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Complications of Circumcision

 

The development of the human penis is a complex sequence of events which results in an utterly individual outcome: no two penises are identical and there is a surprising range of anatomical detail that should be considered normal. Parents need to be assured of this range of normality. Moreover, the desire of practitioners for standard procedures can lead to unpredictable outcomes because of both this anatomical variation and the impossibility of predicting the functional results of surgical correction in infants. This is because the procedures are performed with an emphasis on achieving an acceptable cosmetic outcome on a very small organ which has the capacity for considerable growth and changes during puberty. Furthermore, no surgical procedure can have absolutely predictable outcomes because of the variations in healing and scar formation, the individual variations in technique, and the effects of infection. Regrettably, it seems that the majority of those performing surgical procedures on the penis of minors take no interest in following up the outcome after the organ has developed. Admittedly this involves a time span of at least a decade, but there have been very few attempts at quality control and many boys are left with seriously damaged penises; the outcome is often a functional impairment and is seldom tidy, to say the least. ...

Each operator applies the procedure idiosyncratically and without any absolute parameters, to which must be added the fact that it is surgery on a very small organ which will undergo a large increase in size (usually at least three times) at puberty. These factors may account for the wide variation in circumcision outcomes. A major failure in quality assurance with circumcision is that practically all operators never make any assessments of the outcome of their surgery after the period of growth so as to reduce the oft-seen poor results.

- Pathologist Ken McGrath
Ninth International Symposium on
Circumcision, Genital Integrity and Human Rights
Seattle, August 25, 2006

 

Contents

Risks vs benefits
  A Nigerian study
  A Kenyan study
  A Brazilian study
  A Danish study
  A urologist's experience
  Some circumcisionists' study

(in ascending order of severity)
Correctable complications - re-adhesion
Aesthetic damage
Phimosis
Hairy shaft
Wound dehiscence
De-gloving
Haemorrhage (Bleeding)
Meatal stenosis, meatal ulcer
Urethrocutaneous fistula
Infection, including MRSA
  Staphylococcal scalded skin syndrome   Hepatitis
  Tetanus
  Bladder infections
  Septic Arthritis
  other
Neuroma
Blockage of the Urethra
Buried penis
Penoscrotal webbing
Deformity
Gangrene
Necrotising fasciitis (Galloping gangrene)
Epidermal inclusion cyst
Priapism
Gastric rupture
Oxygen deprivation Clamp injuries
Plastibell ring injuries
Loss of glans
Ablation (removal) of the penis
 David Reimer
 Others
Skull fracture!
Death
25 other mishaps

For a fuller list of Reasons Not to Circumcise, click there. Death now has its own page.

Strictly speaking, a disease has complications, surgery such as circumcision has side-effects.

 

Risks vs Benefits

An article in Pediatrics in January 2000 attempts to compare the benefits of circumcision with the risks. However, the only risks considered are the direct complications of surgery - and only some of those.

"Complications" are defined very conservatively, including only those that are noticed before the baby leaves hospital or that lead to him being brought back to the same hospital or doctor. They don't include aesthetic results so bad the parents take him back for more surgery. Nor do they include the ones the penises' owners learn to live with - after all, part of the rationale of circumcision is horror of the penis, so the mother of a cut baby probably doesn't get to see or attend to a significant proportion of uneven cuts, scarring etc.

The researchers did not cite two of the main studies of complications, those of William and Kapila or Patel.

Benefits are defined very generously, using a lot of the work of Wiswell, rather than those who estimate the benefits more conservatively, such as To.

No intrinsic worth is assigned to having intact genitalia, or to not performing invasive surgery, or to having a choice.

The same is true of a study published in New Zealand, sometimes cited as supporting an overall advantage to infant circumcision. A cohort of all the boys born in one city over a period of months in 1977 were followed for eight years. (They are still being followed.) This study is potentially valuable, because only one quarter of the 590 boys were circumcised at birth. Few US studies include enough intact boys to achieve statistical significance.)

It seemed to find that circumcised boys had more penile problems in their first year, intact boys in the longer term, with a difference of "marginal significance" in favour of circumcision. Closer examination shows that boys not circumcised at birth continued to be counted as "uncircumcised" throughout the study, and their "penile problems" included complications of post-neonatal circumcisions!

 

"The estimated 1% to 3% incidence of complications after newborn circumcision covers only the immediate postoperative period prior to the infant's discharge from the hospital. The reported risks are hemorrhage in 1%, infection - occasionally leading to sepsis - in 0.5%, meat[iti]s and meatal stenosis, u[r]ethrocutaneous fistula, adhesions between the glans and remaining prepuce, secondary phimosis, and cosmetically unsatisfactory results. The rate of subsequent repeat surgery to correct adhesions of the glans, meatal stenosis, fistula, and phimosis with buried penis is unknown, but our practice at Children's Hospital of Philadelphia includes about two such cases per month. While this is not a large percentage of the total number of circumcisions preformed, it is a significant number of children undergoing surgery for the complication of this operation. "

- Schwartz, et al. "Pediatric Primary Care: A Problem-solving Approach" pp 861-862.

(At 1.25 million circumcisions of newborns in the US per year, a 0.5% infection rate amounts to 6000 cases per year, and a 4% overall rate of complications requiring treatment represents 48,000 patients experiencing avoidable morbidity.)

Pieretti et al. at the MassGeneral Hospital for Children found 424 (4.7%) out of 8,967 operations in 2003-7 were for complications resulting from previous neonatal circumcision. (Note that this is the fraction of operations, not circumcisions) and 127 boys with concerns following newborn circumcision represented 7.4% of the total volume of cases seen in the pediatric urology outpatient clinic.

De la Hunt found complications requiring attention by the GP in 22% of circumcisions.
de la Hunt MN. "Paediatric Day Care surgery: a hidden burden for primary care?" Ann R Coll Surg Engl. 1999; 81:179-82.

 

Where facilities are scarce, the position is much worse.

Bungoma district, Kenya: Assessment of traditional and medicalised male circumcision
The study, which was conducted to establish a pre-training baseline assessing safety of male circumcision in resource-poor settings found high rates of adverse events for both medical (17%) and traditional circumcision (35%). The most common were profuse bleeding, infections, pain, insufficient foreskin removal and torsion. The study findings highlight what could go wrong if providers are not well trained and adequately equipped to perform male circumcision in hygienic settings with good post-surgical follow-up.

UNAIDS/CAPRISA Consultation
on Social Science Perspectives
on Male Circumcision for HIV Prevention
18-19 January, 2007
Summary Report

 

Epidemiology of complications of male circumcision in Ibadan, Nigeria

Linus Okeke, Adanze A Asinobi and Odunayo S Ikuerowo
BMC Urol. 2006; 6: 21.
Published online August 25 2006

Abstract

Background
The number of infants managed for neonatal circumcision injuries in our unit has been on the increase over the past 16 years. In our search for the sources and reasons for these injuries, we were unable to identify any previous studies of circumcision injuries from our environment. We therefore decided to carry out this study in order to shed some light on this growing problem.

