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Complications of Circumcision
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The development of the human penis is a complex
sequence of events which results in an utterly individual outcome: no two penises are identical
and there is a surprising range of anatomical detail that should be
considered normal. Parents need to be assured of this range of
normality. Moreover, the desire of
practitioners for standard procedures can lead to unpredictable outcomes
because of both this anatomical variation and the impossibility of
predicting the functional results of surgical correction in infants.
This is because the procedures are performed with an emphasis on
achieving an acceptable cosmetic outcome on a very small organ which
has the capacity for considerable growth and changes during puberty.
Furthermore, no surgical procedure can have absolutely predictable
outcomes because of the variations in healing and scar formation, the
individual variations in technique, and the effects of infection.
Regrettably, it seems that the
majority of those performing surgical procedures on the penis of minors
take no interest in following up the outcome after the organ has
developed. Admittedly this involves a time span of at
least a decade, but there have been very few attempts at quality
control and many boys are left with seriously damaged penises; the
outcome is often a functional impairment and is seldom tidy, to say the
least. ...
Each operator applies the procedure
idiosyncratically and without any absolute parameters, to which must be
added the fact that it is surgery
on a very small organ which will undergo a large increase in size
(usually at least three times) at puberty. These factors
may account for the wide variation in circumcision outcomes. A major
failure in quality assurance with circumcision is that practically all
operators never make any assessments of the outcome of their surgery
after the period of growth so as to reduce the oft-seen poor results.
- Pathologist Ken McGrath
Ninth International Symposium on
Circumcision, Genital Integrity and Human Rights
Seattle, August 25, 2006
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For a fuller list of Reasons
Not to Circumcise, click there. Death
now has its own page.
Strictly speaking, a disease has complications, surgery
such as circumcision has side-effects.
Risks vs Benefits
An article in Pediatrics
in January 2000 attempts to compare the benefits of circumcision with
the risks. However, the only risks considered are the direct
complications of surgery - and only some of those.
"Complications" are defined very conservatively,
including only those that are noticed before the baby leaves hospital
or that lead to him being brought back to the same hospital or doctor.
They don't include aesthetic results so bad the parents take him back
for more surgery. Nor do they include the ones the penises' owners
learn to live with - after all, part of the rationale of circumcision
is horror of the penis, so the mother of a cut baby probably doesn't
get to see or attend to a significant proportion of uneven cuts, scarring etc.
The researchers did not cite two of the main studies of
complications, those of William
and Kapila or Patel.
Benefits are defined very generously, using a lot of the
work of Wiswell, rather than those who estimate the benefits more
conservatively, such as To.
No intrinsic worth is assigned to having intact
genitalia, or to not performing invasive surgery, or to having a
choice.
The same is true of a study published in New
Zealand, sometimes cited as supporting an overall advantage
to infant circumcision. A cohort of all the boys born in one city over
a period of months in 1977 were followed for eight years. (They are
still being followed.) This study is potentially valuable, because only
one quarter of the 590 boys were circumcised at birth. Few US studies
include enough intact boys to achieve statistical significance.)
It seemed to find that circumcised boys had more penile
problems in their first year, intact boys in the longer term, with a
difference of "marginal significance" in favour of circumcision. Closer
examination shows that boys not circumcised at birth continued to be
counted as "uncircumcised" throughout the study, and their "penile
problems" included complications of post-neonatal circumcisions!
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"The estimated
1% to 3% incidence of complications after newborn circumcision covers
only the immediate postoperative period prior to the infant's discharge
from the hospital. The reported risks are hemorrhage in 1%, infection -
occasionally leading to sepsis - in 0.5%, meat[iti]s and meatal
stenosis, u[r]ethrocutaneous fistula, adhesions between the glans and
remaining prepuce, secondary phimosis, and cosmetically unsatisfactory
results. The rate of subsequent repeat surgery to correct adhesions of
the glans, meatal stenosis, fistula, and phimosis with buried penis is
unknown, but our practice at Children's Hospital of Philadelphia
includes
about two such cases per month. While this is not a large percentage of
the total number of circumcisions preformed, it is a significant number
of
children undergoing surgery for the complication of this operation. "
-
Schwartz, et al. "Pediatric
Primary Care: A Problem-solving Approach" pp 861-862.
(At 1.25
million circumcisions of newborns in the US per year, a 0.5% infection
rate amounts to 6000 cases per year, and a 4% overall rate of
complications requiring treatment represents 48,000 patients
experiencing
avoidable morbidity.)
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Pieretti
et al. at the MassGeneral Hospital
for Children found 424 (4.7%) out of 8,967 operations in 2003-7 were
for complications resulting from previous neonatal circumcision. (Note
that this is the fraction of operations, not circumcisions) and 127
boys with concerns following newborn circumcision represented 7.4% of
the total volume of cases seen in the pediatric urology outpatient
clinic.
De la Hunt found complications
requiring attention by the GP in 22%
of circumcisions.
de la Hunt MN. "Paediatric Day Care surgery: a hidden burden for
primary care?" Ann R Coll Surg Engl. 1999; 81:179-82.
Where facilities are scarce, the position is much worse.
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Bungoma district, Kenya: Assessment of
traditional and medicalised male circumcision
The study, which was conducted to establish a pre-training baseline
assessing safety of male circumcision in resource-poor settings found high rates of adverse events for both
medical (17%) and traditional circumcision (35%). The most common were
profuse bleeding, infections, pain, insufficient foreskin removal and
torsion. The study findings highlight what could go wrong
if providers are not well trained and adequately equipped to perform
male circumcision in hygienic settings with good post-surgical
follow-up.
UNAIDS/CAPRISA Consultation
on Social Science Perspectives
on Male Circumcision for HIV Prevention
18-19 January, 2007
Summary Report
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Linus Okeke, Adanze A Asinobi and Odunayo S
Ikuerowo
BMC Urol. 2006; 6: 21.
Published online August 25 2006
Abstract
Background
The number of infants managed for neonatal circumcision injuries in our
unit has been on the increase over the past 16 years. In our search for
the sources and reasons for these injuries, we were unable to identify
any previous studies of circumcision injuries from our environment. We
therefore decided to carry out this study in order to shed some light
on this growing problem.
Methods
The patients were made up of 370 consecutive consented children
attending our infant welfare clinic for immunization over a period of 3
months. Information on their demographic data, their age at
circumcision, where, why and who circumcised them was obtained from
their mothers. They were clinically examined for the presence and type
of complications of circumcision.
Results
Our circumcision rate was 87%. Neonatal circumcision had been performed
in 270 (83.9%) of the children. Two hundred and fifty nine (80.7%) were
performed in hospitals. The operation was done by nurses in 180
(55.9%), doctors in 113 (35.1%) and by the traditional circumcisionist
in 29 (9%) of the children. Complications of circumcision occurred in
65 [20.2%] of the children. Of those who sustained these complications,
35 (53.8%) had redundant foreskin, 16 (24.6%) sustained excessive loss
of foreskin, 11 (16.9%) had skin bridges, 2 (3.1%) sustained amputation
of the glans penis and 1 (1.5%) had a buried penis. One of the two
children who had amputation of the glans also had severe hemorrhage and
was transfused. Even though the complications tended to be more likely
with nurses than with doctors or traditional circumcisionists, this did
not reach statistical significance (p = 0.051). [That is, doctors were no better at
circumcising than nurses.]
Conclusion
We have a very high rate
of complications of circumcision of 20.2%. We suggest that
training workshops should be organized to adequately retrain all
practitioners of circumcision on the safe methods available. [The complication rate could also
be reduced by reducing the circumcision rate.]
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A Brazilian study
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J. Ped. Urol. (2010) xx, 1-6
Prospective randomized trial comparing dissection
with Plastibell circumcision
José Murillo Bastos Netto, José Gonçalves de
Araújo Jr,
Marcos Flávio de Almeida Noronha, Bruno Rezende Passos,
José de Bessa Jr, André Avarese Figueiredo
Received 23 August 2009; accepted 7 January 2010
Abstract
Objective: To compare and evaluate
dissection and Plastibell™ circumcision
techniques for the treatment of phimosis.
Methods: In 2006-2007, 125
children were submitted to circumcision by the same surgeon.
The children were randomly divided into two groups (PD: Plastibell™ and
DC: dissection). In
both groups the surgery was performed under general anesthesia and
dorsal penile block.
The dissection circumcision used the double circular incision
technique. Follow-up was done
on days 15, 45 and 90 after surgery.
Results: Sixty-eight patients
were included in DC and 57 in PD. The mean age at surgery was
71.76 +/- 31.56 months for DC and 70.95 +/- 31.73 months for PD. There
was no difference in
Kayaba’s classification for phimosis or indication for surgery between
the groups. Surgical time
for DC was 14.64 +/- 1.93 min and for PD 3.29 +/- 1.48 min (P <
0.001). The incidence of immediate
complications was similar, but late complications, especially
adhesions, were greater in
DC (P < 0.01). The use of pain medication (paracetamol) was
similar during the first 2 days
after surgery, but was greater in PD from the 3rd day after surgery (P
< 0.05).
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Table 2 Immediate and late
complications.
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DC n (%)
[N=68]
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PD n (%)
[N=57]
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p
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Immediate complications
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Total
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10 (16.17%)
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3 (5.26%)
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0.08
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Hemorrhagic
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5 (7.35%)
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2 (3.51%)
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Reoperation
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1 (1.47%)
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0
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Other
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5 (7.35%)
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1 (1.75%)
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Late complications
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Total
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8 (11.76%)
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3 (5.25%)
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0.34
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Cicatricial
[scarring]
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6 (8.82%)
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2 (3.50%)
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Hemorrhagic
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2 (2.94%)
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1 (1.75%)
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Adhesions
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20 (29.41%)
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6 (10.52%)
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0.014
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Conclusions: Plastibell™
circumcision has a shorter surgical duration with fewer late
complications,
but requires more analgesic medication after the 3rd day post surgery.
[One
boy in six suffered an immediate complication and one in nine a late
complication, from the sleeve procedure. More than one in 20 suffered
an early complication, and another one in 20 a late complication from
the Plastibell™. Nearly three in ten suffered an adhesion from a sleeve
procedure, and more than one in ten from the Plastibell™. The p-values
reflect only the signicance of difference between the two operations.
As usual, the authors are only concerned which operation is "better",
not whether it should be done at all.]
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A Danish study - 5%
complications
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Danish Medical Journal Dan Med J
2013;60(8):A4681
May 30, 2013
Complication rate after circumcision in a
paediatric surgical setting should not be neglected
Jørgen Thorup, Sebastian Cortes Thorup
& Inge Botker Rasmussen Ifaoui
Abstract
Introduction: As a consequence of the
discussion on whether the health benefits of newborn male circumcision
outweigh the risks and the discrepancies in reported figures of
complications, we evaluated our results from a paediatric surgical
department.
Material and methods: Patient
file data from children who had undergone ritual circumcision in the
1996-2003- period were retrieved. Complications recorded until December
2011 were noted.
Results: Circumcision in 315
boys aged from 3 weeks to 16 years (median five years) were evaluated. A total of 16 boys (5.1%) had significant
complications, including three incomplete circumcisions
requiring re-surgery, two requiring re-surgery six months and five
years postoperatively due to fibrotic phimosis and two requiring
meatotomy due to meatal stenosis two and three year postoperatively.
Acute complications included two superficial skin infections one week
postoperatively and five cases with prolonged stay or re-admissions for
bleeding the first or second postoperative day, whereof two underwent
operative treatment. Finally, two had anaesthesiological complications
leading to a need for overnight surveillance, but no further treatment.
Discussion: Parents should be
counselled and be required to provide informed consent that any health benefits of childhood
circumcision do not outweigh the reported complication rate
and that therefore they should weigh the health benefits against the
risks in light of their religious, cultural and personal preferences.
