Pediatric Surgery, Al Azher University, Cairo, Egypt
It is estimated that one-third of males worldwide are circumcised. The procedure is most commonly practiced in the Muslim world, Israel (where it is near-universal for religious reasons), the United States, and parts of Southeast Asia and Africa. It is relatively rare in Europe, Latin America, parts of Southern Africa, and most of Asia.
Prevalence of reported complications of male circumcision ranged from 7 to 50.1%. Late complications of 7.39 % were reported.
KeywordsComplicationsMale circumcisionPenile granulomaIatrogenic urethral fistulasPost circumcision hair coilPenile skin lossKeloid formationGangrenePenile lossAblatio penisSkin bridgePenile ischemia
It is estimated that one-third of males worldwide are circumcised. The procedure is most commonly practiced in the Muslim world, Israel (where it is near-universal for religious reasons), the United States, and parts of Southeast Asia and Africa. It is relatively rare in Europe, Latin America, parts of Southern Africa, and most of Asia  (Fig. 35.1).
Mass circumcision of a young children by unexperienced personal in unequipped centres
Prevalence of reported complications of MC ranged from 7 % to 50.1 %. Late complications of 7.39 % were reported . At 2010, a review of literature founded that MC performed by medical providers, have a typical complication rate of 1.5 % for babies and 6 % for older children, with few cases of severe complications . In Africa and developing countries the circumcision rate was 87 %, with a very high rate of complications reaching 20.2 % .
Circumcision remains as one of the most controversial topics in current urological practice. The most important argument against circumcision is the permanent change of anatomy, histology and function of the penis, with potential complications, primary haemorrhage was the most common (52 %), whereas infection, meatal stenosis, incomplete circumcision, penile oedema, glanular injury, penile adhesions, iatrogenic hypospadias and urethral injuries were also detected at different rates .
There may be a minor complications after circumcision which cannot be avoided even when the procedure is undertaken by specialised pediatric surgeons or urologist, in a properly equipped centres; specially if the child or his penis is congenitally abnormal, the obvious examples are, circumcising a child with an excessive suprapubic or a child with webbed penis or microphallus.
After practicing circumcision, and managing other’s complication for a thousands of boys along 34 years in a country like Egypt, (with about 90 % circumcision rate), I found most parents had a great urge to do this surgery even for a handicapped or critically ill child, as you can see the child in Fig. 35.2, who had a Hip Spica Cast for bilateral hip dislocations, but family insisted to do circumcision for him (Fig. 35.2).
Family urge for circumcision may pouch them to do this procedure even for a baby with critical illness
So the best way to minimise complications of MC, in my opinion, and to compete against its serious impaction in man health, is to standardise the procedure, learning both families and physicians about potential complications and how they could mange it early, and properly.
The spectrum of post MC complications is so wide to be discussed in this chapter, which concerning mainly about congenital anomalies, but these anomalies of the penis which discussed in this book may had a great impaction in the incidence of serious complications, so we will just spot some light over the uncommon complications, which usually raise a debate about its management.
There are different sets to classify MC complications: Either early, or late, minor or major, local or systemic, rare or common.
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35.1 Post Circumcision Penile Granuloma: (Fig. 35.3)
(a) Granuloma with severe infection and skin loss from the lateral aspect of the shaft of the penis. (b) Post circumcision granuloma at the dorsum of the glans
The development of post circumcision penile granuloma was described well in a large series by Atikeler et al. , in which 26 cases of granuloma (5 %) were found in 523 circumcised boys, with a mean time to development of 3.2 months. The cause of post circumcision granuloma has been postulated to be a foreign body (e.g. talcum powder, excess suture material, or smegma particles) introduced during circumcision between preputial layers, resulting in a tissue response manifested as a granuloma of different types (Fig. 35.3a).
This is a reaction to the stitches not dissolving as intended. It appears as bumps under the skin around the wound as the skin creates a tiny wall of scar tissue around the suture to separate it from the body.
This occurs weeks to months after surgery if the body rejects the suture (again, from the stitches not absorbing as intended) and attempts to remove them by pushing the stitches out to the surface of the skin. Sutures that migrate in this way have been known to be the source of additional problems.
Pyogenic granuloma: Will be described with balanitis (Chap. 39)
Smegma granuloma: (Chap. 19)
Excessive penile skin loss
Which occurs when so much of the prepuce is drawn forward that the entire penile skin sheath is removed. From puberty on, penile bowing (curvature) and pain occur at the time of erection, commonly skin loss seen at the ventral surface of the penis. (Fig. 35.4), but a circumferential skin loss is not rare, which complicate extensive perpetual excision by unexperienced surgeon or unqualified circumciser (Fig. 35.5).
Post circumcision ventral skin loss, due to circumcision of a webbed penis by simple application of the crushing forceps
Circumferential skin loss which will need a rotational flap or free skin graft
Excessive skin loss complication encountered mainly after circumcision of a congenitally abnormal penis as in cases of webbed penis, microphallus, concealed penis and penis with a congenital chordee.
In webbed penis, If surgeon tried to circumcise a baby by the classical method, usually he will end with extensive loss of the ventral skin, so removal of prepuce from the dorsum only leaving the ventral prepuce to cover the shaft with fine stitches may be enough, with an acceptable penile look, as we can see in Fig. 35.6a, b and c. This simple method can be done by surgeons who had minimal experience with the different methods of flaps or V-Y plasty described in literature for managing such cases . But sometimes, specially in severe cases, a pedicled skin grafts or flap are indicated.
(a) Webbed penis, managed with circumcision by dissection method, leaving a plenty of skin at the ventral surface, with an acceptable look and reasonable functional penile length (b)