Methods
The patients were made up of 370 consecutive consented children attending our infant welfare clinic for immunization over a period of 3 months. Information on their demographic data, their age at circumcision, where, why and who circumcised them was obtained from their mothers. They were clinically examined for the presence and type of complications of circumcision.

Results
Our circumcision rate was 87%. Neonatal circumcision had been performed in 270 (83.9%) of the children. Two hundred and fifty nine (80.7%) were performed in hospitals. The operation was done by nurses in 180 (55.9%), doctors in 113 (35.1%) and by the traditional circumcisionist in 29 (9%) of the children. Complications of circumcision occurred in 65 [20.2%] of the children. Of those who sustained these complications, 35 (53.8%) had redundant foreskin, 16 (24.6%) sustained excessive loss of foreskin, 11 (16.9%) had skin bridges, 2 (3.1%) sustained amputation of the glans penis and 1 (1.5%) had a buried penis. One of the two children who had amputation of the glans also had severe hemorrhage and was transfused. Even though the complications tended to be more likely with nurses than with doctors or traditional circumcisionists, this did not reach statistical significance (p = 0.051). [That is, doctors were no better at circumcising than nurses.]

Conclusion
We have a very high rate of complications of circumcision of 20.2%. We suggest that training workshops should be organized to adequately retrain all practitioners of circumcision on the safe methods available. [The complication rate could also be reduced by reducing the circumcision rate.]

 

A Brazilian study

J. Ped. Urol. (2010) xx, 1-6

Prospective randomized trial comparing dissection with Plastibell circumcision

José Murillo Bastos Netto, José Gonçalves de Araújo Jr, Marcos Flávio de Almeida Noronha, Bruno Rezende Passos, José de Bessa Jr, André Avarese Figueiredo Received 23 August 2009; accepted 7 January 2010

Abstract
Objective: To compare and evaluate dissection and Plastibell™ circumcision techniques for the treatment of phimosis.

Methods: In 2006-2007, 125 children were submitted to circumcision by the same surgeon. The children were randomly divided into two groups (PD: Plastibell™ and DC: dissection). In both groups the surgery was performed under general anesthesia and dorsal penile block. The dissection circumcision used the double circular incision technique. Follow-up was done on days 15, 45 and 90 after surgery.

Results: Sixty-eight patients were included in DC and 57 in PD. The mean age at surgery was 71.76 +/- 31.56 months for DC and 70.95 +/- 31.73 months for PD. There was no difference in Kayaba’s classification for phimosis or indication for surgery between the groups. Surgical time for DC was 14.64 +/- 1.93 min and for PD 3.29 +/- 1.48 min (P < 0.001). The incidence of immediate complications was similar, but late complications, especially adhesions, were greater in DC (P < 0.01). The use of pain medication (paracetamol) was similar during the first 2 days after surgery, but was greater in PD from the 3rd day after surgery (P < 0.05).

Table 2 Immediate and late complications.

DC n (%)
[N=68]

PD n (%)
[N=57]

p

Immediate complications

Total

10 (16.17%)

3 (5.26%)

0.08

Hemorrhagic

5 (7.35%)

2 (3.51%)

Reoperation

1 (1.47%)

0

Other

5 (7.35%)

1 (1.75%)

Late complications

Total

8 (11.76%)

3 (5.25%)

0.34

Cicatricial
[scarring]

6 (8.82%)

2 (3.50%)

Hemorrhagic

2 (2.94%)

1 (1.75%)

Adhesions

20 (29.41%)

6 (10.52%)

0.014

Conclusions: Plastibell™ circumcision has a shorter surgical duration with fewer late complications, but requires more analgesic medication after the 3rd day post surgery.

[One boy in six suffered an immediate complication and one in nine a late complication, from the sleeve procedure. More than one in 20 suffered an early complication, and another one in 20 a late complication from the Plastibell™. Nearly three in ten suffered an adhesion from a sleeve procedure, and more than one in ten from the Plastibell™. The p-values reflect only the signicance of difference between the two operations. As usual, the authors are only concerned which operation is "better", not whether it should be done at all.]

 

A Danish study

Danish Medical Journal Dan Med J 2013;60(8):A4681
May 30, 2013

Complication rate after circumcision in a paediatric surgical setting should not be neglected

Jørgen Thorup, Sebastian Cortes Thorup & Inge Botker Rasmussen Ifaoui

Abstract
Introduction: As a consequence of the discussion on whether the health benefits of newborn male circumcision outweigh the risks and the discrepancies in reported figures of complications, we evaluated our results from a paediatric surgical department.

Material and methods: Patient file data from children who had undergone ritual circumcision in the 1996-2003- period were retrieved. Complications recorded until December 2011 were noted.

Results: Circumcision in 315 boys aged from 3 weeks to 16 years (median five years) were evaluated. A total of 16 boys (5.1%) had significant complications, including three incomplete circumcisions requiring re-surgery, two requiring re-surgery six months and five years postoperatively due to fibrotic phimosis and two requiring meatotomy due to meatal stenosis two and three year postoperatively. Acute complications included two superficial skin infections one week postoperatively and five cases with prolonged stay or re-admissions for bleeding the first or second postoperative day, whereof two underwent operative treatment. Finally, two had anaesthesiological complications leading to a need for overnight surveillance, but no further treatment.

Discussion: Parents should be counselled and be required to provide informed consent that any health benefits of childhood circumcision do not outweigh the reported complication rate and that therefore they should weigh the health benefits against the risks in light of their religious, cultural and personal preferences. As ritual circumcision is legal, a strong focus on high surgical/anaesthesiological standards is needed to avoid complications.

 

A Paediatric Urologist writes

Men's Health magazine 2/5/2009 9:07 AM CST

Neonatal circmcision is totally unnecessary, and there is no current role for preventative or prophylactic neonatal circumcision.

Unfortunately, 70-80% of neonatal circumcisions are performed by obstetricians, who can neither manage their complications (2-5% incidence) nor obtain proper informed consent (defined as outlining risks and benefits of a procedure, as well as alternatives-including nothing) for neonatal circumcision. Currently, the American College of OB-GYN (ACOG) have no paramenters for training (learning and performing neonatal circumcision, managing complications)of residents, who then go out and continue this practice.

In my practice, as a pediatric urologist, I manage the complications of neonatal circumcision. For example, in a two year period, I was referred 275 newborns and toddlers with complications of neonatal circumcision. None of these were 'revisions' because of appearance, which I do not do. 45% required corrective surgery (minor as well as major, especially for amputative injury), whereupon some could be treated locally without surgery.

Complications of this unnecessary procedure are often not reported, but of 300 pediatric urologists in this country who have practices similar to mine...well, one can do the math, to understand the scope of this problem...let alone, to understand the adverse cost-benefit aspect of complications (>$750,000) in this unfortunate group of infants and young children. Fortunately, neonatal circumcision is on the decline as parents become educated...but the complications still continue.

