Bleeding remains one of the commonest complications encountered during and after circumcision. The reported incidence ranges from 0.1 to 35 percent20 because of (1) Varying criteria for diagnosis or recording.
(2) Inadequacies in documentation.
Various authors have defined haemorrhage in relation to circumcision.
A Jewish Mohel asserted that some amount of bleeding is a necessary part of the ritual Jewish circumcision.61 Gee and Ansell62 defined it as; those instances from 4 - 72 hours after circumcision in which a note in the chart indicated that physician took special effort to stem the flow of blood.
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Al -Samarai et al29 considered it as; oozing of blood lasting beyond 20 minutes and or persistent arterial bleeding as haemorrhage. All the above criteria require that the circumcised newborn be admitted and closely monitored hence may not be applicable where circumcisions are done as day cases. Eni3 regarded haemorrhage as being serious when; there is continuous bleeding after 6 hours of surgery. Most parents in our community will be too anxious to wait for so long before seeking for help. However, to Fraser 51 and his associates, it is significant when the loss is more than a few drops of blood. This criterion is simple to understand and can be applied by all circumcisers and parents but the amount of blood loss should be quantified to make it more objective.
Post circumcision bleeding occurs in neonates probably because of postnatal decrease in prothrombin.46 In majority of cases, bleeding is minor and all that is required to achieve haemostasis is gentle pressure.
Excessive bleeding may be due to anomalous vessels, 61, 64 presence of bleeding disorders,63 improper tying of plastibell ligature or use of wrong sizes of plastibell.
Documented measures for controlling bleeding includes gentle pressure with the hand when the bleeding is minor,20 the use of circumferential bandage20,25 the use of pharmacological agents such as adrenaline solution soaked gauze or sponge, application of gel foam, application of silver nitrate sticks, topically applied thrombin61,64 ligation of bleeding vessels.1,64 replacement of clotting factors or cryoprecipitate,61 the use of electrocautery.20,60 Blood transfusion following circumcision is rare,but has been reported in Nigeria.1,53
Badejo in Ile-Ife53 had 20 (16 boys, 4 girls) of his 37 referred patients that presented with profuse post -circumcision bleeding with anaemia (PCV< 10%). The boys were bleeding from retracted penile vessels, lacerated glans and frenular damage.
Measures taken to stem the bleeding were: ligation of the vessels, administration of vitamin K, re- circumcision and blood transfusion. All the patients survived.
It was however, not ascertained in the study what method(s) of circumcision employed by the circumcisers were not ascertained.
More recently Bode and Kene-Ewulu 1 reported a case of post circumcision bleeding which occurred following the use of plastibell while 3 were from open method all referred to the Teaching Hospital. The plastibell group resulted from slipped ligature and
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bleeding was mostly from dorsal artery of the penis, which was amenable to suture ligation.
They found that bleeding resulted from haemorrhagic disease of the newborn and it was stemmed with prolonged pressure and parenteral vitamin K.
In the same series, another baby presented in shock following open method of circumcision in the hand of a nurse and had to have blood transfusion. He had bled so profusely from dorsal artery of the penis, which was suture ligated on presentation.
Bleeding from the frenular artery was not sutured so as to avoid compromising the urethra lying subcutaneous and superficially close to the ventral coronal surface and the baby survived. However, no method of arresting bleeding at circumcision is devoid of problems1.
The use of Plastibell, which enhances bloodless circumcision65, was noted to cause dysuria almost twice as frequently as the open dissection method in a comparative study of the methods in circumcised babies by Fraser et al.63
While firm pressure might not arrest the bleeding in all cases, the use of circumferential dressing commonly practiced by Jewish mohels has been noted to cause acute obstructive uropathy in some Nigerian babies in England.66 Topical agents such as adrenaline in concentration greater than 1 in 10000 International units has been reported to cause tarchycardia, heart failure, acrocyanosis and local pallor of penis. These were treated with phentolamine or spinal anaesthetic induced sympathectomy.67
The use of monopolar diathermy to coagulate bleeding vessels may result in total ablation of the penis. This resulted from uncontrolled flow of electrical current from indifferent electrode (plate) to the active electrode (forceps) and the tissue surrounding the coagulating forceps, all of which are heated up. This results in coagulation, which may spread proximally in small vessels. The extent of vessel coagulation may be greater than anticipated or intended leading to total ablation of the penis20.
Gearhart and Rock68 described 4 cases in which the damages so caused were beyond plastic repairs such that those children were managed by gender re-assignment and feminizing genioplasty.
William and Kapilla20 recommended the judicious use of bipolar diathermy.
During circumcision the penis should be made to either touch the thigh or abdomen while
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it is being coagulated with electrocautery to diffuse current flow to the virtually increased surface area.
Wound infection/sepsis.