As ritual circumcision is legal, a strong focus on high
surgical/anaesthesiological standards is needed to avoid complications.
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A Paediatric Urologist writes
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Men's
Health magazine 2/5/2009 9:07 AM CST
Neonatal circmcision is totally unnecessary, and
there is no current role
for preventative or prophylactic neonatal circumcision.
Unfortunately, 70-80% of neonatal circumcisions
are performed by
obstetricians, who can neither manage their complications (2-5%
incidence)
nor obtain proper informed consent (defined as outlining risks and
benefits of a procedure, as well as alternatives-including nothing) for
neonatal circumcision. Currently, the American College of OB-GYN (ACOG)
have no paramenters for training (learning and performing neonatal
circumcision, managing complications)of residents, who then go out and
continue this practice.
In my practice, as a pediatric urologist, I manage
the complications of
neonatal circumcision. For example, in
a two year period, I was referred
275 newborns and toddlers with complications of neonatal circumcision.
None of these were 'revisions' because of appearance, which I do not
do.
45% required corrective surgery (minor as well as major, especially for
amputative injury), whereupon some could be treated locally without
surgery.
Complications of this unnecessary procedure are
often not reported, but of
300 pediatric urologists in this country who have practices similar to
mine...well, one can do the math, to understand the scope of this
problem...let alone, to understand the adverse cost-benefit aspect of
complications (>$750,000) in this unfortunate group of infants
and young
children. Fortunately, neonatal circumcision is on the decline as
parents
become educated...but the complications still continue.
Until the time that the USA falls in step with the
rest of the planet who
does not submit newborns to neonatal circumcision, ACOG should assure
that
the training of obstetricians to perform this procedure is adequate,
particularly in avoiding and managing complications of a procedure that
is
unnecessary, and that obstetricians learn to obtain proper informed
consent from parents who have no idea of the problems that can ensue.
M.David Gibbons, MD
Associate Professor, Pediatric Urology, Georgetown University School of
Medicine and George Washington School of Medicine. Attending Pediatric
Urologist, Childrens National Medical Center, Washington, DC. Director,
Pediatric Urology, Georgetown University Hospital, Washington, DC.
Head,
Pediatric Urology, Inova Fairfax Hospital For Children, Falls Church,
Virginia. Posted at Men's Health Magazine on The Debate Over
Circumcision: Should
All Males Be Circumcised? in the comments section
(http://www.menshealth.com/)
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Some circumcisionists did a study....
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JAMA Pediatr. Published online May 12, 2014.
doi:10.1001/jamapediatrics.2013.5414
Rates of Adverse Events Associated With
Male Circumcision in US Medical Settings, 2001 to 2010
Charbel El Bcheraoui, PhD; Xinjian Zhang,
PhD; Christopher S. Cooper, MD; Charles E. Rose, PhD; Peter H. Kilmarx,
MD; Robert T. Chen, MD, MA
Importance Approximately 1.4
million male circumcisions (MCs) are performed annually in US medical
settings. However, population-based estimates of MC-associated adverse
events (AEs) are lacking. [And
isn't that scandalous in itself, when the operation is performed with
no diagnosis?]
Objectives To estimate the
incidence rate of MC-associated AEs and to assess whether AE rates
differed by age at circumcision.
Design We
selected 41 possible MC AEs based on a literature review
and on medical billing codes. [One
of the commonest complications is meatal stenosis following meatal ulcer.
The word "meatal" does not occur in the text of the study, only in one
of the references, which is then ignored.] We
estimated a likely risk window for the incidence calculation for each
MC AE based on pathogenesis. We used 2001 to 2010 data from SDI Health,
a large administrative claims data set, to conduct a retrospective
cohort study.
Setting and Participants SDI
Health provided administrative claims data from inpatient and
outpatient US medical settings.
Main Outcomes and Measures For
each AE, we calculated the incidence per million MCs. We compared the
incidence risk ratio and the incidence rate difference for circumcised
vs uncircumcised newborn males and for males circumcised at younger
than 1 year, age 1 to 9 years, or 10 years or older. An AE was
considered probably related to MC if the incidence risk ratio significantly exceeded 1 at P
< .05 or occurred only in circumcised males. [Since P is itself a measure of
significance, how was this "significant excess" over 1 decided on? Room
for a fudge-factor here - they can just say the significance is "not
enough" over one and ignore the risk.]
Results Records were available
for 1 400 920 circumcised males, 93.3% as newborns. [Extremely large numbers prove
nothing. Garbage in still means garbage out, just more of it.]
Of 41 possible MC AEs, 16 (39.0%) were probable. The incidence of total
MC AEs was slightly less than 0.5%. [That's
still 6000 adverse events/year, 16/day in the USA.]
Rates of potentially serious MC AEs ranged from 0.76 (95% CI,
0.10-5.43) per million MCs for stricture of male genital organs to
703.23 (95% CI, 659.22-750.18) per million MCs for repair of incomplete
circumcision. Compared with boys circumcised at younger than 1 year,
the incidences of probable AEs were approximately 20-fold and 10-fold
greater for males circumcised at age 1 to 9 years and at 10 years or
older, respectively.
Conclusions and Relevance Male
circumcision had a low incidence of AEs overall, especially if the
procedure was performed during the first year of life, but rose 10-fold
to 20-fold when performed after infancy.
[The
narrow definition of "adverse effects", and the arbitrary measures of
significance, mean this study will inevitably underestimate the risks
of circumcision. Death from circumcision
would not show up in this study, for example, because the baby would
not be returned to the hospital.]
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This study, predictibly, got world-wide headlines of the
form "Circumcision safer if done earlier". ("Hurry! This offer won't
last!")
A Utah study - 11.5% complication rate
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The Societies for Pediatric Urology
poster presentation at the 66th annual meeting, May 18-20, 2018
Identification of circumcision
complications using a regional claims database
Glen Lau, Jaewhan Kim, Anthony Schaeffer, Salt
Lake City, UT
INTRODUCTION AND OBJECTIVES:
Circumcision remains a very common procedure in the United States.
Published complication rates are lower than clinical practice suggests.
We aimed to use a population-based claims database to define the
regional 2 year complication rate in boys who underwent circumcision.
We hypothesized that this rate would be between 1 and 5%.
METHODS: The Utah All-Payer
Claims Database (UAPCD) contains data from health insurance carriers,
Medicaid, and third party administrators in Utah. The data consist of
medical and pharmacy claims as well as insurance and health care
provider data, and all residents in the State of Utah are included
unless they opt out. The UAPCD was queried for all male patients aged
0-730 days undergoing circumcision (CPT 54150, 54160 and 54161) during
the year 2013. Subjects were censored if they had less than 2 years of
post-procedure data. Demographic, medical and procedure-specific data
was abstracted. ICD-9 and -10 codes were used to identify infectious,
bleeding, urethral, skin and wound healing-related complications.
Encounters for circumcision revision (CPT 54161, 54163), or lysis of
penile adhesions (CPT 54162) were noted.
RESULTS: In 2013 there were
26,069 male births and 6298 circumcisions were captured. [That's a rate of only 24.1%.]
The mean age at circumcision was 9.8 days for those who had
circumcision with a clamp (CPT 54150), 16.3 days for those who had a
surgical circumcision other than clamp (CPT 54160) and 309.3 days for
boys who had a formal circumcision after the neonatal period (CPT
54161). 725 (11.5%) complications were identified. The two most common
complications were phimosis in 433 (6.9%) and other wound related
complications such as acquired torsion, buried penis and edema in 168
(2.7%). Infectious/inflammatory (1.2%), urethral (0.5%), and bleeding
(0.3%) complications were rare. 101 (1.6%) patients underwent surgical
revision or lysis of penile adhesions. Complications did not differ
significantly between patients who h the original circumcision in a
hospital vs. an outpatient setting (p=0.33) or in an urban vs. rural
location (p=0.22). When adjusted for healthcare setting and location,
the difference in complications between patients less than 90 compared
to those 90 to 730 days old was not significant.
CONCLUSIONS: The incidence of post-circumcision
complications at 2 years is much higher than expected at 11.5%,
but does not appear to be influenced by age at circumcision, healthcare
setting or a rural vs. urban location. A minority of subjects needed
reoperation during the ensuing 2 years.
Source of Funding: None
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A
California study - worse than thought
Journal of Surgical Research
January 2019, 233, 111-117
DOI: https://doi.org/10.1016/j.jss.2018.07.069
A longitudinal population analysis of
cumulative risks of circumcision
Ya-Ching Hung, David C. Chang, Maggie L. Westfal,
Isobel H. Marks,
Peter T. Masiakos, Cassandra M. Kelleher
Abstract
Background
Circumcision is widely accepted for newborns in the United States.
However, circumcision carries a risk of complications, the rates of
which are not well described in the contemporary era.
Methods
We performed a longitudinal population analysis of the California
Office of Statewide Health Planning and Development database between
2005 and 2010. Using International Classification of Procedures, Ninth
Revision, Clinical Modification and Current Procedural Terminology
codes, we calculated early and late complication rates by Kaplan–Meier
survival estimates. Late complications were defined as those that
occurred between 30 d and 5 y after circumcision. [So complications - such as these -
discovered after
5 years
of age, including puberty and adulthood, were not
counted.]
Descriptive analysis of complications was obtained by analysis of
variance, chi-square test, or log-rank test. On adjusted analysis, a
Cox proportional hazard model was performed to determine the risk of
early and late complications, adjusting for patient demographics.
Results
A total of 24,432 circumcised children under age 5 y were analyzed.
Overall, cumulative complication rates over 5 y were 1.5% in neonates,
0.5% of which were early, and 2.9% in non-neonates, 2.2% of which were
early. On adjusted analysis, non-neonates had a higher risk of early
complications (OR 18.5). In both neonates and non-neonates, the
majority of patients with late complications underwent circumcision
revision.
Conclusions
Circumcision has a
complication rate higher than previously recognized. Most patients with late complications after
circumcision received an operative circumcision revision.
Clinicians should weigh the surgical risks against the reported medical
benefits of circumcision when counseling parents about circumcision. [Ethical clinicians should decline
to
perform unnecessary surgery on healthy children.]
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The following complications are listed in
approximately increasing order of severity.
Correctable complications
Re-adhesion
Circumcising is supposed to make a penis
"maintenance-free". Yet these mothers, all in one region, all report
the need for excessive maintenance, including having to "scrub with a
washcloth" making "diaper changes traumatic" - all without questioning
circumcision itself.
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In Reuters, via Medscape:
Most Penile Adhesions Resolve
Spontaneously
After Neonatal Circumcision
[The real
headline:
More Than Two-thirds of Circumcised Babies have
Penile Adhesions]
WESTPORT, Aug 03 (Reuters Health) - Penile
adhesions are common after neonatal circumcision, but most do not
require any intervention, according to researchers from the Cleveland
Clinic Foundation, in Ohio.
Dr. Lee E. Ponsky and colleagues looked for penile
adhesions in all
circumcised boys who presented to their pediatric urology clinic. In
total, 254 boys were examined, ranging in age from 1 month to 19 years,
8 months.
The prevalence of penile adhesions declined with
age, the investigators
found. [That, or the
incidence of penile adhesions has been increasing
over the last 20 years.] All told, 71% of infants had adhesions
compared with 28% of boys ages 1 to 5
years, 8% of those ages 5 to 9 years and 2% of older boys. About one
third of infants had adhesions more severe than grade 1, compared with
10% of boys ages 1 to 5 years and none of the boys older than 5 years.
Seven of the patients had been treated for
adhesions, and three of these had recurrences, Dr. Ponsky and
colleagues note.
The findings indicate that most penile adhesions
resolve spontaneously with time, the researchers write. Although the
study did not address the reasons for spontaneous resolution, they
point out that possible mechanisms include "an increased number of
erections with age, penile growth, hormonal influence on local tissue
and keratin pearl formation." [This
indicates ignorance of the normal development of the intact penis, and
how it might be affected by circumcision.]