Until the time that the USA falls in step with the rest of the planet who does not submit newborns to neonatal circumcision, ACOG should assure that the training of obstetricians to perform this procedure is adequate, particularly in avoiding and managing complications of a procedure that is unnecessary, and that obstetricians learn to obtain proper informed consent from parents who have no idea of the problems that can ensue.

M.David Gibbons, MD
Associate Professor, Pediatric Urology, Georgetown University School of Medicine and George Washington School of Medicine. Attending Pediatric Urologist, Childrens National Medical Center, Washington, DC. Director, Pediatric Urology, Georgetown University Hospital, Washington, DC. Head, Pediatric Urology, Inova Fairfax Hospital For Children, Falls Church, Virginia. Posted at Men's Health Magazine on The Debate Over Circumcision: Should All Males Be Circumcised? in the comments section (http://www.menshealth.com/)

 

Some circumcisionists did a study....

JAMA Pediatr. Published online May 12, 2014. doi:10.1001/jamapediatrics.2013.5414

Rates of Adverse Events Associated With Male Circumcision in US Medical Settings, 2001 to 2010

Charbel El Bcheraoui, PhD; Xinjian Zhang, PhD; Christopher S. Cooper, MD; Charles E. Rose, PhD; Peter H. Kilmarx, MD; Robert T. Chen, MD, MA

Importance Approximately 1.4 million male circumcisions (MCs) are performed annually in US medical settings. However, population-based estimates of MC-associated adverse events (AEs) are lacking. [And isn't that scandalous in itself, when the operation is performed with no diagnosis?]

Objectives To estimate the incidence rate of MC-associated AEs and to assess whether AE rates differed by age at circumcision.

Design We selected 41 possible MC AEs based on a literature review and on medical billing codes. [One of the commonest complications is meatal stenosis following meatal ulcer. The word "meatal" does not occur in the text of the study, only in one of the references, which is then ignored.] We estimated a likely risk window for the incidence calculation for each MC AE based on pathogenesis. We used 2001 to 2010 data from SDI Health, a large administrative claims data set, to conduct a retrospective cohort study.

Setting and Participants SDI Health provided administrative claims data from inpatient and outpatient US medical settings.

Main Outcomes and Measures For each AE, we calculated the incidence per million MCs. We compared the incidence risk ratio and the incidence rate difference for circumcised vs uncircumcised newborn males and for males circumcised at younger than 1 year, age 1 to 9 years, or 10 years or older. An AE was considered probably related to MC if the incidence risk ratio significantly exceeded 1 at P < .05 or occurred only in circumcised males. [Since P is itself a measure of significance, how was this "significant excess" over 1 decided on? Room for a fudge-factor here - they can just say the significance is "not enough" over one and ignore the risk.]

Results Records were available for 1 400 920 circumcised males, 93.3% as newborns. [Extremely large numbers prove nothing. Garbage in still means garbage out, just more of it.] Of 41 possible MC AEs, 16 (39.0%) were probable. The incidence of total MC AEs was slightly less than 0.5%. [That's still 6000 adverse events/year, 16/day in the USA.] Rates of potentially serious MC AEs ranged from 0.76 (95% CI, 0.10-5.43) per million MCs for stricture of male genital organs to 703.23 (95% CI, 659.22-750.18) per million MCs for repair of incomplete circumcision. Compared with boys circumcised at younger than 1 year, the incidences of probable AEs were approximately 20-fold and 10-fold greater for males circumcised at age 1 to 9 years and at 10 years or older, respectively.

Conclusions and Relevance Male circumcision had a low incidence of AEs overall, especially if the procedure was performed during the first year of life, but rose 10-fold to 20-fold when performed after infancy.

[The narrow definition of "adverse effects", and the arbitrary measures of significance, mean this study will inevitably underestimate the risks of circumcision. Death from circumcision would not show up in this study, for example, because the baby would not be returned to the hospital.]

This study, predictibly, got world-wide headlines of the form "Circumcision safer if done earlier". ("Hurry! This offer won't last!")

 

The following complications are listed in approximately increasing order of severity.

Correctable complications

Re-adhesion

Circumcising is supposed to make a penis "maintenance-free". Yet these mothers, all in one region, all report the need for excessive maintenance, including having to "scrub with a washcloth" making "diaper changes traumatic" - all without questioning circumcision itself.

Six mothers on Facebook tell of post-circumcision adhesions

 

In Reuters, via Medscape:

Most Penile Adhesions Resolve Spontaneously
After Neonatal Circumcision

[The real headline:
More Than Two-thirds of Circumcised Babies have Penile Adhesions]

WESTPORT, Aug 03 (Reuters Health) - Penile adhesions are common after neonatal circumcision, but most do not require any intervention, according to researchers from the Cleveland Clinic Foundation, in Ohio.

Dr. Lee E. Ponsky and colleagues looked for penile adhesions in all circumcised boys who presented to their pediatric urology clinic. In total, 254 boys were examined, ranging in age from 1 month to 19 years, 8 months.

The prevalence of penile adhesions declined with age, the investigators found. [That, or the incidence of penile adhesions has been increasing over the last 20 years.] All told, 71% of infants had adhesions compared with 28% of boys ages 1 to 5 years, 8% of those ages 5 to 9 years and 2% of older boys. About one third of infants had adhesions more severe than grade 1, compared with 10% of boys ages 1 to 5 years and none of the boys older than 5 years.

Seven of the patients had been treated for adhesions, and three of these had recurrences, Dr. Ponsky and colleagues note.

The findings indicate that most penile adhesions resolve spontaneously with time, the researchers write. Although the study did not address the reasons for spontaneous resolution, they point out that possible mechanisms include "an increased number of erections with age, penile growth, hormonal influence on local tissue and keratin pearl formation." [This indicates ignorance of the normal development of the intact penis, and how it might be affected by circumcision.]

Based on their findings, the Cleveland researchers advise against routine lysing of penile adhesions, except perhaps when they involve the circumcision line. [Another conclusion is that these adhesions could be prevented by not circumcising.]

"Adhesions that involve the circumcision line may be more likely to cause skin bridges," they note. [How else do they think skin bridges are caused?]

J Urol 2000;164:495-496.

 

This site for mothers recounts many adhesions requiring "re-circumcision". The option of not circumcising does not seem to have been considered.

Other unspecified damage requiring re-circumcision

''totally messed up'...''that happened to Zachary too''

Facebook, July 17, 2014

http://www.gofundme.com/g3xk4g?fb_action_ids=10204557043113504&fb_action_types=og.shares

 

Aesthetic damage

Unaesthetic outcomes of circumcision are seldom reported. One purpose of circumcision is to create a "maintenance-free penis" and mothers are less inclined to inspect it than mothers of intact sons. Click here for pictures of
  • skin-bridges
  • skin-tags
  • scarring
  • unevenness
  • excessive skin removed
  • There is a collection of ugly circumcisions on Tumblr

     

    One reason aesthetic damage is so common is that the baby's penis is tiny compared to the man's. Any mishap is enlarged, like writing on a balloon.

    balloon wrritten on when deflatedthe same balloon, inflatedballoon written on when inflated

    Balloon inscribed then inflated

    Balloon inflated then inscribed

     

    Phimosis

    Blalock et al. found phimosis in 2.9% of 521 circumcised boys, two-thirds of them (10/15) with buried penis. Since "phimosis" (usually a misdiagnosis of the normal infant attachment of the foreskin to the glans) is a common reason for circumcision, this is ironic indeed.

