Challenges , contra indications and complications of pediatric circumcision

1. By
Amr Abdellatif
Registrar of pediatric surgery NWAFH
Under supervision of
Dr. Majed Attoun
Consultant of pediatric surgery NWAFH

2. Is circumcision the oldest known
surgical procedure ??

3. Iconographic evidence puts circumcision much further back
into the Paleolithic period, with many cave paintings and
sculptures showing circumcised penises(1)
(1) Angulo JC, García-Díez M. Male genital representation in Paleolithic art: erection and circumcision before history. Urology. 2009;74:10–4.

4. • By egyptian times, around 5,000 years before present
• (BP), circumcision was well documented, recorded in pictures and texts .
• Most Egyptian mummies are circumcised,
providing the first tangible evidence of the
operation.
• Grave statues & figures of the ancient
Egyptians at different ages – typically show a
circumcised penis .
Circumcision scene from the tomb of Ankh-ma-Hor Saqqara (Sakkara), Egypt,
2,5003,000 BC (Reproduced by kind permission of the Wellcome Library, London)

6. Circumcision as ritual and religious procedure
 Medical professionals interact with people
from all walks of life.
 So we should consider religious , regional and
cultural expectations when dealing with a
subject as sensitive as circumcision.
In Islam :
 circumcision is not mentioned in the Qur’an but Muslims everywhere regard it as essential.
 This practice is attributed to the Prophet of Islam ( Prophet Mohammed – PBUH ) .
 Male circumcision is part of the fitrah according to our prophet(1)
 Circumcision is a common if not a universal practice in Arabian countries.
 The prevelance in the majority of the Muslim world is that children born in hospitals are
circumcised before discharge.
 In rural areas, the practice is delayed to a few weeks or even up to the age of 5–7 years.
(1)‫قال‬ ‫وسلم‬ ‫عليه‬ ‫هللا‬ ‫صلى‬ ‫النبي‬ ‫أن‬ ، ‫عنه‬ ‫هللا‬ ‫رضى‬ ‫هريرة‬ ‫أبي‬ ‫عن‬:‫الفطرة‬ ‫من‬ ‫خمس‬:‫الختان‬‫اآلباط‬ ‫ونتف‬ ،‫الظفر‬ ‫وقلم‬ ،‫الشارب‬ ‫وقص‬ ،‫واالستحداد‬ ،

7. Current Medical Evidence Supports Male Circumcision
( benefits of circumcision )
1 . Hygiene
Microorganisms accumulate under the foreskin, and can induce inflammatory
processes leading to balanitis
• Smegma accumulate under the foreskin.
• Its initial function is lubrication and protection of the glans
• but if it is not removed by regular washing it becomes mixed with epithelial cells and
infected by bacteria (Mycobacterium smegmatis ), forming solid aggregates with
offensive odour.

8. 2 . Inflammatory Dermatoses
• Lack of circumcision increases the risk of inflammation of the glans (balanitis) and foreskin
(posthitis).
• the incidence in the uncircumcised is twice as high as in those who are circumcised (1)
3 . Phimosis
• protection against phimosis is one of the best known benefits of circumcision .
4 . Urinary Tract Infections
• A meta-analysis in 2005 noted 1,222 UTIs in 107,873 uncircumcised infants, that is, 1.1%, and a
summary OR for the protective effect of circumcision against UTI of 0.13 (95% CI 0.080.20), that
is, circumcision reduced UTI 7.7-fold (1)
(1) Jakobsson B, Esbjörner E, Hansson S. Minimum incidence and diagnostic rate of fi rst urinary tract infection. Pediatrics. 1999;Part 1:222–6.

