Some Complications of Circumcision and Their

Surgical Repair
LOUIS T. BYARS, M.D., St. Louis, and LT. COMDR. WILLIAM C. TRIER (MC), U. S. N.

Complications of circumcision have most It is the purpose of this paper to report

commonly consisted of bleeding and infec- several complications of circumcision re-
tion, the latter usually mild.1,2 However, quiring surgical repair.
serious and even fatal infections have oc-
curred as a result of both ritual and medical Concealed Penis
circumcision. Diphtheritic infection of the A 2-month-old male infant was admitted to St.
wound,3 fatal staphylococcal bronchopneu- Louis Children's Hospital because of penile de-
monia,4 staphylococcal septicemia resulting formity and difficulty in urination.
in osteomyelitis of the femur,5 and tetanus 6 The history indicated that the infant at birth
was a normal, full-term child except that the penis
have been reported. Of more immediate in- seemed shorter than normal. Circumcision was
terest to the physician, be he general carried out with the use of a Gomco clamp. In a
practitioner, plastic surgeon, urologist, ob-
stetrician, or general surgeon, are the com- Fig. 2.—Large urethral fistula. A catheter
plications of circumcision resulting in traverses the extensive defect. The accompanying
chordee, due to scar contracture, is not apparent
deformity or dysfunction of the penis itself. from this view. A two-stage repair is under way,
the first operation, for relief of ventral flexion,
Submitted for publication May 13, 1957.
From the Department of Surgery, Division of
having been completed.
Plastic Surgery, Washington University School of
Medicine.
The opinions or assertions contained herein are
the private ones of the writers and are not to be
construed as official or reflecting the views of the
Navy Department or the Naval Service at large.

Fig. 1.—A, "concealed penis." The penis was

forced into a completely subcutaneous position by
wound contraction following circumcision. Prom¬
inence which is visible is site of a small fistula
leading to the urethral meatus, deep to the level of
pubic skin.
B, result six weeks after liberation of penis.
Elevation of tissue seen in A is now located at
the base of the scrotum, below the penis. Addition
of skin to shaft will be required at a later opera¬
tion.

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 few weeks, however, the mother returned to the ondary to scar contracture. This situation,
physician with the infant because she had noticed quite like that of congenital hypospadias
that "the skin had grown back over the penis,"
and the child had been experiencing difficulty in
with chordee, is being corrected by a two-
urination. This skin was reportedly excised but stage repair, which has been described pre¬
"grew over again," and the infant was referred viously.7 Two cases of subglandular
for correction of this deformity. urethral fistulas following circumcision have
Physical examination on admission revealed a been treated, as illustrated in Figure 3>A, B,
healthy, normal male infant except for the and C. This is a simple and dependable tech¬
external genitalia. The penis was not visible and
was found to be completely buried in the sub¬
nique which has proved valuable in the
cutaneous tissue of the pubic region and scrotum. treatment of urethral fistulas associated with
A sinus emerged through a small, scarred aperture repair hypospadias8 (Fig. 4). Johnson
of
in a tag of tissue just above the scrotum (Fig. reported a fistula of the penile urethra sec¬
1A). The scrotum was normal and contained both ondary to infection in the operative wound
testes. Palpation of the pubic area disclosed what in an adult, with its repair by a method
appeared to be the shaft of a normal penis sub-
cutaneously, but it was impossible to find and described by Davis.9,10 A preliminary
catheterize the urethral meatus. suprapubic cystotomy preceded the actual
A vertical incision was made in the pubic skin repair of the fistula.
overlying the palpable penis, splitting the sinus
tract. The glans penis was found enveloped in what Loss of Penile Skin
proved to be the tightly adherent mucous membrane
of the prepuce. This was dissected from the glans Loss of skin of the penis resulting from
and retracted. Considerable smegma was found circumcision is not uncommon and presents
in the coronal sulcus. The shaft of the penis was no particular features different from those
normal. The free edge of mucous membrane was
then sutured to the surrounding skin edges of the
expected in loss of the skin of the penis
operative wound. At the conclusion of the opera¬ following industrial and farm accidents.
tion the glans was in a normal external position, This loss has resulted from the removal
as illustrated in Figure 15, but a skin deficiency of too much preputial skin,1 the use of the
remained. It was decided to postpone replacement high-frequency cutting current,11 and local
of this skin until the child should reach the age anesthetic agents or other injected sub¬
of 3 or 4 years in order to conserve essential
stances mistaken for anesthetic solutions.12
tissue and not risk an inadequate reconstructive
operation in such a small infant at this time. The application of partial-thickness skin
In attempting to reconstruct the develop¬ grafts to the denuded shaft of the penis in
ment of this complication, it would appear
such instances 12,13 has given excellent re¬
that a combination of factors might be in¬ sults (Figs. 5 and 6).
volved : Readherence of mucous membrane
to glans and the tendency of the penis to
Laceration of Penis
retract into the fatty mons pubis may have Accidental circumcisional lacerations of
united to force the penis into a submerged the glans and urethral meatus have been
position. The circular circumcision wound encountered. An interesting case of partial
then was free to contract to match-stem size amputation of the penis during circumcision,
and secure the organ in its trapped position. with its repair, has been reported by
Lerner.14
Urethral Fistula
Loss of Penis
Urethral fistula as a sequela of circum¬
cision is seemingly uncommon. Figure 2 Several cases of total or partial slough
is an operating-room photograph of the of the penis from use of the electrosurgical
penis of a 10-year-old boy who was circum¬ unit at circumcision have been reported to
cised soon after birth. A complete segment us by personal communication, and loss of
of urethra was destroyed, resulting in a the penis from the use of a rubber band
large defect of the urethra and chordee sec- as a tourniquet has been reported.15 Figure