     

    Hairy shaft

    The shaft of the penis is normally hairless, but erection of a tightly circumcised penis can pull hairy scrotal skin on to the shaft, causing discomfort on intercourse.


    Picture of a hairy shaft

    One sufferer is shock-jock Howard Stern. He discussed it on May 4, 2006 at 6.15am.

    Wound Dehiscence

    Parting of the joined cut edges.

     

    Kristen and I also had a bizarre sexual allergy to each other. Whenever we made love, a painful rash spread across me which would take about three weeks to heal. We went to a number of doctors, but we never resolved the problem. I even had a circumcision to try to stop the reaction. Being circumcised aged 24 is not a good idea, particularly if the night after your operation you find yourself watching Jane Fonda's erotic film Barbarella. Before I could stop myself, I had burst my stitches! Hearing my screaming, Kristen came running to see what the matter was. When she found out what had happened, she was in stitches. I no longer was.

    - Richard Branson "Losing My Virginity" p 142

    Branson has heavily promoted circumcision in Africa, in a clear case of the Fox Who Lost His Tail

    Pictures of wound dehiscence (NSFW)

     

    De-gloving
    (Where the outer skin layer slides out of alignment with the mucosa, like a glove coming off a finger)


    Picture of a de-gloved penis

    (not for the squeamish)
    doctors' comments
     

    From the PSOT blog

    To Plastibell or Not To Plastibell?

    Comment for the STFM procedure list dialog on Circumcison Techniques.

    I have been unhappy with the Plastibell device...

    Mogen is the easiest and fastest with excellent safety, but lack of fundamental skills with needle and thread intimidate many from being able to do these procedures past the newborn period.

    ...
    REPLY MF-MD I would still vote that residents need to learn Plastibel, too. I did more Plastibels than Gomco's in residency, and am much more comfortable with them, and faster. A Urologist that has helped us with complications we've had with Gomcos said he sees far more complications with Gomco's than Plastibel's. And I've had 2 situations lately where we started one procedure, and for various reasons switched to the other (one each way!). And sometimes you go to do a Gomco and find the size you need isn't available... Just my thoughts. Mary

    REPLY -WMR I've never seen a long term complication from a Gomco, but continue to believe that the procedure is not medically indicated. What are the complications you witnessed that required care of a urologist, and could you give me an estimate of their frequency?

    REPLY MF-MD I see residents differentially pull too much of the outer skin through, leading to a "de-gloving" problem which distresses the parents. [It probably distresses the babies, too.] I've also see residents inadvertently separate the two layers as they get the skin off the bell, again leading to bleeding and a "de-gloved" appearance. Obviously this is a teaching issue, and we work to prevent it. I see/hear this about once a year, overall. The only complication I've had with a Plastibel in 18 years (18 years mine and 3 years residency teaching) was once when we probably used a ring that was slightly too large and it slipped up onto the shaft after it separated and required some imagination to get it off! Mary

    REPLY-FORMAN The only complication I used to get from a Gomco was the occasional bleeding, easily sutured with some gut suture.

    REPLY WMR--WE have seen the degloved effect once every 70 Mogens in the hands of inexperienced physicians, but it is easily identified. It does not require urological consultation, but you do need to identify the correct anatomical plane and reapply the clamp.
    ...

    Wm MacMillan Rodney MD
    Adjunct Professor of Family Medicine
    Meharry/Vanderbilt School of Medicine
    Medicos para la Familia
    Memphis and Nashville, Tn.
    www.psot.com

    See also Ethics for more admissions from this doctor.

    A de-gloving in Muncie, IN

     

    De-gloving in Muncie IL, ex Facebook

    Film director Frank Capra was a victim of de-gloving as an adult.

    Lantz's story

     

    Haemorrhage (Bleeding)

    Patel found 35 cases of haemorrhage from 100 circumcisions, mainly just oozing, but a baby's body has pitifully little blood (a breakfast-cup to a soft-drink can full, 300-350ml), and so a tiny loss, 30ml, about two tablespoons, may call for a blood transfusion.

     

    Circumcised baby 'almost died'

    By LORNA KNOWLES

    14 June 2000 Daily Telegraph
    (Sydney, Australia)

    A SYDNEY GP circumcised 14 infant boys without adequate anaesthetic and caused one baby to "almost bleed to death", a tribunal heard yesterday.

    Dr Aladdin Matter is accused of professional misconduct over the circumcisions of the babies, aged from 32 days to eight months at his Greenacre rooms between March 1996 and July 1998.

    The Health Care Complaints Commission alleges the procedures were contrary to a condition of his registration imposed by the Medical Board in 1996. The commission alleges in circumcising an eight-month-old boy, identified as Child N, on May 31 1997, Dr Matter: failed to provide adequate analgesia or anaesthetic; removed an excessive amount of the outer foreskin; failed to remove part of the inner foreskin; failed to stop the bleeding and failed to provide adequate post-operative care.

    "He (the baby) was admitted to the New Children's Hospital, having almost bled to death," Lisa Stapleton for the commission alleged.

    The hearing continues.


    (September 17, 2000)
    Dr Matter was convicted and banned from medical practice for three years.

     

    They forgot one huge myth; the myth that circumcision itself is a safe procedure. It nearly killed my son. He was a perfectly healthy, normal baby, I brought him home after the plastibell procedure, and his wound never stopped slowly oozing blood. After his nap, I changed his diaper and it was like a crime scene. He needed a blood transfusion and emergency surgery to save his life. It is not a risk free procedure, it is surgery on a tiny infant! He is ok now, although he had issues with adhesions for over 2 years.

    Jessica S. on Pregnancy Beat, February 26, 2013

     