Infection is the second most common post circumcision complication reported in some series in which it occurs in up to 10 percent of patients.20 In the majority of cases this is usually mild and manifested by local inflammatory changes, but occasionally there is ulceration and suppuration. Most infections are of little consequence and settle with local treatment. Occasionally, sepsis may have much more alarming consequences and may even cause death.1
The perineum of a newborn is known to be colonized by both skin and bowel commensal organisms within the first few days of life. Post circumcision sepsis has been extensively documented in the form of septicaemia,3 tetanus,2 diphtheria,20 meningitis,69 Fournier’s gangrene69 and necrotising fasciitis,70 osteomyeltis,20 staphylococcal, scalded skin syndrome71 broncho-pneumonia and polyarthritis20 along with occasional death.2, especially in ritualistic settings 11,61. Badejo in Ile-Ife53 reported that five of the thirty-seven cases had circumcision wound infections due to mixed coliform and E coli.
Report from a study in Lagos1 indicates, that 14 (16%) out of 90 babies evaluated had infection. Infection occurred within 4 to 7 days of circumcision. Ten resulted following the use of plastibell while 4 resulted following the open method. In thirteen cases the wound infections were superficial and responded well to topical antibiotics within a week.
However, one baby circumcised by a nurse who had employed the open method developed necrotising fasciitis and died of overwhelming sepsis within a few days after a delayed referral to the Teaching Hospital.
In a Zaria study, 59 infections were seen in 10 (20.4%) of 48 cases of older boys with mean age 4 years who were evaluated but there was no recorded case of death from this complication.
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It is worthy of note that inadequately treated circumcision wound infection can lead to lymphoedema, swelling, wound dehiscence, scarring, keloids formation69 and poor cosmesis and negative consequence on the sexual life of the patient in the future20.
Skin Bridge
This is the tissue connecting the coronal ridge of the glans to the shaft of the penis.72 The aetiology of this condition is unknown although injury to the glans at the time of circumcision or incomplete separation of the inner preputial skin have been advanced as possible factors. Skin bridge is a complication of infant circumcision and does not occur in adult circumcision because infant circumcision requires forceful separation of the foreskin from the glans.73 Natural separation occurs between infancy and age 18years .61
Removing an infant foreskin prior to natural separation results in an exposed raw glans, the coronal ridge of which can fuse to the raw skin edge of the penis shaft where foreskin was cut, creating an adhesion or skin bridge. This happens after the Doctor must have lost interest in the case and the mother who has been told her son's circumcised penis is now maintenance free, does not notice that anything is wrong because she has no idea what it is supposed to look like.72
In the early post-operative days, the adhesions can be released by simple retraction but when it is late, the fusion may be complete 74. The skin bridge is not only ugly but creates a space where smegma and possibly bacteria may be trapped. Unlike the intact foreskin it can not be readily cleansed and simple retraction will not work. Such a child must be referred to the urologist. During erection and or sexual activity skin bridge can pull on the glans and be painful. An adult may have one or several skin bridges of various length and widths. Some are flushed with penile surface while others actually create a loop of skin through which one can insert a pencil. 72
In the series reviewed by Bode and Kene-Ewulu 1 there were 22 skin bridges all of which occurred over the coronal sulcus resulting in implantation dermoid cyst with a punctum on each side. Two cases that were infected were discharging purulent materials .The age of the patients ranged from 4 months to 11 years. Out of these, 6 patients (27%) whose skin bridge followed the use of plastibell were all circumcised by Doctors. Of the remaining 16 (73%), who were circumcised by open method, 11 were done by Doctors and
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2 by Nurses. A simple division of the skin bridge with adequate separation of the edges till full healing was all that was needed in these patients.
Urethro - Cutaneous Fistula
Fistulae resulting from circumcision could be mistaken for congenital hypospaedias. Aina 58 in Lagos highlighted the differences that are in iatrogenic urethro- cutaneous fistula.
(1) There is a history of circumcision.
(2) There is absence of dorsal hood and ventral chordae on the penis.
(3) The opening of post circumcision urethral fistula is situated ventrally usually in the coronal sulcus. It is usually but not invariably wide in caliber and oval, except when it is due to post circumcision periurethral abscess.
(4) It is usually possible to demonstrate the presence of a communicating channel between the fistula opening and the original urethral opening at the tip of the glans.
(5) Some of the fistulae can be recognized within 48 hours of circumcision. It is therefore possible that it occurs during operation.
Urethro-cutaneous fistulae are the commonest of all the severe complications of circumcision seen in most of our Teaching Hospitals in Nigeria. 1, 53,56,58
Aina58 in Lagos reported 12 of 19cases (64%) of circumcision complications as being accounted for by fistulae. In Ile-Ife, study 4 of the 37 complications were cases of iatrogenic hypospaedias20.
Bode and Kene-Ewulu1 reported 25 out of 90 (37%) cases of circumcision complications managed in their series. Report from the study of genital injuries in Lagos by Osegbe et a56 indicated that 9 cases of circumcision-induced-urethro-cutaneous fistulae were seen out of the total of 34 cases (26.5%) evaluated over a 5-year period.