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 Fig. 3.—A, drawing of subglandular urethral fistula following circumcision. Skin of the
undersurface of the penis has been mobilized by incision around the corona. More tissue can
be gained by making a dorsal slit in the prepuce and bringing redundant tissue to the undersurface.
B, a purse-string suture has been placed around the mouth of the fistula. The ends of the
purse-string suture have been brought through the flap of skin on the undersurface of the
penis, where the suture will be tied so that the knot will be external rather than in the wound.
The suture emerging from the meatust will ensure inversion of the mouth of the fistula when
traction is exerted on it. After purse-string suture is tied, inverting stitch is removed through
the meatus. No catheter is used, and the urinary stream is not diverted.
C, completion of operation, with fistula closed in watertight fashion by purse-string suture,
which is tied on the outside of the skin to avoid unnecessary suture material within the wound.
Redundant skin on the undersurface of the penis permits skin closure at a different level from
that of the fistula. This overlapping of wound reduces likelihood of recurrence. The urinary
"

stream is not diverted.

Fig. 4.—A, , C, scheme illustrated in Figure 3 applied to urethral fistula in shaft of penis,
such as might result from infection or hypospadias repair. The same principles are involved
as those illustrated in Figure 3.

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 Fig. 5.—A, loss of scrotum, skin of shaft of penis, and one testis from trauma. Similar
skin loss has been seen and repaired following circumcision.
B, result from immediate repair with free skin graft. This same procedure has been
utilized to replace skin lost following injection of solution employed for local anesthesia during
circumcision.

Fig. 6.—A, technique employed in patient shown in Figure SA and B. Heavy split-thickness
skin graft was sutured accurately to cover the skin defect. Sutures at glans and base of penis
were left long and tied over cotton waste, as illustrated in B. This, along with additional
circular dressings, splinted the wound and provided pressure. This technique has been employed
in repair of skin loss following circumcision.

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 normal-appearing and functioning penis as
the goal.

Summary
1. An unusual complication of circum¬
cision is reported and its initial correction
described.
2. A technique for the repair of urethral
fistulas resulting from circumcision or other
causes is described.
3. The technique for resurfacing the
penis with skin grafts is reviewed.
4. Additional reported complications of
circumcision are cited.
200 Doctors Building, 100 North Euclid at West
Pine (8).

REFERENCES

1. Campbell, M.: Clinical Pediatric Urology, with

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2. Pugh, W. S.: Circumcision, S. Clin. North
America 15:461-470 (April) 1935.
Fig. 7.—A, absence of glans following ritual 3. Rosenstein, J. L.: Wound Diphtheria in the
circumcision. B, attempted retraction of penile skin,
demonstrating fixation of skin to distal urethral Newborn Infant Following Circumcision, J. Pediat.
stump. 18:657-685 (May) 1941.
4. Sauer, L. W.: Fatal Staphylococcal Broncho-
7A and are of the penis of
photographs pneumonia Following Ritual Circumcision, Am. J.
Obst. & Gynec. 46:583 (Oct.) 1943.
a 2^2-year-old
child who underwent ritual
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6. Gosden, M.: Tetanus Following Circumcision,
Conclusions Tr. Roy. Soc. Trop. Med. & Hyg. 28:645-648
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1. Serious complications of circumcision 7. Byars, L. T.: A Technique for Consistently
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2. While a simple operation, circumcision (Feb.) 1951.
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attention to detail, and respect for tissues lowing Circumcision, U. S. Nav. M. Bull. 49:120\x=req-\
due any other surgical procedure. 122 (Jan.-Feb.) 1949.
3. Deforming or disabling complications 10. Davis, D. M.: The Pedicle Tube-Graft in the
of circumcision should be corrected at the Surgical Treatment of Hypospadias in the Male,
with New Method of Closing Small Urethral
earliest possible time and to an extent com¬
Fistulas, Surg. Gynec. & Obst. 71:790-796 (Dec.)
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 11. Hamm, W. G., and Kanthak, F. F.: Gangrene
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