Based on their findings, the Cleveland researchers
advise against routine lysing of penile adhesions, except perhaps when
they involve the circumcision line. [Another
conclusion is that these adhesions could be prevented by not
circumcising.]
"Adhesions that involve the circumcision line may
be more likely to cause skin bridges," they note. [How else do they think skin
bridges are caused?]
J Urol 2000;164:495-496.
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This site for mothers recounts many adhesions requiring "re-circumcision".
The option of not circumcising does not seem to have been considered.
Other unspecified damage requiring
re-circumcision
Facebook, July 17, 2014
Gofundme
- Facebook, cJanuary 25, 2016
Aesthetic damage
Unaesthetic outcomes of circumcision are seldom
reported. One purpose of circumcision is to create a "maintenance-free
penis" and mothers are less inclined to inspect it than mothers of
intact sons. Click here for pictures of
There is a collection of ugly
circumcisions on Tumblr
One reason aesthetic damage is so common is that the
baby's penis is tiny compared to the man's. Any mishap is enlarged,
like writing on a balloon.
 |
 |
 |
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Balloon inscribed then inflated
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Balloon inflated then inscribed
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Unspecified Damage 
It is unclear what the "ridges" are, or how probing might fix them.
There should be no clamping and hence no bruising of the testicles.
Phimosis
Blalock
et al. found phimosis
in 2.9%
of 521 circumcised boys, two-thirds of them (10/15) with buried penis. Since "phimosis"
(usually a misdiagnosis of the normal infant attachment of the foreskin
to the glans) is a common reason for circumcision, this is ironic
indeed.
Hairy shaft
The shaft of the penis is normally hairless, but
erection of a tightly
circumcised penis can pull hairy scrotal skin on to the shaft, causing
discomfort on intercourse.
One sufferer is shock-jock Howard Stern. He
discussed it on May 4, 2006 at 6.15am.
Wound Dehiscence
Parting of the joined cut edges.
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Kristen and I also had a bizarre sexual allergy to
each other. Whenever we made love, a painful rash spread across me
which would take about three weeks to heal. We went to a number of
doctors, but we never resolved the problem. I even had a circumcision
to try to stop the reaction. Being circumcised aged 24 is not a good
idea, particularly if the night after your operation you find yourself
watching Jane Fonda's erotic film Barbarella.
Before I could stop myself, I had burst my stitches! Hearing my
screaming, Kristen came running to see what the matter was. When she
found out what had happened, she was in stitches. I no longer was.
- Richard Branson "Losing My
Virginity" p 142
Branson has heavily promoted circumcision in
Africa, in a clear case of the Fox Who
Lost His Tail
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Pictures of
wound dehiscence (NSFW)
De-gloving
(Where the outer skin layer slides out of alignment with the mucosa,
like a glove coming off a finger)
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From
the PSOT blog
To Plastibell
or Not To Plastibell?
Comment for the STFM procedure list dialog on
Circumcison Techniques.
I have been unhappy with the Plastibell device...
Mogen is the easiest and fastest with excellent
safety, but lack of fundamental skills with needle and thread
intimidate many from being able to do these procedures past the newborn
period.
...
REPLY MF-MD I would still vote that residents need to learn Plastibel,
too. I did more Plastibels than Gomco's in residency, and am much more
comfortable with them, and faster. A Urologist that has helped us with
complications we've had with Gomcos said he
sees far more complications with Gomco's than Plastibel's.
And I've had 2 situations lately where we started one procedure, and
for various reasons switched to the other (one each way!). And
sometimes you go to do a Gomco and find the size you need isn't
available... Just my thoughts. Mary
REPLY -WMR I've never seen a long term complication
from a Gomco, but continue to believe that the procedure is not
medically indicated. What are the complications you witnessed that
required care of a urologist, and could you give me an estimate of
their frequency?
REPLY MF-MD
I see residents
differentially pull too much of the outer skin through, leading to a
"de-gloving" problem which distresses the parents. [It probably distresses the babies,
too.] I've
also see residents inadvertently separate the two layers as they get
the skin off the bell, again leading to bleeding and a "de-gloved"
appearance. Obviously this is a teaching issue, and we
work to prevent it. I see/hear this about once a year, overall. The
only complication I've had with a Plastibel in 18 years (18 years mine
and 3 years residency teaching) was once when we probably used a ring
that was slightly too large and it slipped up onto the shaft after it
separated and required some imagination to get it off! Mary
REPLY-FORMAN The only complication I used to get
from a Gomco was the occasional bleeding, easily sutured with some gut
suture.
REPLY WMR--WE
have seen the degloved effect once every 70 Mogens in the
hands of inexperienced physicians, but it is easily identified. It does
not require urological consultation, but you do need to identify the
correct anatomical plane and reapply the clamp.
...
Wm MacMillan Rodney MD
Adjunct Professor of Family Medicine
Meharry/Vanderbilt School of Medicine
Medicos para la Familia
Memphis and Nashville, Tn.
www.psot.com
See also Ethics
for more admissions from this doctor.
|
A de-gloving in Muncie, IN
Film director Frank
Capra was a victim of de-gloving as an adult.
Lantz's story
Too much skin removed on one side
- Reddit, May 31, 2016
...My brother
would have been an amazing police officer. He killed himself 2 weeks
before he was to become one. The ridicule could have been avoided,
the self loathe and torture of being deformed could have been avoided.
He was circumcised shortly after he was born. It was botched badly. His
penis was cut short, the opening grew to the side and it was
crooked....
|
- Michelle G on Twitter, May 9,
2018
- reply to Michelle G on Twitter,
May 9, 2018
Haemorrhage
(Bleeding), including
haemophilia, is now on its own page
Meatal
stenosis, meatal ulcer
In babies:
|
A baby's long foreskin prevents the re-entry of
urine. Ammonia from stale urine attacking the meatus, the opening of
the urethra in
the glans of a
circumcised baby, is believed to attack the delicate surface, creating
an ulcer. Bacteria like E. coli may also play a
part.
This can lead to narrowing (stenosis) of the meatus, which may have to
be corrected by surgery; meatotomy. Patel
found 31 cases of meatal ulcer and 8 meatal stenoses in 100
circumcisions. Meatal ulcer can cause urinary retention and if
untreated, kidney failure.
Meatotomy was so common
among Jews in
19th century England that it was called "the second circumcision".
|
|
Urol
J. 2008 Fall;5 (4):233-6
Lubrication of circumcision site for
prevention of meatal stenosis in children younger than 2 years old.
Bazmamoun H, Ghorbanpour M, Mousavi-Bahar SH.
Department of Pediatrics, Division of Gastroenterology, School Of
Medicine, Hamadan University Of Medical Sciences, Hamadan, Iran.
dbazmamoun@yahoo.com
INTRODUCTION: Circumcision is
one of the most common surgical operations throughout the world, and
meatal stenosis is one its late complications. We evaluated the topical
use of a lubricant jelly after circumcision in boys in order to reduce
the risk of meatal stenosis.
MATERIALS AND METHODS: A
randomized control trial was performed, in which 2 groups of boys
younger the 2 years old underwent circumcision according to the sleeve
method. The parents in the study group were instructed to use petroleum
jelly on the circumcision site after each diaper change for 6 months.
In the control group, no topical medication was used. The children were
followed up regularly and evaluated for meatal stenosis, bleeding,
infection, and recovery time.
RESULTS: A total of 197 boys in
each group completed the study. None of the children in the study group
but 13 (6.6%) in
the control group developed meatal stenosis (P <
.001). Infection of the
circumcision site was seen in 3 (1.5%) and 23 (11.7%) children of the lubricant and control groups, respectively (P
< .001), and bleeding was seen in 6 (3.0%) and 37 (18.8%),
respectively (P < .001). The mean time of recovery in the
lubricant group was 3.8 +/- 1.2 days, while it was 6.9 +/- 4.2 days in
the control group (P = .03). CONCLUSION: Based on the findings of this
study, it seems logical to use a lubricant jelly for reducing
postcircumcision meatal stenosis and other complications.
PMID: 19101896 [PubMed - in process]
[Experimenting
on children in this way would be utterly unethical in the western
world.
The
experiment shows that to prevent meatal stenosis, parents
must use petroleum jelly on the circumcision site after each diaper
change for 6 months. So much for circumcision making
care easier.]
|
In children:
|
The Surgeon, 2016
Cultural background, non-therapeutic circumcision
and the risk of meatal stenosis and other urethral
stricture disease: Two nationwide register-based
cohort studies in Denmark 1977 - 2013
Morten Frisch, Jacob Simonsen
ABSTRACT
Background:
Meatal stenosis is markedly more common in
circumcised than genitally intact males, affecting 5 - 20 per cent
of
circumcised boys. However, no population-based study
has estimated the relative risk of meatal stenosis and other urethral
stricture diseases
(USDs) or the population attributable fraction (AFp)
associated with non-therapeutic
circumcision.
Methods:
In two nationwide cohort studies (comprising 4.0
million males of all ages and
810 719 non-Muslim males aged 0 - 36 years, respectively), we compared
hospital contact
rates for USD during 1977 - 2013 between circumcised and intact Danish
males. Hazard ratios
(HRs) were obtained using Cox proportional hazards regression, and the
AFp
estimated the proportion of USD cases in <10 year-old boys that
is due
to non-therapeutic circumcision.
Results:
Muslim males had higher rates of meatal stenosis
than ethnic Danish males,
particularly in lt
10 year-old boys (HR 3.44, 95 per cent confidence interval 2.42 -
4.88). HRs
linking circumcision to meatal stenosis (10.3, 4.53 - 23.4) or other
USDs (5.14, 3.48
- 7.60) were high, and attempts to reduce potential misclassification
and confounding further
strengthened the association, particularly in <10 year-old boys
(meatal stenosis: 26.3, 9.37 - 73.9; other USDs: 14.0, 6.86 - 28.6).
Conservative
calculations revealed that at least 18, 41,
78, and 81 per cent of USD cases in
<10 year-old boys from countries
with circumcision prevalences as in Denmark, the United Kingdom, the
United States and Israel, respectively,
may be attributable to non-therapeutic circumcision.
Conclusion:
Our study provides
population-based epidemiological evidence that circumcision
removes the natural protection against meatal stenosis
and, possibly,
other USDs as well.
|
|
BRITISH
JOURNAL OF UROLOGY, Volume 75, Number 1: Pages 91-93,
January 1995.
Clinical presentation and pathophysiology
of meatal stenosis following circumcision.
Persad R; Sharma S; McTavish J; Imber C;
Mouriquand PD
Department of Paediatric Urology, Addenbrooke's Hospital, Cambridge,
UK.
OBJECTIVE: To describe the
clinical presentation and pathophysiology of meatal stenosis occurring
after circumcision.
PATIENTS AND METHODS: The
clinical presentation and operative findings are reported in 12
children who presented with meatal stenosis over a period of 3 years.
The cardinal symptoms of meatal stenosis were
penile pain at the initiation of micturition (12 of 12), narrow, high
velocity stream (8 of 12) and the need to sit or stand back from the
toilet bowl to urinate (6 of 12). Following surgical correction with
meatotomy there was no recurrence of stenosis after a mean follow-up of
13 months. Traumatic meatitis of the unprotected post-circumcision
urethral meatus and/or meatal ischaemia following damage to the frenular artery at circumcision
are suggested as possible causes of meatal stenosis.
Preservation of the frenular artery at
circumcision, or the use of an alternative procedure (preputial
plasty), may be advisable when foreskin surgery is required, to avoid
meatal stenosis after circumcision.
...