9. 5 . Common Sexually Transmitted Infections
A meta-analysis in 2006 of ulcerative STIs that examined 26 research articles (from the USA, UK,
Australia, Africa, India, and Peru) found circumcision protect against AIDS by ( 76% ), syphilis (by
39%) and genital herpes (HSV-2) by12%(1).
(1) Weiss HA, Thomas SL, Munabi SK, Hayes RJ. Male circumcision and risk of syphilis, chancroid, and geni-tal herpes: a systematic review and meta-
analysis. Sex Transm Infect. 2006;82:101–9.
(2) Bosch FX, Albero G, Castellsagué X. Male circum-cision, human papillomavirus and cervical cancer: from evidence to intervention. J Fam Plann Reprod
Health Care. 2009;35:5–7.
(3) Ross RK, Shimizu H, Paganini-Hill A, Honda G, Henderson BE. Case-control studies of prostate can-cer in blacks and whites in southern California. J Natl
Cancer Inst. 1987;78:869–74.
6 . Penile Cancer and HPV Infection
A meta-analysis in 2009 of 14 studies, involving 5,880 circumcised and 4,257 uncircumcised men,
found circumcision to give 1.9 fold protection against high-risk HPV types(2).
7 . Prostate Cancer
Uncircumcised men have a 1.6- to 2.0-fold higher incidence of prostate cancer(3)

10. 8. Prevention of Cervical Cancer in Women.
9. Herpes Simplex Viral infection in Women.
10. Chlamydia in Women.
11. Bacterial Vaginosis and Trichomonas in Women.
Add to that …

11. Why Parents Choose to Have Their Boys Circumcised ??
A survey in 2007 in Melbourne, Australia, of parents who
were having their sons circumcised found that the most
common reason was hygiene (96%), followed by family
tradition (57%), medical benefit and aesthetics (36%), with
14% believing it improved sexual performance/enjoyment as
an adult, and looked better to women(1)
(1) Xu B, Goldman H. Newborn circumcision in Victoria, Australia: reasons and parental attitudes. ANZ J Surg. 2008;78:1019–22.

13. No surgical procedure, even one as simple as newborn circumcision, should be
performed without a strong working knowledge of the anatomy involved.
Please don’t do circumcision unless you
understand the pediatric genital anatomy very
well …

14. When speaking to the parents about deferring circumcision, the term
“anomalous” or “small” –for example- may be misleading. It might be better to say
something like the penis is normal, or within normal limits, but its presentation
at this time is not ideal for circumcision.
 Normal, Abnormal, and Anomalous of genital organs

15.  External Appearance and Landmarks of genital male organs
Thorough assessment of the external appearance of genitalia is an essential component of a pre-
circumcision exam.
1 . Ventral and Dorsal surfaces with Their Junctions :

16. 2 . Coronal Sulcus
The groove that delineates the glans from the penile shaft
 It is an important landmark for circumcision.
 It is the point to which the foreskin is removed.
 Rule of thumb is examination test to defer circumcision if there is less than 1 cm of dorsal
shaft skin (the distance between the dorsal junction and the coronal sulcus).
Abnormal Normal

17. 3 . Median Raphe
 Extending from the anus along the midline scrotum and
ventral penis
 Formed by fusion of the urogenital folds during embryo
development.
 It could be a sign of suspecting anomalies
 For example, if the raphe has an irregular course along
the penis, it might indicate a rotated penis, hypospadias
or chordee …

18. 4 . Prepuce
 The prepuce ( foreskin or hood ) is the sheath of skin
that normally surrounds and extends distally beyond
the glans tapering down to the preputial ring.
 The outer side of the prepuce is continuous with the
penile skin and the inner side is mucous membrane.

19. Anatomic Contraindications to Circumcision
Circumcision is elective. so, only good anatomical candidates should
be considered.
For example, upon first sight, do the penis and scrotum have a “typical”
appearance in size, shape, and presentation?
If not, a more thorough and focused pre-circumcision exam is in order
to take a right decision.
Remember, there is no shame in deferring a circumcision for a
pediatric surgeon if you found any anomaly or even suspecting it.

20. Complications of circumcision may result from
1. poor surgical technique
2. incorrect postoperative care
3. unrecognized penile anomalies that predispose the circumcision
to a poor result.
REMEMBER : Proper patient selection is critical to achieve a favorable outcome
Again remember that the last chance to discover an anatomical
contraindication is during the pre-circumcision exam.
Thus, to aid the clinician, each condition will be presented below with
a TIP to help easy spot of such anomalies.

