51. Circumcision: Avoidance and Treatment of Complications

Marta Skrodzka¹ and Peter Malone^{1, 2}

(1)

University College London Hospital, Institute of Urology, Department of Andrology, London, UK

(2)

The Royal Berkshire Hospital, Harold Hopkins Department of Urology, Reading, UK

Marta Skrodzka

Peter Malone (Corresponding author)

Email: peter.malone2@nhs.net

Keywords

CircumcisionLichen sclerosusBuried penisMeatal stenosisUrethrocutaneous fistulaUrethral injuryPenile reconstruction

51.1 Introduction

Circumcision has been practiced in large numbers for millennia. Early Egyptian paintings and mummies have shown that the technique has been practiced as early as 4000 BC [1] and in 2007 the World Health Organisation estimated that 30% of the world’s adult male population had been circumcised [2]. One might have thought that, given how long we have been performing this operation and the number of times it has been done, we might have perfected the technique by now. Not a bit of it. Any genitourinary tertiary referral centre will be all too familiar with patients referred in because the circumcision has not been successful or worse [3]. This may be due to poor hygiene or technique, but, occasionally, it can be a technically difficult operation, either due to the severity of the pathology, particularly lichen sclerosus (LS) , or occult anatomical variations, for example some patients with a forme fruste of hypospadias have a gossamer urethra which is more liable to injury [4]. Other anatomical variations, such a buried penis with mega-prepuce, may not be hidden but the signs can be subtle to the inexperienced [5]. Rare conditions such as pilonidal sinus of the penis require amendments to the technique [6]. Similarly obese adults and paediatric patients require a more careful approach due to the tendency of the penis to become buried in the supra-pubic fat pad [7].

The most common reason that circumcision is performed, however, is for religious and cultural reasons. Most consultant genitourinary surgeons, including the authors of this chapter, have little experience of this as it is usually performed by a trained religious practitioner, for example a Mohel in the Jewish faith, a trained nurse, operative or general practitioner. This chapter, therefore, will look at the way to deal with the complications of religious and cultural circumcision and how to perform a circumcision for medical indications, in a way to avoid or at least minimise the risk of complications.

51.2 Medical Indications for Circumcision

The most common indication is for phimosis secondary to lichen sclerosus [8] although it can also help other forms of glans inflammation, such as Zoon’s balanitis [9]. Circumcision is likewise advised in those few adolescents and adults with a persistent congenital phimosis or a relative phimosis (a foreskin which will retract when the penis is flaccid but is not slack enough to allow painless retraction when the penis is erect) to allow hygiene and painless intercourse [10]. Preputioplasty is an alternative for this group. Circumcision is performed for malignancy and pre-malignant change, not only of the foreskin, but also the glans, as PeIN (Penile Intraepithelial Neoplasia ) of the glans can regress after removal of the foreskin [11]. It has increasingly been used as prophylaxis against sexually transmitted diseases, particularly HIV in those areas where the incidence is high, e.g. sub-Saharan Africa [2]. Rarely it is required to stop repeated infections of the foreskin [9] and has been also advocated for the management of recurrent urinary tract infections in boys, although a recent meta-analysis found little to justify its routine use for this indication [12]. It is indicated in the very rare cases of pilonidal sinus of the penis where the technique needs to be modified to remove the hair containing sinuses [6]. The foreskin in penile lymphoedema can be so large and unsightly, that circumcision is beneficial. In mild cases circumcision alone can suffice, but with more severe cases the penile shaft and scrotum can also require debulking with or without skin grafting [13].

51.3 When Not to Operate

Circumcision can be life-saving or curative of disabling symptoms, but the consequences of complications can be tragic. The best way to avoid complications is not to operate without good cause, especially in children with phimosis.

At birth the prepuce is usually phimotic and adherent to the glans with a shared epithelium between the glans and prepuce, frequently referred to as preputial adhesions . As the child matures the adhesions separate and the foreskins slackens to allow it to retract and reveal the glans penis. Gairdner (1949) [14] showed that only about 5% of babies under 6 months had a retractile foreskin but this had risen to 92% by the age of 5 and Øster (1968) [10] showed that this had risen further to 99% by the age of 14–16 (Fig. 51.1). Similarly the incidence of congenital preputial adhesions falls from 63% in 6 year olds to only 3% in 16 year olds without intervention [10]. An inability to retract the foreskin in children, by itself, therefore, should not be an indication for circumcision. The authors’ experience is that congenital preputial adhesions almost always disappear by adulthood, as opposed to those that develop in adults which are usually secondary to lichen sclerosus [15].