DISCUSSION AND CONCLUSIONS
Meatal stenosis as a
complication is often missed by the clinician because children do not usually have late follow-up
after circumcision. The symptoms of pain are often
mistaken for symptoms of a lower urinary tract infection and symptoms
of distal urethral impairment of urinary flow are usually ignored for
many months
...
88 circumcisions
(and 91
preputial plasties) were performed at this institution: seven of
these patients (8%)
presented with meatal
stenosis.
...
|
In adults:
|
A pathologist writes:
A patch of surface necrosis [dead tissue] is commonly seen on the glans of adult circ
patients. In all the ones I have seen, the necrosis (which appears as a
dark purple area) was in the ventral
aspect from about the attachment of the frenulum up to and
partly surrounding the meatus; I have never seen necrosis in the dorsal aspect. Even if
the frenular artery is not severed (standard methods caution about
taking care not to cut this artery by damaging the frenulum, hence the
noticable increase in numbers of cut boys with an intact frenulum over
the last decade or two), the disruption of the venous drainage via the
paired frenular veins would have the same effect of preventing
circulation across the extensive capillary plexus [network] in the skin
of the glans and meatus. This disruption is inevitable as all the
superficial veins (including the frenular) are cut in any form of
circumcision, but I suspect that the dorsal surface has other
alternative routes via the deeper veins.
Loss of circulation through the glanular skin would take some days for
the capillary bed to undergo angiogenesis [growth of blood vessels] in
the healing sequence, during which time the epithelial [top layer]
cells would die, which in turn would expose the underlying [layer], and
that is exactly how an ulcer is defined.
Once the dermis is exposed, abrasion with clothing etc. will irritate
and impair/delay healing. Healing of this ulcer increases the collagen
in the tissue as part of the repair process which we see as a scar,
this being increased with any irritation or extension of the healing
time and the loss of stretch capacity leads to [narrowing] of the meatal opening.
|
A series of cases were reported a few years ago in
J Urol using
topical anesthesia for meatotomy.
Most cases are done under general anesthesia. It costs about $1500 to
have it done as
an outpatient.
Urethrocutaneous
Fistula
| J Pediatr Surg 2003 Apr;38 (4):642-3
A very late onset urethral fistula coexisting
with skin bridge
after neonatal circumcision: A case report.
Yazici M, Etensel B, Gursoy H.
Adnan Menderes University, Department of Pediatric
Surgery, Aydin, Turkey.
Complications of neonatal circumcision are
generally minor and occur early; a few reports exist on the late or
serious kind. The authors describe a case of urethrocutaneous
fistula occurring 13 years postcircumcision. The patient also had a
skin bridge, another late complication of circumcision. The authors
suggest erections in puberty as the triggering factor for onset of
fistula. To our knowledge, neither such a late occurrence of fistula
nor coexistence of these complications have been reported.
J Pediatr Surg 38:642-643. Copyright 2003, Elsevier Science (USA). All
rights reserved.
PMID: 12677587 [PubMed - in process]
[Lack
of reporting of these complications has more to do with failure of
follow-up of circumcision, than actual rarity. Skin bridges are
remarkably common.]
|
Facebook, May 10, 2013
|
Infection
Making a wound on a newborn near the source of
faeces presents a significant risk of infection. Patel found 8
infections from 100 circumcisions. Infection can lead to meningitis and
death.
Staphlococcus
|
Enzenauer RW, Dotson CR, Leonard T, et al. Male
Predominance in Persistent Staphylococcal Colonization and Infection of
the Newborn.
Hawaii Medical Journal 1985;44 (10):389-90, 392, 394-6.
The authors conclude:
The increased incidence of staphylococcal
colonization and pyoderma in
males may be associated with circumcision performed after the first 24
hours of life in the nursery.
Circumcision is performed on approximately 90% of
the male infants horn at our hospital.6 In our
study population, 87% of the males were circumcized.
Circumcision, by its very nature, requires more
staff-patient "hands-on" contact. The infants are all lined up and
tbeir stomachs lavaged [pumped] clear in preparation for the procedure.
The circumcisions are done daily, as a group, in a small area, using
reusable circumcision restraints.
Postoperatively, there is also more handling of
the diaper area in caring for the fresh, hemorrhagic wound.
A larger study. involving more infants, is
required to validate the hypothesis that circumcision is the culprit
responsible for the increased rate of staphylococcal colonization and
infection in newborn males. This may be due to the remarkably high rate
of neonatal circumcision done in the United States. A much smaller
study would be satisfactory if it were performed in Great Britain or
one of the developed countries of Europe, where the incidence of
noncircumcision is more equal to the rate of circumcision in the U.S.
Gellis eloquently indicted circumcision, noting
that the infant "has
enough portals of entry for organisms as it is," referring to the
infant's nose, mouth, conjunctiva, and the cut end of his umbilicus.
"It seems totally unnecessary to aid and abet lurking bacteria by
adding a raw wound to his genitalia."19
Tuberculosis & Airborne Disease Weekly
Tuesday, April 4, 2000
Staphylococcus Rash in Babies Linked to Health Care Workers
2000 APR 4 - (NewsRx.com)
An outbreak of Staphylococcus aureus pustulous
rash in a group
of newborn, circumcised babies has been linked to medical workers
in the neonatal nursery.
The outbreak occurred in the newborn nursery of a
150-bed naval
hospital in eastern North Carolina and lasted from August to
January of 1999.
"Cases were newborn males who had undergone a
circumcision
procedure and post-discharge required anitmicrobial treatment for
severe postulous diaper rash," reported
K.K. Hoffmann and
colleagues. Seventeen cases out of 36 total were cultured,
and
all 17 showed methicillin-sensitive, erythromycin-resistant S.
aureus.
As usual, the article is at pains to
blame the health workers, not the circumcisions.
|
In one hospital in Long Island, in October 2003, four baby boys contracted
antibiotic-resistant staph. infections after being
circumcised.
One man has been severely
disabled for life as a result of a staphlococcal infection
from circumcision, resulting in, among other things, the removal of half his brain.
Doctors Opposing Circumcision warns (23 October,
2005) that the risk of Methicillin-Resistant Staphylococcus Aureus
(MRSA) is now too great to allow non-medically indicated ciricumcision
to continue:
|
... The advent of MRSA in epidemic proportions
increases risks associated with male neonatal circumcision beyond those
previously contemplated and further increases the desirability of the
non-circumcision option. MRSA and other antibiotic-resistant varieties
of SA, such as vancomycin-resistant Staphylococcus aureus
(VRSA), increase risk, including death, to newborn circumcised boys. In
view of this increased risk, the American Academy of Pediatrics and the
American College of Obstetricians and Gynecologists should review their
policy (2002) of offering elective medically unnecessary
non-therapeutic neonatal circumcision at parental request.
... Medical practitioners must consider the
epidemic status of MRSA and exercise their independent judgment
regarding the performance of non-therapeutic neonatal circumcision.
There is an ethical duty to not perform
scientifically invalid medical treatment, especially when it puts the
patient at risk. Doctors must act in the best interests of their
child-patients regardless of parental requests. Doctors may
conscientiously object to the performance of non-therapeutic
circumcision of children.
Complete
text
|
Staphylococcal scalded skin syndrome
(Also known as Ritter's disease, toxic epidermal
necrolysis and in adults, Lyall syndrome.)
In the American Journal of Diseases of the Child,
Vol 132, No 12: Pp 1187-8, December 1978, Staphylococcal scalded skin syndrome
A complication of circumcision, David Annunziato
and Louis M. Goldblum describe three cases, one
fatal.
Hepatitis B
|
Turk
J Gastroenterol. 2002 Mar;13 (1):1-5
Hepatitis B seroprevalance and risk
factors in urban areas of Malatya.
Kurcer MA, Pehlivan E.
Inonu University Medical School, Department of Public Health, Malatya.
BACKGROUND/AIMS: To determine
the prevalence of hepatitis B viral markers
and to assess possible risk factors in urban areas of Malatya.
METHODS:
This was a sero-epidemiological, community based cross-sectional study
and
included 646 participants ( female 352, male:294) from 192 houses. A
face
to face questionnaire was carried out and HBsAg, anti-HBc and anti- HBs
markers were analyzed from blood samples using Micro ELISA technique.
RESULTS: The prevalence of
HBsAg, anti-HBc and anti-HBs were found to be
6.0%, 29.3% and 30.3% respectively. In the final logistic regression,
HBV
infection (=anti HBc+) was independently associated with the age group
of
21 years and older (OR=3.7, 95% CI=1.884-7.494), in illiterate subjects
(OR=2.1, 95% CI=1.180-3.326), in farmers and labourers (OR=2.8, 95%
CI=1.042-7.953) and in these with multiple sexual partners (OR=2.1, 95%
CI=1.574-8.168). In addition, HBV
infection was significantly higher in
circumcised male children compare to uncircumcised ones
( chi2=5.58,
P=0.01), in ones who gave birth to child at home compare to in ones who
gave birth to a child at hospital ( chi2=13.86, P=0.0001).
CONCLUSION: The
results of our study indicate that Malatya province has a moderate
endemicity with regard to HBV infection.
PMID: 16378266 [PubMed]
|
Tetanus
|
Bull Soc Pathol Exot. 2008 Feb;101 (1):54-7
Post-circumcision tetanus in Dakar,
Senegal
[Article in French]
Soumaré M , Seydi M , Dia NM , Diop SA , N'dour CT
, Diouf L , Diop BM , Sow PS .
This study aimed at describing the epidemiology,
clinical features and prognosis of post-circumcision tetanus at the
infectious diseases clinic in Fann Hospital in Dakar.
Data were collected retrospectively for analysis
from patients' files recorded from January 1, 1999 to December 31,
2006. 54 cases were included, accounting for 4% of all tetanus cases
admitted to the clinic during the study period (54 cases/1291). The
patients' average age was 9 +/- 3.7 years old (range = 1-17 years) and
52% of them were schoolboys.
In most cases (76%), tetanus symptoms occurred
beyond 7 days after circumcision. The average delay from onset of the
disease to admission was 2.3 days (range = 0-6 days). The circumcision took place at
home in 39% of cases, in health
center in 35% of cases and in unspecified area in 26% of
cases. The majority of patients (85%) had never received tetanus
vaccine and, in 72% of the cases, the circumciser was designated as a
male nurse.
Generalized tetanus was observed in all cases,
most of which was a mild form of the disease (63%). During
hospitalisation, thirteen patients (24%) had complications among which
diaphragmatic and intercostal muscle spasms (3 cases), bacteraemia (5
cases), respiratory infection (4 cases), urinary tract infection (4
cases), and fracture of the vertebrae (1 case). The case fatality rate was 7.4% (4 deaths).
Vaccination together with health education of the
population as well as a better sensitization of the practitioners are
necessary to eradicate tetanus after circumcision. [Not circumcising would also have
that effect.]
|
Bladder Infections
|
miffyrabbit in The
Guardian, May 12, 2010
... My parents decided to circumsize me as a
toddler. ... they considered it to be more hygienic. Consequently
through my life I've been blighted with bladder infections - two of
which hospitalised me. Urinary tract infections are far more serious in
men than women; obviously because of the difference in plumbing. Also,
but less importantly, I have absolutely no sensation where it matters
in my private parts because I had such an aggressive circumsition.
|
Septic Arthritis
Other unspecified infections
- Soggy Mamas on Facebook, October
25, 2014
- Soggy Mamas on Facebook, December
10, 2014
- posted
in Circumcision Mutilation Watch,
June 29, 2016
Neuroma
Destruction of the large number of the
nerve-endings of the prepuce is inevitable in circumcision. Human and
animal studies show that when a nerve is cut, the cut end swells up
greatly and the fibre sprouts and branches, resulting in "a disordered
tangle of axons, Schwann cells and fibrous tissue" instead of the
original receptor. According to Cold and Taylor, studies of
circumcision sites show amputation neuromas - well-known for causing
sensations of pain. It may be speculated that a
confusion between these pain sensations and sexual pleasure
are an outcome of circumcision.