    ... My husband and I took Quinn to have his circumcision performed at the office of a recommended urologist. We naively believed that this was “just a routine procedure”. ... Quinn was strapped down and the doctor numbed his penis. He screamed in pain and I felt my stomach drop. A few minutes later the doctor did the cut and the nurse commented, “That’s a beauty.” The doctor invited my husband to take a look seemingly proud of what he had just done. ... my mom took Quinn into my room to change his diaper before we sat down to dinner. I heard my mom yell for me in a frantic voice. I rushed in to see what was alarming her and was shocked to see Quinn had bleed through his cloth diaper and the diaper cover. There was a lot of blood and it was still oozing out of the circumcision site. ... I called Quinn’s pediatrician. He instructed us to apply very firm pressure to his penis for 10 minutes and if the bleeding did not stop to go to the emergency room. ... By the time we got to the ER Quinn had lost a lot more blood. I was holding him in the waiting room and my jeans were soaked with his blood, the blanket I had wrapped him in was soaked with blood, his little socks were soaked with blood. ... he was losing more blood and was answered with “Mmm.” I then questioned why Quinn was looking so pale and why his lips were turning blue. The EMT responded “There could be a lot of reasons for that.” ... When we finally arrived at the next ER the paramedic on duty there took one look at Quinn and said “His color is awful. We need to get an IV in this baby right away.” They put in the IV and placed an oxygen mask on my baby’s face. ... I looked down to see his car seat full of blood. ... The urologist that had performed the circumcision came in and placed four sutures in Quinn’s penis. He had cut the frenula[r] artery when performing the original surgery. The bleeding finally stopped. ... due to his rapid heart rate and breathing as well as his listless state that I needed to call 911 right away and go back to the ER with Quinn. ... We were then sent by ambulance to a hospital with a pediatric unit. We were admitted to the hospital and spent 23 hours there being observed. ... He lost 5 ounces and needed to show the doctors that he could eat well before we could go home. The next two weeks we had follow up appointments and more blood work to make sure Quinn’s hemoglobin and hematocrit continued to rise. He has to take iron supplements until his levels are normal again. All of this because we believed the LIE that circumcision is “just a simple procedure.” ... I believe Quinn is alive today because my midwife let his cord pulse. He had that extra blood in his little body and it acted as his safety net. Our family was blessed with another son 15 months after Quinn’s birth. Ezra remains intact as will any future sons.

    Holly Lowmiller on Facebook, May 10, 2013

     

    Unreported bleeding, ex Facebook

    Facebook, August 23, 2013

     

    ''He nearly died''

    Facebook, December 31, 2013

     

    Baby with anaemia from loss of blood

    Facebook, June 26, 2014

     

    Had to be cauterised - took three hours

    Facebook, June 30, 2014

     

    ...complications...doing blood transfusion

    Facebook, July 15, 2014

     

    ...bled horribly...through 2 diapers...drs said it was fine

    Facebook, July 17, 2014

     

    Degloving and haemorrhage

    LiveJournal, June 5, 2008

    He had his circumcision yesterday and it was a NIGHTMARE.

    ... The procedure was done so we waited 10 or so minutes before he was to be checked again being told he was the first baby they had seen never cry during all of it. My doctor came back to check to see if there was any bleeding and as soon as he took the bandage off there was a lot of blood. The skin of the shaft had beccome completely seperated which i was told can sometimes happen but from the head to the shaft skin was almost a full inch! His skin was almost completely at the base of his penis. I watched as the docter tried pulling it up and could only help but think that it didn't seem normal for it too be that bad.

    ... They strapped him down again and we watched as the put a gel foam on him to adhere the shaft to the head. Screaming at this point, bleeding all over and me by this point lactating all over the place, practically through my breast pads. The gel foam took and they wanted us to stay another half hour.

    ... We stopped at the store for gauze and Vaseline and let him sleep for 10 minutes when we got home before i checked him and tried to ready him for a full feeding.

    I opened his diaper to find that he had soaked through the guaze already and i had to get 2 napkins to control the bleeding. I yelled at my fiance to get the car to we could go to the hospital. Of course we get there, had to register, see the triage nurse, do insurance crap and FINALLY get into pediatric ER.

    Doctors come in to see him and he is GUSHING blood, soaking gauzes, and they give me more gauze and tell me apply pressure here & there and then leave the room. At this point it is just my fiance and I with my screaming little boy holding him down watching him bleed all over. He's hungry again, I'm lactating like crazy again and we have to keep calling the doc's back in because he's going through so much gauze. I asked the doctors about stitching and the likeliness of it happening. One response was "Oh no, that wouldn't fix this".

    ... there were other kids in there but with (by the looks of it) only sprains and such. Not any others bleeding profusely. Especially not any babies. You'd think we'd get more attention. All the while asking me if any blood diseases ran in my family on the ocassion that they did come in. (Which they don't and i explained this 5 or 6 times)

    ... AGAIN NO HELP and me furious that nothing had been done yet, him still bleeding and i can't hold him and feed him.

    So i get pissed and after a good 45-60 minutes of all of this and i said seriously, what the fuck are you waiting for?! Then they tell me that they are waiting for the right size suture. We had to demand to know this, were never informed. Then more waiting....and more aking from us of what the hell the hold up is. "Oh, we're still waiting for the sutures." FINALLY, the urologist comes in, straight to the point looks at it and knows he need a stitch or two because guess what.... THEY NICKED AN ARTERY. An artery! Which of course would explain the pumping blood and prove my other doctors IDIOTS.

    The urologist and the lady with him were very quick to access and close him up, saving the day. They were kind, explained everything that was going on and very reassuring that he'd be okay. I had to watch him be stitched up at 6:30 close to almost 2 hours after we had gotten to the ER. Bleeding stopped almost immediately when they closed the artery and almost had to so his shaft so it would stay up. The bed, a pile of guaze, the bed, his clothes,blanket and myself all covered in blood. He was real pale so then they hooked him up to an IV and kept him on it for an hour and a half.

    ... Needless to say i am beyond upset. I was a scary calm the whole time and a nurse even commented on me 'taking this so well' being a first time mom. I couldn't cry, i couldn't do anything....i had to worry about keeping my son together because no one else was!

    Oh, and then [the father] overheard the urologist say to the doctors that if my son had bled for 15 more minutes he would have gone into shock.

    ... How often do things like this happen with this procedure?

     

     

    If a baby proves to be haemophilic (having blood that doesn't clot, leading to uncontrollable bleeding), circumcising him can be catastrophic.

    Damon Courtenay was born in Sydney in 1966:

    By the time we'd had Damon home ten days and he was due to be taken back to hospital for his circumcision, we were into a routine. ... I think it was simply a common social custom which we took more or less for granted, happy to let the hospital undertake the inconsequential operation. After Brett and Adam, we knew circumcision wasn't a big deal and we brought Damon straight back home from the hospital.

    [That night at a wedding reception, his father has a premonition and they hurry home.]

    I pulled the blanket away from my sleeping son and reached down for him. Then I saw that his nappy was soaked with blood.

    Damon proved to be haemophilic. He was given an HIV-infected blood transfusion some time before 1985 and died of AIDS complications on April 1, 1991, hence the title of his father's book about him:

    - April Fool's Day: A Modern Love Story
    by Bryce Courtenay
    (Also sold as April Fool's Day: a Modern Tragedy

     

    Meatal stenosis, meatal ulcer

    In babies:

    A baby's long foreskin prevents the re-entry of urine. Ammonia from stale urine attacking the meatus, the opening of the urethra in the glans of a circumcised baby, is believed to attack the delicate surface, creating an ulcer. Bacteria like E. coli may also play a part. This can lead to narrowing (stenosis) of the meatus, which may have to be corrected by surgery; meatotomy. Patel found 31 cases of meatal ulcer and 8 meatal stenoses in 100 circumcisions. Meatal ulcer can cause urinary retention and if untreated, kidney failure.

     

    Urol J. 2008 Fall;5 (4):233-6

    Lubrication of circumcision site for prevention of meatal stenosis in children younger than 2 years old.