However a study from Zaria in northern Nigeria, 59 the scope of which was limited to complications of traditional male circumcision only revealed 5 cases out of 48 cases complications reviewed.
Bode and Kene- Ewulu1 observed that almost two-thirds of fistulae constituting 50% of all complications occurred in the hands of nurses, all of who exclusively employed
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the open method. Osegbe et al 56 too reported that midwives accounted for 44% of penile injuries.
The fistula that results from plastibell have been described as often lying on the dorsal aspect of the coronal groove.56 Bode and Kene-Ewulu1 reported one of such cases.
Some authors have outlined the plausible causes of iatrogenic fistulae: 1,56,58,75 (a) Failure to tease off the normal preputial layer from glans. Both layers are usually gummed together.
(b) Deep insertion of a stitch into the frenulum.
(c) Over enthusiastic excision of tissue along the ventral aspect of the coronal sulcus where the urethra is superficially located.
(d) Post circumcision infection leading to pus collection in the ventral aspect of the corona between the skin and the urethra. This peri-urethral abscess can cause necrosis of the overlying skin and segment of the urethra lying deep to the abscess; producing a urethro cutaneous fistula. Such fistula opening is not usually wide.
(e) Circumcision of penis with unrecognized rare penile anomaly, such as megalo-urethra76
Penile Lymphoedema
This may be caused by wound infection,20 wound separation71 or by proximal dislocation of the ring of the circumcision device.77 In most cases, the oedema settles when the cause in removed. The aetiology is unknown and there is paucity of literature with regards to the management.
Failure of the Ring to Drop off or Retention of the Ring
This is usually caused by injudicious combination of fitting too large a ring and taking too much skin. The pulled penile skin then slides proximally pulling the ring on the shaft of the penis. This may impair venous return and cause penile oedema with or without cyanosis.77
When the ring is cut (preferably with bone cutting forceps) the oedema subsides within a week or two. In some cases the shaft may be denuded depending on the degree of tension and sliding of the pulled ring. Al-Samarai 29 in Saudi Arabia found that only 3 out of 2000 cases of neonatal circumcision done with plastibell (0.15%) had this complication.
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When the ring migrates distally, it can cause the retention of ring because the tension in the suture may not be effective enough to cause total necrosis of the foreskin. A remnant tag of skin to which the retained ring is attached may require excision.
Fraser et al 63 found that the average separation of plastibell occurred at a mean of 9 days, the earliest being the 5th day and latest the 16th day.
Meatal Stenosis
This post-circumcision complication is often missed by the clinician because children do not usually have late follow-up after circumcision.78 The symptoms of pain are often mistaken for symptoms of UTI and symptoms of obstructive uropathy are usually ignored for many months until parents witness their child’s voiding habit.
A group of urologists in the United Kingdom 78 reported 12 cases of meatal stenosis over a period of 3 years. The ages of the children range from 2 to 10 years. They presented with post circumcision meatal stenosis. They found that all of them had acute penile or glanular pain at initiation of micturition. They presented either with high velocity urinary stream or urine spillage around the bed forcing the child to sit or stand back from the toilet so as to avoid spillage or occasional urethral bleeding. The interval from time of circumcision to the onset of presentation with stenosis was 4 months to 8 years. All had oval glanular mucosa with a pinhole meatus, and a thin membrane that bridged the inner margins. They referenced another study by Thomas et al in which no meatal stenosis was found in 100,151 circumcisions performed before the age of one month. They noted that the incidence of this complication could not have been well evaluated in that study because children were not followed up for a long time. They suggested that the following are possible causes:
(1) Meatitis: - Glanular exposure through circumcision exposes the everted meatal mucosa to the irritating effect of friction and trauma from children underwear.
(2) Ischaemia :- During circumcision the frenular artery may be damaged. The frenular artery is probably the vascular supply to the urethral meatus and to a large area of distal male urethra. The frenulum was considered as the meso-artery, which links the vascularity of the penile shaft to that of penile core. Any damage to this blood supply can lead to ischaemia of the meatal mucosa. The treatment is simple meatotomy.
xlii Inclusion Cyst
Cyst may be caused by implantation of smegma in the circumcision wound or by surgical rolling in of epidermis at the time of circumcision. 20 The cyst can grow to a large size or become infected. These cysts are distinguished from penile epidermoid cyst only by their location. The treatment is surgical excision. It tends to be commoner in female circumcision as reported by Badejo53 Four girls and a boy presented with post-circumcision inclusion cyst in his series. All of them had surgical excision.
Granuloma
The use of silica talc on surgical gloves has been associated with the formation of granuloma. Such a lesion was described in a circumcision wound 15 years after the original surgical procedure.20
NON-OPERATIVE COMPLICATIONS