../images/468369_1_En_51_Chapter/468369_1_En_51_Fig1_HTML.jpg — Fig 51.1

The percentage of boys with a retractable foreskin as they get older

51.3.1 Congenital Megaprepuce and Buried Penis

This relatively rare condition is frequently referred to urologists for treatment of phimosis by general practitioners. The key to the diagnosis is awareness of the paucity of shaft skin, and, in the case of congenital megaprepuce, the typical penoscrotal swelling with micturition. Urine can frequently be expressed by pressure applied in this area [16]. This is due to an extensive sac formed by a very large, redundant, inner prepuce, trapped by short, phimotic penile shaft skin. Circumcision, under these circumstances, is disastrous as it converts a congenital megaloprepuce into a trapped penis. In this case penoplasty is required, where every millimetre of shaft skin is preserved and, if necessary, the shaft is partially covered with inner preputial skin. Surgeons seeing paediatric patients for penile problems should familiarise themselves with this condition for fear of inappropriately removing what little shaft skin is available.

51.4 Complications of Circumcision

It is a fair adage that anything that can go wrong will go wrong (Murphy’s law attributed to John Stapp). The reported complications of circumcision bear testament to that law. They include death, bleeding, infection, sepsis, loss of part or all of the penis, taking too much or leaving too much inner preputial or penile shaft skin, meatal stenosis, urethral injury, urethrocutaneous fistula, poor cosmetic outcome, lymphoedema of the penis, particularly the remaining inner prepuce, decreased sensitivity of the glans, inclusion dermoid cysts, failure to expose the corona by releasing preputial adhesions or the formation of skin bridges. In addition, in cases where the operation has been performed to treat lichen sclerosus, it may fail to halt the progress of the condition, particularly in the obese.

When looking at the complications of circumcision there is obviously a difference between surgery in underdeveloped countries, frequently done by lay practitioners or nurses in a rural setting and surgery performed by trained urological surgeons under aseptic conditions with ready access to emergency care in the event of complications. The incidence of complications and their severity are so different that it is difficult to compare them in any one paragraph about a particular complication. That is not to say that severe complications aren’t reported in major surgical centres in affluent countries, just that they are less frequent by an order of magnitude although some, like tetanus [17] are not seen when surgery is done under aseptic conditions in a vaccinated community.

51.4.1 Circumcision in Developing Countries

In parts of the world, circumcision is performed as a ‘right of passage’ to manhood by lay practitioners in a rural environment. Under these circumstances severe infections including tetanus [17] are not uncommon and can be devastating or lethal. Meel (2010) [18] reported 25 deaths in a single large regional hospital in the Mthatha district of South Africa during the 2 year period 2005/6. The average age of the deceased was 17.6 years with the youngest being 12. Appiah et al. (2016) [19] reported 72 cases of circumcision related injuries during an 18 month period referred in to a single teaching hospital in Ghana. 78% of the complications were urethrocutaneous fistulae with 3 (7%), complete amputations. The mortality, however, seems lower than in the South African series, probably because the majority of these operations were performed by nurses in a rural hospital setting.

51.4.2 Complications in Developed Countries

Weiss et al. (2010) [20] reported a systematic review of circumcisions in male neonates, infants and children. He reviewed 52 papers from 21 countries which included sufficient information to estimate the frequency of adverse events. Retrospective analysis of the complications of child circumcision undertaken by medical providers gave a range of serious adverse events from 0% to 2.5%. Talini et al. (2018) [3], however, reported that, in a total of 2441 circumcisions in Brazil, 3.27% required surgical intervention for complications and Thorup et al. (2013) [21] reported a 5.1% significant complication rate when late complications were included. Comparison between different series is difficult due to the lack of standardised collection and reporting of data.