21.  Hypospadias
 Epispadias
 Chordee
without
hypospadias
 Micropenis
 Buried penis
 Penoscrotal
transposition
 Penile torsion
 Penoscrotal
webbing
 Significant
hydroceles and
hernias
 bilateral
impalpable
testes
Primary Penile
Abnormalities
Dartos Fascia
Abnormalities
Penoscrotal
Anomalies and
Distortions
Ambiguous Genitalia
1 2 3 4

22. 1. Hypospadias and Chordee
TIP
 Downward curvature of the penis or glans
 Defective ventral prepuce
 translucent skin or mucous membrane along the
raphe
 unusual urine stream
10% of boys with hypospadias
have intact prepuce and no
ventral curvature
Circumcision should be deferred untill hypospadias
repair

23. 2 . Epispadias
TIP
 Defective dorsal prepuce
 any cleft or opening on the dorsum
 If normal prepuce you will feel a groove or cleft
below the dorsal skin
3 . Micropenis
TIP
 Very small penis
 May need hormonal assessment if persist or
associated with undescended testis
Circumcision should be deferred untill epispadias repair
Circumcision should be deferred untill growth of the
penis

24. 1 . Buried Penis
TIP
 There is less than 1 cm of exposed penile skin
 The foreskin feels empty
 The glans is present within the foreskin only
when there is some sort of erection
 Sometimes it is usually due to excess suprapubic
fat
Circumcision should be deferred and if preferred by the parents then
correction of the anomaly should be done before circumcision

25. 2 . Penoscrotal Transposition
TIP
 Penis appears to emerge at the same level as the
scrotum
 split scrotum may be present (bifid scrotum)
circumcision is contraindicated untill repair of the
anomaly as all tissues available is needed for complex
reconstructive repair

26. 3 . Penile rotation
TIP
 Glans rotation counterclockwise greater than 45°
 deviated median raphe
circumcision should be deferred if surgical repair is
being considered and circumcision can be performed at
the time of the repair.

27. 1 . Webbed Penis
TIP
 The scrotum attaches to the distal one-half of
the ventral penis
 Scrotal looking skin on ventral penis
 Penis may have mid-shaft downward curvature,
especially when erect
 Usually there is normal dorsal skin and defective
ventral skin (DD from buried penis)
circumcision should be deferred because
 it would create an appearance of having no ventral
penile skin with glans tethered to scrotum.
 It can also lead to secondary phimosis.
If the parents prefer circumcision, it should be done
surgically under general anesthesia at age of 6 months
at least.
Normal

28. 2 . Hydroceles
TIP
 Scrotum appears ballooned and engulfs part or
all the penis
circumcision should be deferred ( why ? )
1. If you will correct hydrocele you will do circumcision
at the same time.
2. Also large hydrocele makes it difficult to judge how
much skin to remove.

29. TIP
 Bilateral impalpable testes
 Split scrotum
 Mid-scrotal orifice
 Hypospadias with a single impalpable testis
circumcision should be deferred ( why ? )
All genital skin must be preserved for potential
reconstructive procedures.

31. A. Newborn Circumcision Techniques
1 . Mogen Clamp Technique ( not commonly used )
 Arrow points to aperture which should be no more than 2–3
mm.
1. Faster procedure
2. decreased overall pain
3. may be easier with a shorter penis
4. one size nearly fits all.
1. Partially blind procedure (associated with a higher incidence of glans avulsion)

32. 2 . Gomco ® Technique
1. Visible protection of the glans
2. more familiar to most providers and hospital
staff
1. complicated equipment pieces that need to
be properly matched and can be awkward to
use for the novice
2. longer procedure with increased neonatal
pain.