    Bazmamoun H, Ghorbanpour M, Mousavi-Bahar SH.
    Department of Pediatrics, Division of Gastroenterology, School Of Medicine, Hamadan University Of Medical Sciences, Hamadan, Iran. dbazmamoun@yahoo.com

    INTRODUCTION: Circumcision is one of the most common surgical operations throughout the world, and meatal stenosis is one its late complications. We evaluated the topical use of a lubricant jelly after circumcision in boys in order to reduce the risk of meatal stenosis.

    MATERIALS AND METHODS: A randomized control trial was performed, in which 2 groups of boys younger the 2 years old underwent circumcision according to the sleeve method. The parents in the study group were instructed to use petroleum jelly on the circumcision site after each diaper change for 6 months. In the control group, no topical medication was used. The children were followed up regularly and evaluated for meatal stenosis, bleeding, infection, and recovery time.

    RESULTS: A total of 197 boys in each group completed the study. None of the children in the study group but 13 (6.6%) in the control group developed meatal stenosis (P < .001). Infection of the circumcision site was seen in 3 (1.5%) and 23 (11.7%) children of the lubricant and control groups, respectively (P < .001), and bleeding was seen in 6 (3.0%) and 37 (18.8%), respectively (P < .001). The mean time of recovery in the lubricant group was 3.8 +/- 1.2 days, while it was 6.9 +/- 4.2 days in the control group (P = .03). CONCLUSION: Based on the findings of this study, it seems logical to use a lubricant jelly for reducing postcircumcision meatal stenosis and other complications.

    PMID: 19101896 [PubMed - in process]

    [Experimenting on children in this way would be utterly unethical in the western world.

    The experiment shows that to prevent meatal stenosis, parents must use petroleum jelly on the circumcision site after each diaper change for 6 months. So much for circumcision making care easier.]

     

    In children:

    BRITISH JOURNAL OF UROLOGY, Volume 75, Number 1: Pages 91-93, January 1995.

    Clinical presentation and pathophysiology of meatal stenosis following circumcision.

    Persad R; Sharma S; McTavish J; Imber C; Mouriquand PD
    Department of Paediatric Urology, Addenbrooke's Hospital, Cambridge, UK.

    OBJECTIVE: To describe the clinical presentation and pathophysiology of meatal stenosis occurring after circumcision.

    PATIENTS AND METHODS: The clinical presentation and operative findings are reported in 12 children who presented with meatal stenosis over a period of 3 years.

    The cardinal symptoms of meatal stenosis were penile pain at the initiation of micturition (12 of 12), narrow, high velocity stream (8 of 12) and the need to sit or stand back from the toilet bowl to urinate (6 of 12). Following surgical correction with meatotomy there was no recurrence of stenosis after a mean follow-up of 13 months. Traumatic meatitis of the unprotected post-circumcision urethral meatus and/or meatal ischaemia following damage to the frenular artery at circumcision are suggested as possible causes of meatal stenosis.

    Preservation of the frenular artery at circumcision, or the use of an alternative procedure (preputial plasty), may be advisable when foreskin surgery is required, to avoid meatal stenosis after circumcision.

    ...

    DISCUSSION AND CONCLUSIONS
    Meatal stenosis as a complication is often missed by the clinician because children do not usually have late follow-up after circumcision. The symptoms of pain are often mistaken for symptoms of a lower urinary tract infection and symptoms of distal urethral impairment of urinary flow are usually ignored for many months

    ... 88 circumcisions (and 91 preputial plasties) were performed at this institution: seven of these patients (8%) presented with meatal stenosis.

    ...

    In adults:

    A pathologist writes:
    A patch of surface necrosis [dead tissue] is commonly seen on the glans of adult circ patients. In all the ones I have seen, the necrosis (which appears as a dark purple area) was in the ventral aspect from about the attachment of the frenulum up to and partly surrounding the meatus; I have never seen necrosis in the dorsal aspect. Even if the frenular artery is not severed (standard methods caution about taking care not to cut this artery by damaging the frenulum, hence the noticable increase in numbers of cut boys with an intact frenulum over the last decade or two), the disruption of the venous drainage via the paired frenular veins would have the same effect of preventing circulation across the extensive capillary plexus [network] in the skin of the glans and meatus. This disruption is inevitable as all the superficial veins (including the frenular) are cut in any form of circumcision, but I suspect that the dorsal surface has other alternative routes via the deeper veins.
    Loss of circulation through the glanular skin would take some days for the capillary bed to undergo angiogenesis [growth of blood vessels] in the healing sequence, during which time the epithelial [top layer] cells would die, which in turn would expose the underlying [layer], and that is exactly how an ulcer is defined.
    Once the dermis is exposed, abrasion with clothing etc. will irritate and impair/delay healing. Healing of this ulcer increases the collagen in the tissue as part of the repair process which we see as a scar, this being increased with any irritation or extension of the healing time and the loss of stretch capacity leads to [narrowing] of the meatal opening.


    Picture of Meatal stenosis

    A series of cases were reported a few years ago in J Urol using topical anesthesia for meatotomy. Most cases are done under general anesthesia. It costs about $1500 to have it done as an outpatient.

     

     

     

    Urethrocutaneous Fistula

    J Pediatr Surg 2003 Apr;38 (4):642-3

    A very late onset urethral fistula coexisting with skin bridge after neonatal circumcision: A case report.

    Yazici M, Etensel B, Gursoy H.

    Adnan Menderes University, Department of Pediatric Surgery, Aydin, Turkey.

    Complications of neonatal circumcision are generally minor and occur early; a few reports exist on the late or serious kind. The authors describe a case of urethrocutaneous fistula occurring 13 years postcircumcision. The patient also had a skin bridge, another late complication of circumcision. The authors suggest erections in puberty as the triggering factor for onset of fistula. To our knowledge, neither such a late occurrence of fistula nor coexistence of these complications have been reported.
    J Pediatr Surg 38:642-643. Copyright 2003, Elsevier Science (USA). All rights reserved.

    PMID: 12677587 [PubMed - in process]

    [Lack of reporting of these complications has more to do with failure of follow-up of circumcision, than actual rarity. Skin bridges are remarkably common.]

     

    ...when they carterized it to stop bleeding he now has a hole that goes all the way threw the top of his penis, cause the idiot doctor some how hit it with the carterizer tool...

    Facebook, May 10, 2013

     

    Infection

    Making a wound on a newborn near the source of faeces presents a significant risk of infection. Patel found 8 infections from 100 circumcisions. Infection can lead to meningitis and death.

    Staphlococcus

    Enzenauer RW, Dotson CR, Leonard T, et al. Male Predominance in Persistent Staphylococcal Colonization and Infection of the Newborn.
    Hawaii Medical Journal 1985;44 (10):389-90, 392, 394-6.

    The authors conclude:

    The increased incidence of staphylococcal colonization and pyoderma in males may be associated with circumcision performed after the first 24 hours of life in the nursery.

    Circumcision is performed on approximately 90% of the male infants horn at our hospital.6 In our study population, 87% of the males were circumcized.