51.4.3 Death

Death following circumcision is fortunately very rare. Nevertheless about 16 deaths a year were reported in England and Wales from 1942 to 1947 mainly from anaesthetic complications, bleeding and infection [14]. The significance of bleeding in small babies should not be underestimated. The circulating blood volume of a 3.4 kg neonate is only about 300 ccs so what would be a relatively small bleed in an older child can exsanguinate a newborn baby. Although rare, in this day and age in affluent countries with a good health care system, fatalities are still occasionally reported, so this eventuality must be taken into consideration in the decision if and where to operate [22]. Furthermore, for every death there are usually several near misses [22] so the mortality rate always underestimates the incidence of severe complications.

51.4.4 Infection

Local infections are usually responsive to antibiotics and heal well without the necessity for surgical intervention. Nevertheless, even in a hospital environment, rare cases of severe infection including necrotising fasciitis have been reported [23] and patients and parents should be advised to seek medical help urgently if there are signs of systemic infection (sepsis) or spreading cellulitis. Prophylactic antibiotics have not been shown to be beneficial, and are not free of morbidity. In a non-randomised study of 84,226 patients, of whom 10.6% had received surgical antibiotic prophylaxis, Chan et al. (2017) [24] showed there was no reduction in the rate of surgical site infection by using prophylactic antibiotics (p = 0.5), but, not surprisingly, a significantly higher rate of a peri-operative allergic reactions (p = 0.0004).

51.4.5 Taking Too Much or Too Little Shaft Skin or Inner Foreskin

It is self-evident that this should be an avoidable complication, unless done deliberately as necessitated by the severity of the initial pathology e.g. for malignancy or severe lichen sclerosus . Taking too little is obviously better than taking too much as more can be taken at a later date. Equally there is no real reason why it cannot be judged accurately. The key is to judge where to place the inner and outer incision lines.

51.5 Technique of Circumcision: One Way to Perform a Circumcision

The penis is anchored to the underside of the symphysis pubis by the diverging corpora and the suspensory ligament. In patients with a large supra-pubic fat pad, the overweight, the obese, babies and young children, the skin is pushed forward. In the obese, the penis can be an internal organ with the shaft skin empty. It is important, therefore, to compensate for this, when deciding where to cut the outer prepuce, and the easiest way is to push the base of the penile shaft skin down to the symphysis pubis before marking the place of the incision. The method of marking is not too important but we favour the use of clips to mark the dorsal and ventral limits of the incision (Fig 51.2b and c). Genital skin does not cut easily unless it is on the stretch, but it is important to mark the limits of the incision before this is done for fear of distorting the anatomy. With a further 2 clips at the tip of the foreskin, a straight cut is made in-between the clips under tension (Fig 51.2d) and when the circumferential incision is completed it produces a perfectly rounded end to the shaft skin to match the cut end of the inner prepuce (Fig 51.2e and j). The inner incision can be judged and marked or scored by direct vision (Fig 51.2g) and this is facilitated on the ventral aspect, particularly in small children, by placing a finger behind the prepuce to immobilise the penis and stretch the skin (Fig 51.2h). It is important not to leave too much inner preputial skin as this can become swollen resulting in a lymphoedematous ring around the corona. This poor cosmetic result frequently requires surgical excision of the ring although it is usually cured by this maneuver. A box stitch at the frenulum should be avoided as it frequently results in a skin tag. It is much better to control the frenular vessels prior to skin closure and just close the skin with perfect skin to skin apposition (Fig 51.2k-l). The dartos should either be closed separately in a 2 layer closure or included into the skin closure to prevent a concave ring just proximal to the corona.

../images/468369_1_En_51_Chapter/468369_1_En_51_Fig2_HTML.jpg — Fig. 51.2

A technique of circumcision. (a) The penis of a child with a pinhole phimosis caused by lichen sclerosus. (b) The dorsal shaft is marked with the base of the penis pushed against the symphysis pubis. (c) The line of the corona is carried around the penis ventrally and marked in the midline. (d) 2 further clips are placed at the tip of the foreskin at 6 and 12 o’clock and straight incision made from just inside the proximal pair of marking clips on both sides. These clips are then removed and the incision completed circumferentially. (e) This leaves the shaft skin perfectly shaped to match the inner preputial skin, later. (f) The dartos is cut in the same line. (g) The inner preputial skin is scored about 5 mm from the corona. (h) On the ventral side this is made easier by placing a finger behind the prepuce to stabilise the penis and make it easy to score the inner prepuce precisely. (i) The foreskin is held well away from the urethra which is protected whilst the foreskin is removed. (j) The inner prepuce and shaft skin should match perfectly. (k) Fine 6/0 (5/0 in adults) dissolvable sutures complete the operation after bipolar haemostasis. (l) Dorsal view of the finished operation

51.6 Lichen Sclerosus

Lichen sclerosus is a progressive inflammatory condition that mainly affects genital skin, although rare, non-genital presentations have been reported [15]. Although it has been postulated that it is an autoimmune disease, the cause is unknown. It has been associated with certain Human Leukocyte Antigen subgroups but not convincingly. What does seem clear, however, is that it is caused by contact between urine and genital skin folds of susceptible individuals [15]. The evidence for this is overwhelming.

