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Doctors Opposing Circumcision
Genital Integrity Policy Statement

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Chapter Five: Post-operative Complications of Circumcision

The immediate postoperative complications of circumcision may be classified as urinary retention, meatitis, meatal ulceration, meatal stenosis, skin tags, adhesions, skin bridges, concealed penis, phimosis, and miscellaneous complications. These complications are iatrogenic.

Urinary Retention

Circumcision sometimes results in urinary retention1 with possible obstructive uropathy.2 Bandages used in ritual circumcision may cause urinary retention.3,4 The plastic ring portion of the Plastibell® may also cause urinary retention,5 which may result in a ruptured bladder,6 renal failure,7 or interruption of circulation in the lower extremities.8,9 Urinary retention caused other complications that led to death in one reported case.10 Urinary retention is not seen in non-circumcised intact boys.

Adhesions and Skin-Bridges

The first step in the genital cutting of newborn boys is separation of the inner surface of the foreskin from the glans penis, to which it is fused at birth. The tearing, which Gracely-Kilgore (1984) compared with “skinning a squirrel,”11 leaves the surface of the glans penis and the inner lining of the foreskin raw. Newborn circumcision wounds are not sutured, so the residual foreskin heals wherever it falls. The residual foreskin may heal together with the glans penis, which results in adhesions that may form a skin bridge,11,12 resulting in tethering.1 Gracely-Kilgore reports that 15 percent of boys seen in her practice had adhesions and three percent required surgical correction.11 Adhesions may require surgical separation by a urologic specialist.13 Adhesions are not seen in non-circumcised intact boys.

Meatal Complications

Meatitis, meatal ulceration, and meatal stenosis are pathology only seen in circumcised boys who have been deprived of the protective foreskin. The connection between circumcision and these iatrogenic pathologies has been known at least since 1921.14 The exposure of the unprotected glans penis to the ammoniacal diaper (nappie) is generally believed to be the cause of inflammation and ulceration.14,15 Persad et al. (1995), however, have suggested that ischemia of the glans penis, caused by the severing of the frenular artery at circumcision, may be the etiologic factor.16 The ulceration may eventually result in the formation of scar tissue, restricting the opening of the urethra. Leitch (1970) reported 8 cases of meatal ulcer and 3 cases of meatal stenosis in a series of 200 circumcisions for an incidence of 5.5 percent.17 A meatotomy may be required to open the urethra.18-19 Meatal complications are not seen in non-circumcised intact boys.

Urinary Tract Infection

Several studies find that more than 50 percent of urinary tract infections (UTI) occur within 12-14 days after ritual circumcision.20-22.

Post-circumcision Phimosis

Oddly enough, circumcision, which is touted to prevent phimosis, actually causes phimosis.22,23 When the circumcision scar forms beyond the glans penis, a phimotic ring results, causing phimosis. Blalock et al. (2003) reported an incidence of 2.9 percent in circumcised boys.23 Leich reported that 11 out of 200 required recircumcision to correct post-circumcision phimosis.17.

Inconspicuous Buried, Trapped, or Concealed Penis

This iatrogenic condition occurs secondary to circumcision.24-30 A second surgery usually is necessary to effect a repair.28-30.

Keloid Formation

Keloids are an overgrowth of scar tissue. Keloids are reported after circumcision.31-33 They require surgical removal and repair.31-33.

Circulation Problems, Ischemia, Necrosis, and Gangrene

Circumcision severs arteries and veins including the frenular artery that supplies the glans penis,16 so it is not surprising that circulation problems are reported after circumcision. Gangrene of the penis,34-36 and of the glans penis,37,38 have been reported.

Miscellaneous Complications

Miscellaneous post-operative complications include chordee,39 inclusion cysts,40,41 lymphedema,40,41 neuromas,42 sub-cutaneous mass,43 and cancer.44

References:

  1. Williams N, Kapila L. Complications of circumcision. Brit J Surg 1993;80:1231–6. [Full Text]
  2. Craig JC, Grigor WG, Knight JF. Acute obstructive uropathy—a rare complication of circumcision. Eur J Pediatr 1994;153(5):369–71. [Abstract]
  3. Berman W. Urinary retention due to ritual circumcision. Pediatrics 1975;56:62. [Full Text]
  4. Horowitz J, Schussheim A, Scalettar HE. Letter: Abdominal distension following ritual circumcision. Pediatrics 1976;57:579. [Abstract]
  5. Mihssin N, Moorthy K, Houghton PW. Retention of urine: an unusual complication of the Plastibell device. BJU Int 1999;84(6):745. [Full Text]
  6. Lee LD, Millar AJW. Ruptured bladder following circumcision using Plasticbell device. Br J Urol 1990;65:216–7.
  7. Eason JD, McDonnell M, Clark G. Male ritual circumcision resulting in acute renal failure. Br Med J 1994;309:660–1. [Full Text]
  8. Frand M, Berant, N, Brand N, Rotem Y. Complication of ritual circumcision in Israel. Pediatrics 1974;54:521. [Abstract]
  9. Ly L, Sankaran K. Acute venous stasis and swelling of the abdomen after circumcision. Can Med Assoc J 2003;169(3):216–7. [Full Text]
  10. Paediatric Death Review Committee: Office of the Chief Coroner of Ontario. Circumcision: a minor procedure? Paediatr Child Health 2007;12(4):311–2. [Full Text]
  11. Gracely–Kilgore KA. Penile adhesion: the hidden complication of circumcision. Nurse Pract 1984;9(5):22–4. [Full Text]
  12. Saihaye VU, Goswami AK, Sharma SK. Skin bridge – a complication of paediatric circumcision. Br J Urol 1990;66:214.
  13. Ponsky LE, Ross JH, Knipper N, Kay R. Penile adhesions after neonatal circumcision. J Urol 2000;164(2):495–6. [Abstract]
  14. Brennemann J. The ulcerated meatus in the circumcised child. Am J Dis Child 1921;21:38–47. [Full Text]
  15. Freud P. The ulcerated urethral meatus in male children. J Pediatr 1947;31(4):131–41.[Full Text]
  16. Persad R, Sharma S, McTavish J, et al. Clinical presentation and pathophysiology of meatal stenosis following circumcision. Br J Urol 1995; 75(1):91–3. [Full Text]
  17. Leitch IOW. Circumcision – a continuing enigma. Aust Paediatr J 1970;6:59–65. [Full Text]
  18. Upadhyay V, Hammodat HM, Pease PW. Post circumcision meatal stenosis: 12 years' experience. N Z Med J 1998;111(1060):57–8. [Abstract]
  19. Kunz HV. Circumcision and meatotomy. Prim Care 1986;13(3):513–25. [Abstract]
  20. Menahem S. Complications arising from ritual circumcision: pathogenesis and possible prevention. Isr J Med Sci 1981;17(1):45–8. [Full Text]
  21. Cohen HA, Drucker MM, Vainer S, et al. Postcircumcision urinary tract infection. Clin Pediatr 1992;31(6):322–4. [Full Text]
  22. Goldman M, Barr J, Bistritzer T, and Aladjem M. Urinary tract infection following ritual Jewish circumcision Isr J Med Sci 1996;32:1098–102. [Full Text]
  23. Redman JF, Schriber LJ, Bissada NK. Postcircumcision phimosis and its management. Clin Pediatr 1975;14:407–9.
  24. Blalock HJ, Vemulakonda V, Ritchey ML, Ribbeck M. Outpatient management of phimosis Following newborn circumcision. J Urol 2003;169(6):2332–4. [Abstract]
  25. Stewart DH. The toad in the hole circumcision — a surgical bugbear. Boston Med Surg J 1924;191:1216–8. [Full Text]
  26. Talarico RD, Jasaitis JE. Concealed penis: a complication of neonatal circumcision. J Urol 1973;110:732–3. [Full Text]
  27. Kon M. A rare complication following circumcision: the concealed penis. J Urol 1983;130:573–4. [Full Text]
  28. Radhakrishnan J, Reyes HM. Penoplasty for buried penis secondary to "radical" circumcision. J Pediatr Surg 1984;19:629–31. [Abstract]
  29. Bergeson PS, Hopkin RJ, Bailey RB, et al. The inconspicious penis. Pediatrics 1993;92:794–9. [Full Text]
  30. Raboei L. Surgical management of a concealed penis. Saudi Med J 2003;24(5):S50. [Abstract]
  31. Warwick DJ, Dickson WA. Keloid of the penis after circumcision. Postgrad Med J 1993;69(809):236–7.
  32. Gürünlüoglu R, Bayramiçli M, Numanoglu A. Two patients with penile keloids: A review of the literature. Ann Plast Surg 1997;39:662–5. [PubMed]
  33. Eldin US. Post-circumcision keloid – a case report. Annals of Burns and Fire Disasters 1998;XII(3):174. [Full Text]
  34. Hamm WG, Kanthak FF. Gangrene of the penis following circumcision with high frequency current. South Med J 1949;42:657–9.
  35. Thorek P, Egel P. Reconstruction of the penis with split-thickness skin graft: a case of gangrene following circumcision for acute balanitis. Plast Reconst Surg 1949;4:469–72.
  36. Ahmed S, Shetty SD, Anandan N, Patil KP, Ibrahim AIA. Penile reconstruction following post-circumcision penile gangrene. Pediatr Surg Int 1994;9:295–6.
  37. Rosefsky JB Jr. Glans necrosis as a complication of circumcision. Pediatrics 1967;39:774–6. [Abstract]
  38. Sterenberg N, Golan J, Ben-Hur N. Necrosis of the glans penis following neonatal circumcision. Plast Reconstr Surg 1981;68:237–9.
  39. Kaplan GW. Circumcision: An overview. Curr Prob Pediatr 1977:7:1–33.
  40. Shulman J, Ben-Hur N, and Neuman Z. Surgical complications of circumcision. Am J Dis Child 1964;127:149.
  41. Yildirim S, Taylan G, Akoz T. Circumcision as an unusual cause of penile lymphedema (letter). Ann Plast Surg 2003;50(6):665–6.
  42. Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83 Suppl. 1:34–44. [Full Text]
  43. Atikeler MK, Onur R., Gecit I., et al. Increased morbidity after circumcision from a hidden complication. BJU Int 2001;88(9):938–40. [Abstract]
  44. Bissada NK, Morcos RR, el-Senoussi M. Post-circumcision carcinoma of the penis. I. Clinical aspects. J Urol 1986;135(2):283–5. [Abstract]

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