    Circumcision, by its very nature, requires more staff-patient "hands-on" contact. The infants are all lined up and tbeir stomachs lavaged [pumped] clear in preparation for the procedure. The circumcisions are done daily, as a group, in a small area, using reusable circumcision restraints.

    Postoperatively, there is also more handling of the diaper area in caring for the fresh, hemorrhagic wound.

    A larger study. involving more infants, is required to validate the hypothesis that circumcision is the culprit responsible for the increased rate of staphylococcal colonization and infection in newborn males. This may be due to the remarkably high rate of neonatal circumcision done in the United States. A much smaller study would be satisfactory if it were performed in Great Britain or one of the developed countries of Europe, where the incidence of noncircumcision is more equal to the rate of circumcision in the U.S.

    Gellis eloquently indicted circumcision, noting that the infant "has enough portals of entry for organisms as it is," referring to the infant's nose, mouth, conjunctiva, and the cut end of his umbilicus. "It seems totally unnecessary to aid and abet lurking bacteria by adding a raw wound to his genitalia."19


    Tuberculosis & Airborne Disease Weekly
    Tuesday, April 4, 2000
    Staphylococcus Rash in Babies Linked to Health Care Workers
    2000 APR 4 - (NewsRx.com)

    An outbreak of Staphylococcus aureus pustulous rash in a group of newborn, circumcised babies has been linked to medical workers in the neonatal nursery.

    The outbreak occurred in the newborn nursery of a 150-bed naval hospital in eastern North Carolina and lasted from August to January of 1999.

    "Cases were newborn males who had undergone a circumcision procedure and post-discharge required anitmicrobial treatment for severe postulous diaper rash," reported K.K. Hoffmann and colleagues. Seventeen cases out of 36 total were cultured, and all 17 showed methicillin-sensitive, erythromycin-resistant S. aureus.

    As usual, the article is at pains to blame the health workers, not the circumcisions.

    In one hospital in Long Island, in October 2003, four baby boys contracted antibiotic-resistant staph. infections after being circumcised.

    One man has been severely disabled for life as a result of a staphlococcal infection from circumcision, resulting in, among other things, the removal of half his brain.

    Doctors Opposing Circumcision warns (23 October, 2005) that the risk of Methicillin-Resistant Staphylococcus Aureus (MRSA) is now too great to allow non-medically indicated ciricumcision to continue:

    ... The advent of MRSA in epidemic proportions increases risks associated with male neonatal circumcision beyond those previously contemplated and further increases the desirability of the non-circumcision option. MRSA and other antibiotic-resistant varieties of SA, such as vancomycin-resistant Staphylococcus aureus (VRSA), increase risk, including death, to newborn circumcised boys. In view of this increased risk, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists should review their policy (2002) of offering elective medically unnecessary non-therapeutic neonatal circumcision at parental request.

    ... Medical practitioners must consider the epidemic status of MRSA and exercise their independent judgment regarding the performance of non-therapeutic neonatal circumcision. There is an ethical duty to not perform scientifically invalid medical treatment, especially when it puts the patient at risk. Doctors must act in the best interests of their child-patients regardless of parental requests. Doctors may conscientiously object to the performance of non-therapeutic circumcision of children.

    Complete text

     

    Staphylococcal scalded skin syndrome

    (Also known as Ritter's disease, toxic epidermal necrolysis and in adults, Lyall syndrome.)

    In the American Journal of Diseases of the Child, Vol 132, No 12: Pp 1187-8, December 1978, Staphylococcal scalded skin syndrome A complication of circumcision, David Annunziato and Louis M. Goldblum describe three cases, one fatal.

     

    Hepatitis B

    Turk J Gastroenterol. 2002 Mar;13 (1):1-5

    Hepatitis B seroprevalance and risk factors in urban areas of Malatya.
    Kurcer MA, Pehlivan E.
    Inonu University Medical School, Department of Public Health, Malatya.

    BACKGROUND/AIMS: To determine the prevalence of hepatitis B viral markers and to assess possible risk factors in urban areas of Malatya.

    METHODS: This was a sero-epidemiological, community based cross-sectional study and included 646 participants ( female 352, male:294) from 192 houses. A face to face questionnaire was carried out and HBsAg, anti-HBc and anti- HBs markers were analyzed from blood samples using Micro ELISA technique.

    RESULTS: The prevalence of HBsAg, anti-HBc and anti-HBs were found to be 6.0%, 29.3% and 30.3% respectively. In the final logistic regression, HBV infection (=anti HBc+) was independently associated with the age group of 21 years and older (OR=3.7, 95% CI=1.884-7.494), in illiterate subjects (OR=2.1, 95% CI=1.180-3.326), in farmers and labourers (OR=2.8, 95% CI=1.042-7.953) and in these with multiple sexual partners (OR=2.1, 95% CI=1.574-8.168). In addition, HBV infection was significantly higher in circumcised male children compare to uncircumcised ones ( chi2=5.58, P=0.01), in ones who gave birth to child at home compare to in ones who gave birth to a child at hospital ( chi2=13.86, P=0.0001).

    CONCLUSION: The results of our study indicate that Malatya province has a moderate endemicity with regard to HBV infection.

    PMID: 16378266 [PubMed]

     

    Tetanus

    Bull Soc Pathol Exot. 2008 Feb;101 (1):54-7

    Post-circumcision tetanus in Dakar, Senegal
    [Article in French]

    Soumaré M , Seydi M , Dia NM , Diop SA , N'dour CT , Diouf L , Diop BM , Sow PS .

    This study aimed at describing the epidemiology, clinical features and prognosis of post-circumcision tetanus at the infectious diseases clinic in Fann Hospital in Dakar.

    Data were collected retrospectively for analysis from patients' files recorded from January 1, 1999 to December 31, 2006. 54 cases were included, accounting for 4% of all tetanus cases admitted to the clinic during the study period (54 cases/1291). The patients' average age was 9 +/- 3.7 years old (range = 1-17 years) and 52% of them were schoolboys.

    In most cases (76%), tetanus symptoms occurred beyond 7 days after circumcision. The average delay from onset of the disease to admission was 2.3 days (range = 0-6 days). The circumcision took place at home in 39% of cases, in health center in 35% of cases and in unspecified area in 26% of cases. The majority of patients (85%) had never received tetanus vaccine and, in 72% of the cases, the circumciser was designated as a male nurse.

    Generalized tetanus was observed in all cases, most of which was a mild form of the disease (63%). During hospitalisation, thirteen patients (24%) had complications among which diaphragmatic and intercostal muscle spasms (3 cases), bacteraemia (5 cases), respiratory infection (4 cases), urinary tract infection (4 cases), and fracture of the vertebrae (1 case). The case fatality rate was 7.4% (4 deaths).

    Vaccination together with health education of the population as well as a better sensitization of the practitioners are necessary to eradicate tetanus after circumcision. [Not circumcising would also have that effect.]

