the process of undergoing male to female sex-change. This person had been born a male and was routinely circumcised shortly after birth. For unstated reasons he had never accepted his male gender-status, and at age 50 had chosen to be surgically changed into a woman. He/she was requesting information from me on circumcision and informed me that because of the lack of foreskin, the vaginoplastic surgery was going to be considerably more complicated. If the individual has an intact foreskin, the surgeon has considerably more tissue to work with to construct an artificial vagina. This person used a pseudonym with me and wished not to be identified or contacted by anyone else.

Evidently this can be listed as yet another “complication” of circumcision. If the individual later wishes to be changed into a female, subsequent vaginoplasty is much more difficult. R.R.