- based
on Cold, CJ and Taylor, JR, The Prepuce
in BJU International 83, Suppl 1, 34-44 (1999)
Blockage of
the urethra
|
A baby born in Saskatchewan was circumcised with a
Plastibell
TM
at six days old. In the next two days his bladder swelled to the size
of a tennis ball (in a newborn, that's big). This put pressure on his
inferior vena cava, the main vein draining the lower body, which caused
his lower body to swell and turn blue.
Click
on the thumbnail for a full-size image
Going in through the baby's belly, doctors drained
200 mL of urine. When they removed the Plastibell TM, they found it was
embedded in his glans.
The baby passed more than 600 mL of urine in the following 12 hours. It
took him two days to recover.
One study of 2000 PlastibellTM circumcisions found a
complication rate of 1.8%.
- Linh Ly and Koravangattu
Sankaran
Acute
venous stasis
and swelling of the lower abdomen
and extremities in an infant
after circumcision
CMAJ 2003; 169: 216-217
Another baby, in Ontario, was not so lucky.
|
|
Korean J Pediatr. 2015 Apr;58(4):154-7.
doi: 10.3345/kjp.2015.58.4.154. Epub 2015 Apr 22
Urosepsis and postrenal acute renal failure in a
neonate following circumcision with Plastibell device
Kalyanaraman M, McQueen D, Sykes J,
Phatak T, Malik F, Raghava PS
Abstract
Plastibell is one of the three most common devices
used for neonatal circumcision in the United States, with a
complication rate as low as 1.8%. [Low?
That's one every 24 minutes in the USA.] The
Plastibell circumcision device is commonly used under local anesthesia
for religious [?]
circumcision in male neonates, because of cosmetic reasons and ease of
use. Occasionally, instead of falling off, the device may get buried
under the skin along the shaft of the penis, thereby obstructing the
normal flow of urine. Furthermore, the
foreskin of neonates is highly vascularized, and hence,
hemorrhage and infection are possible when the skin is cut. Necrosis of
penile skin, followed by urethral obstruction and renal failure, is a
serious surgical mishap requiring immediate corrective surgery and
medical attention. We report a case of fulminant
urosepsis, acute renal failure, and pyelonephritis in a
4-day-old male neonate secondary to impaction of a Plastibell
circumcision device. Immediate medical management was initiated with
fluid resuscitation and mechanical ventilation; thereby correcting life threatening complications.
Pediatricians and Emergency Department physicians should be cognizant
of the complications from Plastibell circumcision device in order to
institute appropriate and timely management in neonates.
[All six authors are affiliated with the Department of
Pediatric Critical Care Medicine, Children's Hospital of New Jersey at
Newark Beth Israel Medical Center, Newark, NJ, USA, yet this
complication of an American
circumcision was reported in a South Korean
journal! None of the authors' names is Korean.]
|
Buried
penis
This condition may arise from natural causes
and/or overly "aggressive" circumcision, when it may be known as "iatrogenically
entrapped penis". The shaft of the penis is buried below the surface of
the pubic skin. A true congential buried penis is rare. It is caused by
an abnormally large pad of fat over the pubic bones and dense tissue
that holds and pulls the penis inward. The skin of the shaft is pushed
forward over the glans,
giving the appearance of an unusually long foreskin. Circumcising an
unrecognized buried penis can remove shaft skin as well as the
foreskin, making the case even worse. If the penis was not buried
already, removing too much shaft skin when circumcising can bury it by
pulling it down into the pubic fat. A second circumcision may be
incorrectly performed on patients with various causes of concealment,
preventing repairs made by using the remaining shaft skin or foreskin.
Instead the boy will need a skin graft.
|
By: thirdkane, posted on SueEasy
2008-04-26
I'm a 35 y/o male with a lifetime disfiguration as a result of
circumcision as a child. My penis is inverted inside my body and as a
result have faced a lot of distress emotionally and socially. It has
effected my life negativly in so many ways, love life, school to where
I missed years worth of school because i was ashamed of my disfigurment
to avoid manditory showering with my peers.
|
Boys with a buried penis are often told that they
will grow out of it, and many cases will improve, but some will never
have a penis that looks as long or works as well as it might. A boy
with a deeply buried penis may be ridiculed by other boys. If he has no
visible penis when he is standing up, he may have to sit down to
urinate.
Buried penis can be corrected by (more) surgery,
cutting out pubic fat and sewing down the skin of the groin and
scrotum.
A mother's story
Penoscrotal
Webbing
If too much skin is taken, the skin of the scrotum
is pulled up the shaft of the penis, making it appear shorter and
hairy. The "webbing" arises from the raphe
of the scrotum being pulled ahead of the rest of it. It can be
corrected by more surgery ("Z-plasty")
Painful
erections
![''Too much skin was taken...painful erection and skin rips''[image filed under resent]](Images/resent/resent-fletch.png)
The
scandal is that with no long-term followup, we have no idea how many
men suffer like this.
Deformity
Click here for a
case of gross deformity due to circumcision.
Ischaemia
Glans
ischemia after circumcision and dorsal penile nerve block: Case report
and review of the literature.
Urol Ann. 2015 Oct-Dec;7(4):541-3
Authors: Garrido-Abad P, Suárez-Fonseca C
Abstract
Circumcision is an easy commonly performed surgical procedure in
childhood. However, it is not free of a low number of complications,
(1-5-5%). Here we report a case of a 3-year-old boy with glans
superficial necrosis [tissue
death] after circumcision, managed with topical
(nitroglycerin, gentamicin), oral (pentoxifylline) and epidural (urgent
caudal block with bupivacaine) treatment. A review of the literature
and the different treatments reported by other authors was done. After 7 days of treatment, local
signs of ischemia and severe pain
disappeared, without adverse events related to treatment. Although the
ischemia or necrosis of the glans after circumcision are rare, we may
suspect them in case of presence of severe acute pain or dark color. We
report the successful management of this complication.
PMID: 26692685 [PubMed]
|
Gangrene
|
British Medical Journal BMJ Case
Reports 2012; doi:10.1136/bcr-2012-007096
October , 2012
Electrocautery-induced gangrene of the glans
penis in a child following circumcision
By Gunalp Uzun, Yavuz Ozdemir, Murat
Eroglu, Mesut Mutluoglu
Description
A 7-year-old child was brought to the hyperbaric [raised pressure]
oxygen centre because of cyanosis [blueness] of his glans penis. He had
been circumcised the same day with the use of a monopolar
electrocautery device. Unfortunately, the electrocautery caused a
severe burn injury on the glans of the child. On examination, he had
necrosis [dead tissue] over the glans and shaft of the penis.
figure 1 [NSFW,
Not for the squeamish]
"Necrosis of glans and penile shaft."
Circumcision is a religious and traditional ritual
in some cultures and involves the removal of the preputium penis. It
may be performed by a variety of techniques, and although it is
regarded as a relatively safe procedure, it does, like any surgical
procedure, carry the risk of complications. Choosing the most
appropriate technique and giving the highest attention and care will
avoid most of these
complications. Bipolar electrocautery has been shown to be safe in
circumcision. However, the use of a monopolar electrocautery, as was
the case in this patient, has resulted in a dramatic accident. [Should it be called "unfortunate"
or an "accident" when monopolar electocautery inevitably
fries the penis like a hot-dog cooker] Indeed,
when a monopolar electrode is used, the electrical current is carried
by the small diameter of the penis, which may lead to tissue heating
and thus thermal injury. Although adjunctive hyperbaric oxygen therapy
was administered in the following days, the lesion worsened and
resulted in significant tissue loss involving the whole glans and the
distal parts of the penile shaft.
figure 2 [NSFW
and not for the squeamish]
"Despite hyperbaric oxygen therapy and wound care, debridement [removal
of dead tissue - in this case, most of the penis] was unavoidable."
|
Necrotising
Fasciitis (Galloping gangrene)
Click here for pictures of galloping gangrene
from circumcision (Not for the squeamish.)
Epidermal
Inclusion Cyst
|
IOSR Journal of Dental and Medical Sciences
(IOSR-JDMS), Volume 13, Issue 10 Ver. IV (Oct. 2014), PP 73-75
ost Circumcision Penile Epidermal
Inclusion Cyst: A Case Report
Ofoha C.G., Dakum N.K.
Abstract:
Post circumcision penile epidermal inclusion cysts are rare and few
cases have been reported worldwide. A five year old boy presented with
a complaint of a mass located at the dorsal aspect of the penis along
the circumcision scar. The mass was noticed few weeks after
circumcision. On examination the mass was located at the dorsal aspect
of the penis proximal to the coronal sulcus along the circumcision scar
and measured about 1cm × 1.5cm. It was oval in shape with no
differential warmth and non tender. The mass was smooth, firm, mobile
and with well defined edges. The overlying skin was normal with no
punctum. The mass was excised under general anaesthesia. Histologic
sections show an attenuated cystic structure, lined by stratified
squamous epithelium containing keratin debris and amorphous material.
Histologic diagnosis was epidermal inclusion cyst. Post circumcision
epidermal inclusion cyst is usually easy to diagnose from history and
physical examination. Complete total excision is usually curative and
prevents recurrence
|
Priapism
caused by necrosis
|
Zhonghua Nan Ke Xue. 2005 Jul;11 (7):544-7.
[Integrated treatment for priapism caused by
circumcision: a case report] [Article in Chinese]
Jin BF, Huang YF, Shao CA, Xia XY, Guan FG, Li G,
Wang J.
Department of Andrology,
Nanjing General Hospital of Nanjing Command, PLA,
Nanjing, Jiangsu 210002, China. hexiking@126.com
Priapism [permanent erection] is rare on clinical
condition with complicated pathogenesis which is very difficult to
cure. The paper reported a case of a long-time priapism complicated by
local skin necrosis [tissue death], which was caused by circumcision.
After the failure of routine therapy, we treated the patient with
traditional Chinese therapy, such as TCM herbs combined with bone
scraping and depletion therapy,
and achieved the satisfactory effect.
PMID: 16078678
[PubMed - in process]
|
Gastric
rupture
Connelly KP, Shropshire LC, Salzberg A, "Gastric
rupture associated with prolonged crying in a newborn undergoing
circumcision," Clin Pediatr, Sept. 1992, 560-561.
Oxygen
deprivation
1.
|
The State
Columbia, South
Carolina
July 10, 1992
Boy
in coma most of his 6 years dies
A boy who was in a coma for more than six years
while a legal battle raged around him has died ...
Allen A. Ervin was born in July 1985 and had been
on life support since December 1985, when his brain was damaged from
oxygen deprivation during circumcision. He died at Spartanburg Regional
Medical Center on Wednesday, three weeks before his 7th birthday
... The anesthesiologists who attended to Allen
during the circumcision settled the case for $435,000 and agreed to
lifetime payment of his medical bills.
|
2.
|
From the webpage
of WILLIAM E. ARTZ, P.C.
The infant Plaintiff, age 20 months, was scheduled
for an elective circumcision on 5/18/92. Upon arrival at the hospital,
the infant Plaintiff presented with a fever of 100.4 degrees, runny
nose, and a dry cough for one week. Rather than cancel surgery, the
anesthesiologists cleared the patient. Upon induction of anesthesia,
the infant Plaintiff went into laryngospasm and required a paralyzing
drug and intubation. Concern arose that the infant had developed
pulmonary edema and might need transfer to a tertiary level facility
better able to manage the airway. After 2 ½ hours of observation in the
operating room, a discussion ensued as to whether the infant Plaintiff
needed transfer at all. The pulmonary edema was largely resolved, the
arterial blood gases were dramatically inproved, and the child's O2 saturation
levels and lung function were close to normal. Nevertheless, a decision
was made to transfer.