1.

The pattern of distribution in males and females is strikingly different. While girls and women usually have a figure of eight pattern around the urethra and anus, peri-anal LS is virtually unheard of in males [ 15].
2.

In patients with a perineal urethrostomy, lichen sclerosus frequently develops at the site of the urethrostomy [25].
3.

In children who have lichen sclerosus but still have congenital preputial adhesions, when the adhesions are separated, at the time of circumcision, the underlying skin is seen to have been protected by the adhesions (Fig. 51.3).
4.

Patients with LS have a much higher incidence of urinary dribbling than patients without LS [15].
5.

Patients with persistent skin folds over the penis after circumcision have a higher rate of recurrence [26].

../images/468369_1_En_51_Chapter/468369_1_En_51_Fig3_HTML.jpg — Fig. 51.3

The penis of a boy with lichen sclerosus to show that the glans skin, under the preputial adhesions separated at the time of circumcision, is not affected by the lichen sclerosus

The aim of circumcision, therefore, is to stop the trapping of urine between opposing genital skin folds. Partial circumcision, therefore, has no part to play. If the circumcision is being performed for cultural or religious reasons it is only necessary to please the patient, or parents of the patient, about the cosmetic appearance after surgery. When performed for medical reasons there is a therapeutic goal. In the case of malignancy it is obviously to remove the cancer but also to reduce the area for future cancers to develop. Under these circumstances what is known as a radical circumcision is performed where no inner preputial skin is left and the shaft skin is approximated to the corona. When surgery is performed for lichen sclerosus then a small cuff of inner preputial skin can be left but not so much as to allow urine to be trapped by opposing skin folds. Depasquale et al. (2000) [8] showed that circumcision was effective in controlling lichen sclerosus with only 3.9% of patients, whose pathology was confined to the foreskin and glans, with ongoing LS requiring resurfacing after the circumcision. Nyatsanza et al. (2015) [26] reported a higher rate of recurrent LS in patients where skin folds, covering the glans penis, persisted after surgery.

51.6.1 The Difficult Circumcision

One of the features of lichen sclerosus, in addition to the secondary phimosis and skin changes on the foreskin and glans, is the tendency to form secondary preputial adhesions [15]. These adhesions must be distinguished from the adhesions seen so frequently in babies and children, which are a normal part of the development of the penis and nearly always separate, of their own accord, before adulthood [10]. In patients with lichen sclerosus , they are a frequent finding at circumcision, requiring them to be separated from the corona, before undertaking the operation [27]. Occasionally, however, they are so extensive and dense that the plane between the glans and inner prepuce is lost (Fig 51.4a) and attempts to find it risks de-epithelialisation of the glans with the requirement for skin grafting. Alternatively the adherent part of the prepuce can be left in situ but this partial circumcision is unsightly and frequently painful, especially during intercourse. The authors recently presented their experience of such cases using the ROLOCS (Restoration of the Lost Obscured Coronal Sulcus) technique [28] which involves an antegrade dissection just outside the fused epithelia of the glans and prepuce in a relatively bloodless plane (Fig 51.4b–d). Over the next 6–8 weeks the glans becomes raw and can be sore (Fig 51.4e) before it re-epithelialises, presumably from trapped nests of epithelial or stem cells to form a normal looking and feeling glans with good sensation (Fig 51.4f). Although all 22 patients in this series healed without problems the numbers are relatively low so it would be a wise precaution to warn the patients of the possibility of the need for skin grafting if this fails to happen. There should be a window of opportunity, if the glans granulates, to apply a graft without letting it heal by secondary intention. The need to expose the corona in these cases was accentuated by the high incidence of penile intra-epithelial neoplasia in the group and cases of squamous cell carcinoma just at the point of fusion [28].