33. 3 . PlastiBell ® Technique ( commonly used )
1. Visibly protects glans
2. Popularity makes it familiar to many providers and
hospital staff
3. Simple procedure
4. No bandaging required
5. Disposable, cheap, easy
6. No need for sterilization.
1. Rarely, but significantly the tip of the glans may
protrude completely through the ring and entrap the
glans > ischemia.
2. Increased rate of infection compared to the other
techniques
3. risk of bell falling off prematurely causing hemorrhage
4. Longer procedure with increased neonatal pain
5. Sometimes not accepted by parents to have a foreign
body attached to the penis

34. 5 . Forceps Guided ( bone cutter method )
( commonly used )
1. Faster
2. Glans protected by the concave side of the
forceps.
1. Still blind procedure (associated with a
higher incidence of glans injury)
2. Bleeding also common.

35. 2. Pediatric Circumcision ( 3 – 6 months )
 Performed in the operating room setting.
 Usually after 3 months age and preferably at 6
months age .
 Sleeve Technique ( surgical circumcision ) :
 Performed on all children beyond the neonatal
age ( 3-6 months).
 There is recommendation (experience based in
many pediatric surgery books after 6 months of
age, due to the theoretically – albeit modestly –
increased safety of general anesthesia after this
age(1)
(1) Cohen MM, Cameron CB, Duncan PG. Pediatric anesthesia morbidity and mortality in the perioperative period. Anesth Analg. 1990;70:160–7.

36. Protocol of circumcision at NWAFH
Before age of 3 months After age of 3 months
We do plastibell technique
for all normal babies with local
naethesia ( penile block )
We do surgical circumcision
under general anesthesia as
an elective surgery

38. 1 . Hemorrhage
1. Hyperbilirubinemia : espicially if needs phototherapy or is non-physiologic it is better
to deferre the circumcision .
2. Evidence of Clotting Disorder : postpone circumcision.
3. Avoid the Frenulum : When dissecting the adhesions between the inner mucous
membrane layer of the foreskin and the glans penis.
4. Proper Bandaging .

39. 1. Direct Pressure
2. Applied (Chemical) Hemostasis like : Surgicel ® ,
Gelfoam ® , and BioSeal ® or WoundSeal ®
3. Local Crush : If the bleeding is from a localized area
on the edge of the cut skin, away from the frenulum,
you can crush with a hemostat.
4. Sealants : like dermabond could be applied.
5. Sutures.
6. Cauterization when doing sleeve surgical
circumcision using Bipolar cautery.

40. 2 . Infection
 subacute complication that is rare
 can be serious and even fatal if a necrotizing infection (Fournier’s gangrene or
necrotizing fasciitis) were to occur.
 Mild degrees treated by local antibiotics
 Severe cases and sepsis treated by IV antibiotics and may need even surgical
depridement.

41. 3 . Urinary Retention and Tight Bandaging
 Rarely urinary retention occur from local compression, secondary to site swelling or from
excessively tight bandaging.
 if an infant fails to urinate for 12 or more hours and/or at any time there are signs of ischemia
of the glans, then any circumferential bandages must be removed immediately and baby should
be reassessed .
 Baby is assessed carfully to detect if he needs catheterization or not.
4 . Injury to Glans Penis (Accidental Crush or Amputation)
 Management depends on the extent and location of
laceration or amputation.
 The first step in management is to control any bleeding
with direct pressure and then to assess the severity of
the damage.
 Don’t miss to assess the urethra for any injury.
 Preserve the amputated portion of the glans in iced
saline for possible reconstruction.

42. 5 . Adhesions and Inadequacies
Adhesions : Immediately following circumcision there
may be a few adhesions left in the coronal sulcus.
You can reduce these with a probe or hemostat tip. Or just
leave them and let nature do the work.
Inadequacies : including under or over correction and
may need revision of the circumcision at older age mostly at
age of 5 to 6 years.
6 . Necrosis ( gangrene ) of the glans
 Loss of the glans partially or completely or even entire
penis (very rare) due to necrosis with subsequent
sloughing.
 Maybe due to infection , use of adrenaline in local
anaethestic , tight bandaging or most commonly by
the use of monopolar diathermy in attempts for
heamostasis

43. A message to be said is that circumcision however
it is a minor surgical procedure, it have its own
serious complications , so don’t do unless you
know and understand every thing about it.