Upon arrival at the second hospital, the child
came under the largely unsupervised care of an anesthesiologist in his
fellowship (one year after residency) on rotation from a neighboring
hospital. The treatment plan called for continued intubation and
periodic medication which both sedated and paralyzed the child. The
arterial blood gases taken at 2:50 p.m. on 5/18 showed virtually normal
lung function, making the child a candidate for extubation (tube
removal). The anesthesiologist fellow nevertheless decided to continue
with intubation and sedation. The sedation was being administered
hourly, but the amount was effective for only 30 minutes. Thereafter,
the child, by virtue of his agitation and thrashing about,
self-extubated at approximately 6:00 p.m. As a result, O2 from the
ventilator was delivered down the esophagus into the stomach, causing
projectile vomiting at 6:10 p.m. With the tube out of the trachea and
the child unsedated, the infant Plaintiff was able to breathe on his
own. At 6:20 p.m., the anesthesiologist fellow administered sedation
and a paralyzing drug. At 6:25 p.m., the child's heart rate dropped to
47, and then into the 30's. Instead of removing the endotracheal tube
and reinserting a new tube, the anesthesiologist fellow administered
atropine and epinephrine pharmacologically, causing the heart rate to
rise and then drop again. At 6:40 p.m., he finally removed the tube and
reintubated the child. Ventilation improved dramatically, but the
infant Plaintiff sustained severe hypoxic brain damage as a result of
the 15 minute delay in correcting the airway. The infant remained
hospitalized for two additional months and was eventually discharged
home, where he is cared for by his parents and three sisters.
The infant Plaintiff's cognitive level will not
develop beyond first grade level. He has cerebral palsy of the lower
extremities, but is expected to be able to walk with tendon-lengthening
surgery and a walker. As of age 4, he was not potty trained.
The medicals incurred as of settlement were
$175,000, and the lost wage claim totalled $713,000. Cost of future
care, were the infant to be placed in a full service school, exceeded
$5.6 million by projection, although defense experts felt the child's
needs could be fully met with a present value annuity costing $3
million.
The defendants were two hospitals and an
anesthesia group, plus two individual anesthesiologists.
|
Brain Damage
Click here for the settlement in the case of the brain damage to Jacob Sweet
in Anchorage, Alaska.
Clamp
injuries
| Tuesday August 29 2001 5:34 PM ET
US warns of circumcision clamp injury risk
WASHINGTON (Reuters Health) - Reports of
complications associated with certain kinds of circumcision clamps have
spurred the US Food and Drug Administration (FDA) to issue a letter to
physicians warning them of the potential for injury if the clamps are
misused.
In the letter, doctors are advised not to
substitute or interchange clamp components and to ensure that clamps
appropriately fit the patient.
"Although research suggests that circumcision is
generally a safe procedure, we are concerned that some serious
device-related complications have occurred," the FDA said in the
letter. Between July 1996 and January 2001, the agency has received 105
reports of injuries involving the clamps, including cuts and bleeding,
penile
amputation, and urethral damage.
Clamps are used during circumcision to protect the penis while the
foreskin is being removed [implying
that the foreskin is not part of the penis].
"The use of...clamps that have been reassembled by
users with parts from different manufacturers, or that have bent parts
or mismatched components, has led to clamps breaking, slipping, falling
off during use, tearing penile tissue or failing to make a tight seal,"
the FDA said.
The agency points out that "although...clamps may
appear to have interchangeable parts, these parts may not always be
safely interchanged because they may vary slightly in dimensions."
The injuries associated with other types of
clamps, meanwhile, stem from the use of clamps "that have jaw gap
dimensions greater than those in the manufacturer's specifications, or
use of clamps inappropriately sized for patients." This may "allow too
much tissue to be drawn through the opening of the device, thus
facilitating the removal of an excessive amount of foreskin and in some
cases, a portion of the glans," the FDA said.
For this type of clamp, the agency recommends that
surgeons "ensure that the clamp being used is appropriate for the
patient size," noting that "some manufacturers have two sizes of
clamps, one for adults and the other for infants."
|
| NYTimes
Oy! Did You Hear the One About the
Overzealous Mohel?
11/13/06
11:59 AM
Court Reporter
Plaintiffs: L.G., a minor, by
and through his parents and next friends, Dror Gerges and Sivan Gerges
Defendants: Daniel J. Krimsky;
Mogen Circumcision Instruments Ltd.
Accusation: An Oceanside, Long
Island, rabbi is accused of lopping off the head of an 8-day-old's
penis during a Bris on December 16, 2004.
According to the federal complaint filed last week
in Central Islip, New
York, not only was Daniel Krimsky unqualified to perform a Bris, but
the
circumcision tool he used — called a "Mogen
clamp" for the overly curious
— was faulty, and instructions failed to warn against the (seemingly
obvious) risk of severing. What's worse, the rabbi then tried to hide
his
error, and the boy's injuries only came to light when a physician
attending the Bris noticed something was wrong and spoke up.
"L.G. was required to undergo corrective surgery
... which was not entirely successful," reads the complaint, which is a
delicate way of
saying doctors were unsuccessful in reattaching the boy's penis. " (He)
has
been permanently disfigured and mutilated, and will suffer forever from
a
disfigured and mutilated penis, and from the loss of sexual feeling and
function."
So, what price for a partial penis? [implying a circumcised penis is
not "partial"] Plaintiffs seek $150,000 in
damages from the rabbi and another $150,000 from the makers of the
"Mogen clamp." Only time will tell if the boy will consider that a fair
trade when he grows up.
Disposition: Awaiting response
from the rabbi and the clamp manufacturer, who will likely seek to have
the case tossed like poor
little L.G.'s foreskin.
You can read
the complaint here.
— Nick Divito
|
Plastibell™
Ring injury
|
Journal
of Pediatric Urology Volume 6, Issue 1, Pages 23-27 (February
2010)
Penile injuries from proximal migration
of the plastibell circumcision ring
C.O. Bode and A.O. Ademuyiwaa
Pediatric Surgery Unit, Department of Surgery, College of Medicine
University of Lagos / Lagos University Teaching Hospital, PMB 12003
Lagos, Nigeria
Abstract
Background
Although circumcision is the commonest surgical procedure performed on
male neonates, complications still arise from all methods used by
operators.
Patients and method
This was a prospective study of penile injuries resulting from proximal
migration of the Plastibell device in neonate boys referred to the
Lagos University Teaching Hospital, Lagos, Nigeria. The parameters
measured were patients' biodata, presentation, management and treatment
outcome.
Results
Twenty-three injuries resulting from circumcision with the Plastibell
device all occurred from prolonged retention of the ring. In each case,
the ring was retained and had migrated proximally. There was extensive
skin loss in 17 (74%) babies. Urethrocutaneous fistulae were the result
in nine (39%) of these cases, while partial necrosis of the glans penis
occurred in four (17%). These complications resulted from the use of
wrong-sized Plastibell kits, lack of follow-up by the medical staff,
and inadequate maternal knowledge of ring fall-out time.
Conclusion
Proximal migration of the Plastibell ring can result from employment of
an inappropriate size, causing grievous penile injury. Adequate
information should be provided to mothers of circumcised babies about
possible complications of the Plastibell kit when employed. There is a
need to redesign the Plastibell kit to eliminate its migration up the
penile shaft.
These pictures
appeared on the web about the time this study came out, and may refer
to it. (Not for the squeamish)
|
- BabyCenter, October 18, 2014
Loss of glans
|
Savage
Love
by
Dan Savage
[Village Voice] October 26th, 2004 1:00 PM
Q. I am 24 years old and lost my entire
glans penis, the head of my dick, in a botched circumcision. Basically
I have a shaft but there's no head at the end. Unfortunately, I was
left with my balls so I still have a sex drive, but it's nearly
impossible for me to climax. When I was much younger, around 14 to 16,
I could sometimes masturbate to a climax, but after a couple of years I
stopped being able to do this. Some of the women I've been with never
saw the condition of my penis, and failed to notice when I didn't come.
Others have seen my condition before intercourse and refused to have
sex with me, while still others found out afterward, after I wasn't
able to come, and then never wanted to have sex with me again. Of
course I never dare to ask anyone to suck me, although this might
provide the necessary extra stimulation and actually help me climax. So
my problem, Dan, is twofold: I can't come and I can't get anyone to
stick around and help me try to come. Can you suggest any special
techniques for someone in my condition? Any help would be appreciated.
I'm very miserable, frustrated, and lonely. —MUTILATED AND COMELESS
A. OK, A.Z., after reading MAC's letter, and after
insisting your husband read MAC's letter, is circumcision really
something you want to risk? I know, I know, "complications," as it's
delicately put, are rare after circumcision. But even if the odds are
low—even if they're infinitesimal—the thought of having to look your
glans-less son in the eye one day and say, "We're awfully sorry about
that botched circumcision, son, but your father and I used to know this
woman who once dumped a guy because he was uncircumcised, you see, and
we didn't want to risk that ever happening to you . . . and . . . so.
Sorry." Speaking parent-to-parent, A.Z., and speaking as a contentedly
circumcised adult male who likes his dick just the way it is and has no
truck whatsoever with hysterical anti-circumcision activists (whew!), I
would rather teach my son to wash under his foreskin than assume even
the tiniest risk of him losing the head of his penis in a botched
circumcision.
OK, MAC, on to you. Jesus, Jesus, Jesus. Rarely am
I left speechless or bereft of any suggestions at all after reading a
letter, but Christ almighty, I haven't the faintest idea what to tell
you. But I ache for you, kiddo, and so I'm throwing open the
switchboards here at Savage Love HQ and putting out a call for advice
from my resourceful readers. If anyone out there has any expertise on
headless dicks or knows of any special techniques for people in MAC's
condition, please write in. Write in right now.
|
|
As an infant, I underwent the usual (then)
curcumcision procedure. ... I'm from the upper-midwest US area where
this was common practice. ... It seems something went wrong during the
suposidly "simple" procedure. My glans was sliced off. Apparently there
was an attempt to re-attach it with out success. So I was left without
the usual head on the end of my member. ... Apparently the doctor who
performed the mis-hap, felt a bit guilty about the whole affair (as he
well should have) and at some point later in my infancy modified my
ramaining foreskin, (which was apparently fairly long) so that I would
appear to have a normal intact penis. ... The skin at the tip of my
penis had a small opening, so I was not able to retract it at all. ...
I didn't have the usual bulge at the end. There seemed to be a few
bumps at the end, suggesting the remnants of a coronal ridge, but that
is all.
- Bostel's blog, July 8, 2006
|
>
|
Loss of glans after Plastibell
circumcision
Lana writes [to "Hey LLL: Circumcision Affects
Breastfeeding! Tell moms the truth!" on Facebook, November 26, 2013
Yesterday we had an appointment at the women's and
childrens hospital ...
in the bathroom ...
a little boy came running out of the stall pants-less ...
he didn't have a whole penis. It looked as though someone had taken a
guillotine and chopped it off. There was a catheter in the stump and
the stump was about 1cm long. It was obvious, hideous and very sad to
see.
Then mom feels the need to explain. When he was 8
days old he had a plastibell circumcision. The ring cut the blood
supply to his glans off and it went black, the tissues died and by the
time they rushed him to hospital the head of his penis was in the
diaper unattached to the shaft and even more of the shaft tissue was
necrosing. The surgeon had to remove all the dead cells right up into
the good tissue to save his life. leaving him with a stump and the need
for a catheter in order to urinate.. he would be having many many
surgeries to reconstruct his penis as he grows up ...
|
Case study of reconstruction after loss of
glans from monopolar electocautery (malpractice) in Syria in 2019. (image)
After
one year, the authors claim a good result, but admit that they cannot
assess the sexual outcome. They mention "sex reassignment" as a
decision that may be made after "serious penile injuries" but without
reference to its most notable failure, below. |
Ablation
(removal) of the penis
The tragedy of David (initially named Bruce)
Reimer of Winnipeg, Manitoba, is seldom blamed on circumcision, as it
should be.
|
Bruce was born one of normal identical twin boys
in Winnipeg in 1965. Seven months later, his mother noticed that "their
foreskins were closing, making it hard for them to urinate," a doctor
told her that they had phimosis,
and both boys were scheduled for circumcision at St. Boniface Hospital.
.
(In fact foreskins do not normally close, and
true phimosis is not diagnosable in boys as young as seven months,
since the foreskin has usually not yet separated from the glans. The facts as
given do not stack up. One probability is that the mother had been
wrongly instructed to retract their foreskins, and that this caused
tearing and scarring, leading to the closure. This is a common excuse
for circumcision.)
A power surge in the electocautery needle (used to
seal blood vessels by heat) burnt off Bruce's penis, and it was decided
to reassign his genitals surgically and raise him as a girl, Brenda.
There is a strong suspicion that his being an identical twin was a
factor in the decision, and the case was widely used by Dr John Money
for the next 15 years to demonstrate that gender is completely
malleable, under purely social control.
Brenda was subjected to castration at the age of
22 months, but she was a troubled tomboy throughout her childhood. From
the age of eight onward, she steadfastly refused further surgery, and
at puberty she resisted taking hormones. Her sexual desires, closely
monitored by Dr Money, were towards females, and her parents were made
to face the possibility that their daughter was a lesbian.
At 14 she refused to live as a girl any longer and
was told the truth about his gender.
At 16 he had a penis reconstructed, but the outcome was unsatisfactory
and teasing by his peers led to two suicide attempts. At 21 he had
another reconstruction with a better outcome. He met a woman with three
children, abandoned by their three biological fathers, who was somewhat
disillusioned with men's pride in their penile prowess. For some years
he was a happily married adoptive father, but he said:
"It was like
brainwashing. I'd give just about anything to go to a hypnotist to
black out my whole past. Because it's torture. What they did to you in
the body is sometimes not near as bad as what they did to you in the mind
- with the the psychological warfare in your head."
- The true story of
John/Joan
by John Colapinto
Rolling Stone December 11, 1997
(David was called "John/Joan" in the medical literature.)
"It only added
to the young couple's misery that [brother] Brian's phimosis had long
since cleared up by itself, his healthy penis a constant reminder that the
disastrous circumcision on Bruce had been utterly unnecessary
in the first place."
Colapinto also discusses another very similar
case, also reassigned as female by Dr Money.
In March, 2004, David Reimer committed suicide.
Colapinto has written a
feature article for Slate analyzing his motives. (email here if this
article becomes unavailable.)
|
A more
detailed, scientific account of the case of "John/Joan/John"
is at the CIRP library. It refers to his circumcision as "phimosis
repair by cautery".
|
David was not
born intersexed
(hermaphrodite). For issues of intersexuality, see the Intersex Society of North America
website. Nor was he transsexual (having a gender identity different
from his physical gender at birth). Intactivists in
general have no objection to voluntary sex-change surgery performed on
adults.
It seems gender
identity (what sex we think we are) is laid down in the brain, as is
sexual orientation (what sex we are attracted to), and each is distinct
from biological gender (XX, XY or other chromosomal makeup, and/or the
appearance of the genitals or secondary sexual characterisics) - though
all three may be affected by environment, including upbringing.
|
Other cases of penis ablation from circumcision
(commonly through the use of unipolar electocautery)
are reported by Williams
and Kapila and Bradley
|
(This article comes via Snopes,
because the picture was used to illustrate an urban myth)
Severe Burn of Penis Caused by Excessive
Short-Wave Diathermy
Jiang, Jun et al. (Department of Urology, Third Military Medical
University, Chongqing)
Asian Journal of Andrology. 6 December 2004.
A 38-year-old man was admitted to this Hospital
for severe penile burn caused by excessive short-wave diathermy. Five
days ago, the patient visited a clinic for recurrent genital herpes
simplex. Circumcision was performed and local short wave diathermy
given immediately. The frequency of short wave source was 13.56 MHz
with a penile exposing time of about 2.5 hours. Blisters and
extravasation at the penile skin were seen 1 day and became black 3
days after short-wave diathermy. The patient could micturate [i.e.,
urinate] without hematuria [i.e., blood in the urine]. The whole penis
was burned black and became indurated [i.e., hardened] with a clear
margin with the normal skin at the base of the penis. He felt no pain
in the penis even with needle puncture. Doppler sonography revealed no
blood flow in the penis and severe burn and penile gangrene was
diagnosed.
At day 31 after the treatment, the necrotic part
of penis was resected with only about 1 cm of the penile stump left.
Thrombi were found in the two deep arteries of the corpora cavernosa
and deep dorsal arteries and the veins beneath Buck's fasica. Scrotal
skin was mobilized and shifted to repair the penile stump. Pathological
examination showed necrosis of the penis tissue and thrombi formation
in the corpora cavernosa.
Convalescence was uneventful. The patient could
micturate in standing position by pushing skin around the stump of the
penis backward.
P the diathermy ablation (not for
the squeamish)
|
|
520 So.2d 920 (1987)
Terry W. FELICE, Sr., Individually,
et al., Plaintiffs-Appellees,
v.
VALLEYLAB, INC., et al., Defendants-Appellants.
Court of
Appeal of Louisiana, Third Circuit.
November
4, 1987.
Writs
Denied January 8, 1988.
Brame, Bergstedt &
Brame, David A. Fraser, Lake Charles, for plaintiffs-appellees.
Camp, Carmouche, Barsh, Gray,
Hoffman & Gill, David Frohn, Lake Charles, McGlinchey Stafford,
Mintz, Cellini & Lang, Colvin G. Norwood, Jr., New Orleans, for
defendants-appellants.
Before GUIDRY, FORET and YELVERTON, JJ.
YELVERTON, Judge.
This case involves a surgical accident to a two
year old child. During a circumcision operation the child's penis was
burned off by an electrosurgical device. The father, ...
filed suit against Valleylab, Inc., the manufacturer of the unit, and
the State of Louisiana, ...
The trial judge found the State defendants to be 100% at fault and
returned a verdict in favor of the plaintiffs, ...
individually, against the State in the amounts of $18,968.01 for past
medical expenses and $100,000 in general damages, and in favor of ...
on behalf of the minor child ... in
the amount of $1,730,000. The jury returned a verdict in favor of the
plaintiffs against Valleylab, Inc. in the amount of $2,750,000. The
jury found Valleylab to be 30% at fault. Judgment was rendered
according to the two verdicts. The defendants have appealed and the
plaintiff has answered the appeal. We conclude that the jury was
clearly wrong in finding Valleylab at fault. We agree with the trial
judge that 100% of the fault lies with the State and its agencies. We
reconcile the conflict in the award by finding the jury's assessment,
$2,750,000, the more reasonable.
...
Dr. William Goodger and Dr. Cynthia Glass were residents training at
Moss Regional Hospital. ...
Neither doctor was a
board certified general
surgeon.
...
FACTS
In late January 1984 Jeffery's parents noticed
that he complained of pain when he urinated and that the foreskin of
his penis had difficulty retracting. He was examined by a physician and
his condition was diagnosed as phimosis. [At
two years old, he could not have had true phimosis. It was normal for
his foreskin not to retract.] Circumcision
surgery was recommended, and Jeffery was admitted to Moss Regional
Hospital. The surgery was performed on February 2, 1984 by Dr. William
Goodger, a first year family
practice resident at the hospital, under the supervision
of Dr. Cynthia Glass, a third year
surgical resident. The two residents were the only doctors present
during the surgery. Dr. Glass instructed Dr. Goodger to
perform a circumcision technique known as the guillotine technique. In
this technique the foreskin of the penis is stretched past the end of
the penis and clamped with a hemostat to hold the foreskin in a
position to be cut off. After the excess foreskin is cut away, the
bleeding is controlled and the edges of the foreskin are sutured
together. Generally the cutting in circumcisions is performed with a
scalpel.
Dr. Goodger, under the supervision of Dr. Glass,
was instructed to cut the foreskin with a cutting instrument known as
the Valleylab Electrosurgical Unit, known as an ESU. This unit operates
by applying a high frequency electrical current through a "surgical
pencil" to the cutting area. The electronic cut of the ESU reduces
bleeding at the cutting area and eliminates the necessity of
"tying-off" the vessels. The unit has two modes: cut and coagulation.
The surgery in the present case was begun in the cut mode on a setting
of one on the power dial, and raised to two-and-one-half when the
initial setting failed to make a cut. Dr. Glass instructed Dr. Goodger
to cease cutting after he had cut approximately one-third of the
distance across the foreskin. Dr. Glass observed that something was
wrong because the penis had retracted and was very pale. Dr. Glass then
became aware that the penis had sustained a full thickness burn. The
ESU never touched the clamp during the surgery. The record is clear the
penis was burned by excess electrical current running through the
penis. Dr. Glass then removed the rest of the foreskin with scissors
and sutured it by hand. A burn ointment, Silvadene, was applied to the
burned area.
On February 8, 1984 the child was sent home.
Several days later he began running a high fever and was taken back to
the hospital where he was transferred to New Orleans Charity Hospital.
Eventually his external penile tissue sloughed away leaving him with no
visible penile tissue. Put in simpler terms, his
penis was gone.
Because of this injury Jeffery has suffered from
physical problems with his urethra, the channel between the bladder and
the penis, and has undergone four additional surgical procedures.
...
At trial the expert testimony agreed that the
accident occurred as a result of the introduction of too much
electricity to the cutting area. Dr. James Brennan, a professor of
electrical engineering, explained the general principles. Electricity
has the ability to generate heat through any form of conductor.
However, the heat will be concentrated more where the conductor is
smaller; this principle is known as current density. On the cut mode
the generator is on, constantly generating a continuous stream of
electricity. In the present case the conductor of electricity was a
very small penis of a two year old child.
Dr. Leonard Knapp, a general surgeon, did some
research for purposes of his testimony and explained that when too much
electricity goes through a small area the heat causes the blood vessels
in an appendage to thrombose. ...
In the present case the ESU was intended to be
used in most surgical procedures either to cut the tissue or to be used
to stop the bleeding. The obvious, or ordinary, user of these machines
are the surgeons who manipulate the "surgical pencil". We find that
using the ESU to cut on a small appendage is a foreseeable use of this
machine. The evidence is clear that most
physicians are unaware of the dangers inherent in using the ESU to cut
upon small appendages, such as a child's penis. ...
the danger in the present case was not a danger which a surgeon should
be presumed to know through his familiarity with the machine....
there are no warnings or instructions on how to use the ESU in a
routine circumcision. There were not adequate warnings placed on the
machine itself. The machine merely indicated that the device produces
"hazardous electrical output". It is clear that Valleylab failed to
give adequate notice of the danger inherent in using the ESU in making
a cut in a circumcision, or other surgeries involving small appendages.
This failure resulted in the product being unreasonably dangerous in
normal use.
We find, however, that the absence of warning was
not a cause-in-fact of Jeffery's injury....
By Dr. Glass' own testimony she admitted that she
had never read the warning label on the device itself, and that she had
never read the manual. An adequate warning or instruction would have
been futile under the circumstances.
We accordingly hold that the jury's finding of
liability on the part of Valleylab was clearly wrong, ...
Dr. Goodger had never performed a circumcision with an ESU or in a
surgical suite. Dr. Glass was in charge of the surgery and instructed
Dr. Goodger on the technique to be used. Dr. Glass instructed Goodger
to use the guillotine technique with the use of an ESU to cut the
foreskin. Dr. Goodger assumed Dr. Glass had experience and had been
trained to perform the circumcision in this method. However, Dr. Glass
testified that she had been trained to perform a circumcision with a
scalpel in medical school and that she had not been instructed on the
use of an ESU in circumcisions. She had always performed circumcisions
with a scalpel until one week before the Felice surgery. On that
occasion one week earlier, she and Dr. Boustany, another resident,
discussed the possible benefits in using an ESU for a circumcision. Dr.
Glass was also in charge of that surgery. They believed the ESU would
control the bleeding, so they performed a circumcision with an ESU,
with no ill effects. Dr. Glass never inquired of her supervising
doctors as to whether the use of an ESU was proper for circumcision
surgery. She did not inspect the literature or the manual to see if
there would be any dangers in the use of ESU in circumcision. Dr. Glass
merely decided to try it and see what effect the ESU would have upon
the surgery, since she considered it an improvement upon
well-established technique. Dr. Glass also admitted that she had never
held the ESU "surgical pencil" in her hand to cut the foreskin in a
circumcision. She twice had instructed two residents on a procedure she
had never performed herself. Dr. Glass also admitted that it was a
precept of medicine that any modification of a learned technique would
never be done without a full appreciation of all the risks involved in
the modification.
...
2) The LSU Medical School
The trial judge also found the LSU Medical School
independently negligent for failing to instruct its students in the
proper use and dangers of the ESU unit....
Dr. Glass was properly instructed on how to perform a routine
circumcision using the guillotine technique and making the incision
with a scalpel and scissors.
We find, however, that the medical school was
negligent in its supervision of Dr. Glass in her residency training. At
the time of the Felice surgery, the residency program had in effect the
following regulation:
"No third year resident is to do an elective
operative procedure without staff present in the operating room. This
rule is good for twelve months of the year."
Dr. Isodore Cohn, Chairman of the Department of
Surgery at the LSU Medical School and a professor of surgery, ...
stated that the rule was followed
and applied only in major surgeries, not minor surgeries as in
circumcisions. ...
DAMAGES
...
Dr. Aretta Rathmell, Jeffery's psychiatrist,
testified that the child will need intermittent psychiatric counseling
to help him cope with crises as they occur. She said that there is a
high possibility his loss will affect his self-identity. She said that
Jeffery will undoubtedly experience anger and frustration as he grows
older and probably will direct that anger against his parents.
...
Sexual pleasure, procreativity, marriage in any normal sense, these
things will never exist for him. The suffering of deprivation, both
physical and mental, that will accompany him throughout his life can be
only vaguely imagined. What will his puberty be like? Where will he go
to escape the cruel and ribald jokes of his comrades? For that matter
who will be his comrades? Into what corner of his dark cell will he
seek refuge when the natural urgings of his body wage battle?
There is a suggestion in the evidence that he can
be changed into a woman. As a means of mitigating damages in this case,
we view this prospect as pure speculation. If it is realistic to
imagine he may one day find a new life in this way, it is just as
realistic to speculate that after the sex change, he may wish it had
never been done. [He may
very well wish the circumcision had never been done.]
...
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A partial ablation is reported from New York in
1995. A three-year old Jewish Russian immigrant child was circumcised
by a mohel in a
urologist's outpatient clinic. Consent had been given for the urologist
to perform the circumcision. Instead, the mohel negligently amputated
the head of the boy's penis. The urologist attempted to reattach the
head and transferred the boy to Bellvue hospital by ambulance.
Four-fifths of the head of the penis necrosed (died) and came off.
After a one-month long trial, the family was awarded a total of
$1,000,000. The mohel declared bankruptcy.
Bronx County N.Y.
Plaintif Nozik #20875/90
November 22 1995
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Ouch!
Boys Lose Too Much in Circumcision Slip
Updated 3:22 PM ET June 9, 2000 ANKARA (Reuters)
Health workers carrying out a mass circumcision on more than 200
children in western Turkey cut off more than they should have when they
got to the last two on Friday.
"Whether it was because of their anatomy or
through carelessness, too much was cut off," Anatolian news agency
quoted Manisa health service chief Ismet Nardal as saying.
Doctors in the hospital where the two-day
circumcision marathon was carried out immediately operated on the pair
to try to rectify the error.
"The children's stitched organs have held, the
operation was successful," Nardal said. "They appear to be alright, but
it will only become apparent later if they have lost their sexual
function."
Young boys are circumcised in overwhelmingly
Muslim Turkey before they reach puberty, according to Islamic
tradition.
[This
item - about a lifetime catastrophe for the two boys involved - was
widely reported in the "joke" sections of papers, as the headline
suggests. That in itself is part of the psychopathology of male genital
cutting, helping as it does to prevent questioning of the
operation itself.]
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Jerusalem
Post
Monday, August 14 2000 12:48 13 Av 5760
Baby recovers from 'brit mila' amputation
By Judy Siegel
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AFULA (August 14) - A baby whose penis was
accidentally amputated below the corona by the mohel (ritual
circumciser) and reattached by microsurgery a
month ago was declared fully recovered yesterday at
Ha'emek Hospital in Afula.
Hospital spokesman Danny Brenner said the baby is now
able to urinate normally, and the penile blood vessels and
nerves are fully functioning. The hospital reported the
highly unusual incident to the Health Ministry, but
Ha'emek still doesn't know the identify of the mohel, as
the family refused to give his name and have not yet filed
a complaint.
The parents rushed the baby to the hospital four weeks
ago carrying a plastic bag with the glans penis kept in ice.
Dr. Ya'acov Rosenman, deputy head of the urology
department, and Dr. Boris Lachman performed the
painstaking operation, which took more than eight hours.
Rabbi Yosef Weisberg, the ministry's national supervisor
of ritual circumcisers, had not yet been informed of the
case. "If asked, our committee will investigate.
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Such a
thing is extremely rare, but I have heard of one or two
other cases here over the year. Any mohel who does
such a thing must be blind, have taken a drink, or been
pushed while performing the brit mila," he said.
The fact that there is no circumcision law, "due to
pressure from American Conservative, Reform, and
female circumcisers who are afraid they'll be left out,"
means there are unlicensed mohelim, Weisberg said, but
he could not estimate how many there were out of the
total of several hundred practicing mohelim in the country.
Brenner said that it was possible the family would
complain to the police or sue the mohel for damages now
that the child had recovered, "or maybe they received
payment from the circumciser to keep quiet about the
incident."
Although amputation of the penis is rare in children, said Brenner, the
world's top medical experts in reconnecting
adult penises are in Thailand, as nearly every day,
disgruntled wives cut off their husband's organs in a fit of
anger or jealousy.
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J
Sex Med. 2007 Dec 14 [Epub ahead of print]
Restoration of the Penis Following
Amputation at Circumcision: Shaeer's
A-Y Plasty.
Shaeer O. Department of Andrology, Faculty of Medicine, Cairo
University, Egypt.
Introduction. Male circumcision
is one of the most commonly performed
procedures worldwide. It has an estimated complication rate ranging
from 0.1% to 35%. Amputation of the shaft is one of the most
devastating complications reported, resulting from entrapment of the
phallus between the blades of the clamp or from thermal injury due to
the application of unipolar diathermy.
Aim. In this work, I describe
the guidelines I adopted in the management of 32
male patients
afflicted with amputation of the shaft of the penis upon circumcision.
Methods. "Shaeer's A-Y plasty" was
performed for all patients, whereby
the proximal corpora and crura were released from their attachment to
the pubis and were advanced forward by insetting a specially configured
fat flap into the resultant cavity. Skin grafts were used to cover the
released penis.
Results. In all 32 cases, the released
penis was within
the normal range of penile length, and was cosmetically and
functionally acceptable.
Conclusions. "Shaeer's A-Y plasty" is
capable
of restoring the native phallus [No,
it replaces it with a facsimile] following
amputation, with preservation
of both gender identity and physiological characteristics of the penis
to a large extent.
PMID: 18086176 [PubMed - as supplied by publisher]
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Urology. 2014 Jun 11. pii:
S0090-4295(14)00390-2. doi: 10.1016/j.urology.2014.04.021.
[Epub ahead of print]
Complete Penile Amputation During Ritual
Neonatal Circumcision and Successful Replantation Using Postoperative
Leech Therapy.
Banihani OI, Fox JA, Gander BH, Grunwaldt
LJ, Cannon GM.
Abstract
Circumcision is the most common surgical procedure in males in the
United States, and minor complications are not uncommon. Major
complications like partial penile amputations have been reported with
successful replantation. Complete penile amputations in adult males
have been described, and successful replantation has been reported with
increasing success. We report a case of complete penile amputation at
the penopubic junction using a Mogen clamp in a 7-day-old neonate
with replantation using postoperative leech therapy. To our knowledge
this is the first time leech therapy has been used postoperatively for
neonatal penile amputation.
Copyright © 2014 Elsevier
Inc. All rights reserved.
|
Another
case, in Switzerland
Another case, in Ghana
Hypothermia
| Journal of Paediatrics and Child Health
Surgery and magnetic resonance
imaging increase the risk of hypothermia in infants
Joel M Don Paul,
Elizabeth J Perkins,
Prue M Pereira‐Fantini,
Asha Suka, Olivia Farrell,
Julia K Gunn,
Anushi E Rajapaksa,
David G Tingay
First published: 13 January 2018 |
https://doi.org/10.1111/jpc.13824
Abstract
Aim
Maintaining normothermia is a tenet of neonatal
care. However,
neonatal thermal care guidelines applicable to intra‐hospital transport
beyond the neonatal intensive care unit (NICU) and during surgery or
magnetic resonance imaging (MRI) are lacking. The aim of this study is
to determine the proportion of infants normothermic (36.5–37.5°C) on
return to NICU after management during surgery and MRI, and during
standard clinical care in both environments.
Methods
Sixty‐two newborns requiring either surgery in the
operating
theatre (OT) (n = 41) or an MRI scan (n = 21) at the Royal Children’s
Hospital (Melbourne) NICU were prospectively studied. Core temperature,
along with cardiorespiratory parameters, was continuously measured from
15 min prior to leaving the NICU until 60 min after returning. Passive
and active warming (intra‐operatively) was at clinician discretion.
Results
The study reported 90% of infants were
normothermic before
leaving NICU: 86% (MRI) and 93% (OT). Only 52% of infants were
normothermic on return to NICU (relative risk (RR) 1.75; 95% confidence
interval (CI) 1.39–2.31; number needed to harm (NNH) 2.6). Between
departure from the NICU and commencement of surgery, core temperature
decreased by mean 0.81°C (95% CI 0.30–1.33; P = 0.0001, analysis of
variance), with only 24% of infants normothermic when surgery began
(P < 0.0001; RR 3.80 (95% CI 2.33–6.74); NNH 1.5). After an MRI,
infants were a mean 0.41°C (95% CI 0.16–0.67) colder than immediately
before entering the scanner (P = 0.001, analysis of variance), with
only 43% being normothermic (P = 0.003; RR 2.11 (95% CI 1.35–3.74); NNH
2.1).
Conclusion
Unintentional hypothermia is a common occurrence
during surgery
in the OT and MRI in neonates, indicating that evidence‐based warming
strategies to prevent hypothermia should be developed.
[The relevance of this to foreskin ablation surgery is - like
too much about that surgery - unknown, but could be serious.]
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Unspecified
life-threatening complications
- Facebook, February 17, 2017
Death
Deaths from
circumcision are now on a page of their own. The autopsy report on Ryleigh
McWillis, who died of blood-loss, is on yet another page.
Here are references
for more than 25 other mishaps, mainly ablations.
The Circumcision Information and Resource Centre
has a further compilation
of complications.
A controversial webside, Ulwaluko
shows botched Eastern Cape tribal circumcisions - contains graphic
images.
Stating the obvious, Robert Darby, PhD writes To
avoid circumcision complications, avoid circumcision
in the July-August 2014 issue of the Canadian Urological Association
Journal | Journal de l'Association des urologues du Canada
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