     

    Bladder Infections

    miffyrabbit in The Guardian, May 12, 2010

    ... My parents decided to circumsize me as a toddler. ... they considered it to be more hygienic. Consequently through my life I've been blighted with bladder infections - two of which hospitalised me. Urinary tract infections are far more serious in men than women; obviously because of the difference in plumbing. Also, but less importantly, I have absolutely no sensation where it matters in my private parts because I had such an aggressive circumsition.

     

    Septic Arthritis

     

    Unspecified

    Infection - pus - facebook

    - Soggy Mamas on Facebook, October 25, 2014

     

    Neuroma

    Destruction of the large number of the nerve-endings of the prepuce is inevitable in circumcision. Human and animal studies show that when a nerve is cut, the cut end swells up greatly and the fibre sprouts and branches, resulting in "a disordered tangle of axons, Schwann cells and fibrous tissue" instead of the original receptor. According to Cold and Taylor, studies of circumcision sites show amputation neuromas - well-known for causing sensations of pain. It may be speculated that a confusion between these pain sensations and sexual pleasure are an outcome of circumcision.

    - based on Cold, CJ and Taylor, JR, The Prepuce
    in BJU International 83, Suppl 1, 34-44 (1999)

     

    Blockage of the urethra

    A baby born in Saskatchewan was circumcised with a Plastibell TM at six days old. In the next two days his bladder swelled to the size of a tennis ball (in a newborn, that's big). This put pressure on his inferior vena cava, the main vein draining the lower body, which caused his lower body to swell and turn blue.

    X-ray of swollen bladder (thumbnail)
    Click on the thumbnail for a full-size image

    Going in through the baby's belly, doctors drained 200 mL of urine. When they removed the Plastibell TM, they found it was embedded in his glans. The baby passed more than 600 mL of urine in the following 12 hours. It took him two days to recover.

    One study of 2000 PlastibellTM circumcisions found a complication rate of 1.8%.

    - Linh Ly and Koravangattu Sankaran
    Acute venous stasis
    and swelling of the lower abdomen
    and extremities in an infant
    after circumcision

    CMAJ 2003; 169: 216-217

    Another baby, in Ontario, was not so lucky.

     

    Buried penis


    Picture of a buried penis
    of unknown cause

    Picture of a buried penis
    caused by Tara KLamp in KwaZulu Natal

    This condition may arise from natural causes and/or overly "aggressive" circumcision, when it may be known as "iatrogenically entrapped penis". The shaft of the penis is buried below the surface of the pubic skin. A true congential buried penis is rare. It is caused by an abnormally large pad of fat over the pubic bones and dense tissue that holds and pulls the penis inward. The skin of the shaft is pushed forward over the glans, giving the appearance of an unusually long foreskin. Circumcising an unrecognized buried penis can remove shaft skin as well as the foreskin, making the case even worse. If the penis was not buried already, removing too much shaft skin when circumcising can bury it by pulling it down into the pubic fat. A second circumcision may be incorrectly performed on patients with various causes of concealment, preventing repairs made by using the remaining shaft skin or foreskin. Instead the boy will need a skin graft.

    By: thirdkane, posted on SueEasy
    2008-04-26
    I'm a 35 y/o male with a lifetime disfiguration as a result of circumcision as a child. My penis is inverted inside my body and as a result have faced a lot of distress emotionally and socially. It has effected my life negativly in so many ways, love life, school to where I missed years worth of school because i was ashamed of my disfigurment to avoid manditory showering with my peers.

    Boys with a buried penis are often told that they will grow out of it, and many cases will improve, but some will never have a penis that looks as long or works as well as it might. A boy with a deeply buried penis may be ridiculed by other boys. If he has no visible penis when he is standing up, he may have to sit down to urinate.

    Buried penis can be corrected by (more) surgery, cutting out pubic fat and sewing down the skin of the groin and scrotum.

    A mother's story

     

    Penoscrotal Webbing

    If too much skin is taken, the skin of the scrotum is pulled up the shaft of the penis, making it appear shorter and hairy. The "webbing" arises from the raphe of the scrotum being pulled ahead of the rest of it. It can be corrected by more surgery ("Z-plasty")

     

    Deformity

    Click here for a case of gross deformity due to circumcision.

     

    Gangrene

    British Medical Journal BMJ Case Reports 2012; doi:10.1136/bcr-2012-007096
    October , 2012

    Electrocautery-induced gangrene of the glans penis in a child following circumcision

    By Gunalp Uzun, Yavuz Ozdemir, Murat Eroglu, Mesut Mutluoglu

    Description
    A 7-year-old child was brought to the hyperbaric [raised pressure] oxygen centre because of cyanosis [blueness] of his glans penis. He had been circumcised the same day with the use of a monopolar electrocautery device. Unfortunately, the electrocautery caused a severe burn injury on the glans of the child. On examination, he had necrosis [dead tissue] over the glans and shaft of the penis.
    figure 1 [NSFW, Not for the squeamish]
    "Necrosis of glans and penile shaft."

    Circumcision is a religious and traditional ritual in some cultures and involves the removal of the preputium penis. It may be performed by a variety of techniques, and although it is regarded as a relatively safe procedure, it does, like any surgical procedure, carry the risk of complications. Choosing the most appropriate technique and giving the highest attention and care will avoid most of these complications. Bipolar electrocautery has been shown to be safe in circumcision. However, the use of a monopolar electrocautery, as was the case in this patient, has resulted in a dramatic accident. [Should it be called "unfortunate" or an "accident" when monopolar electocautery inevitably fries the penis like a hot-dog cooker] Indeed, when a monopolar electrode is used, the electrical current is carried by the small diameter of the penis, which may lead to tissue heating and thus thermal injury. Although adjunctive hyperbaric oxygen therapy was administered in the following days, the lesion worsened and resulted in significant tissue loss involving the whole glans and the distal parts of the penile shaft.
    figure 2 [NSFW and not for the squeamish]
    "Despite hyperbaric oxygen therapy and wound care, debridement [removal of dead tissue - in this case, most of the penis] was unavoidable."

     

    Necrotising Fasciitis (Galloping gangrene)

    Click here for pictures of galloping gangrene from circumcision (Not for the squeamish.)

     

    Epidermal Inclusion Cyst

    IOSR Journal of Dental and Medical Sciences (IOSR-JDMS), Volume 13, Issue 10 Ver. IV (Oct. 2014), PP 73-75

    ost Circumcision Penile Epidermal Inclusion Cyst: A Case Report

    Ofoha C.G., Dakum N.K.

    Abstract:
    Post circumcision penile epidermal inclusion cysts are rare and few cases have been reported worldwide. A five year old boy presented with a complaint of a mass located at the dorsal aspect of the penis along the circumcision scar. The mass was noticed few weeks after circumcision. On examination the mass was located at the dorsal aspect of the penis proximal to the coronal sulcus along the circumcision scar and measured about 1cm × 1.5cm. It was oval in shape with no differential warmth and non tender. The mass was smooth, firm, mobile and with well defined edges. The overlying skin was normal with no punctum. The mass was excised under general anaesthesia. Histologic sections show an attenuated cystic structure, lined by stratified squamous epithelium containing keratin debris and amorphous material. Histologic diagnosis was epidermal inclusion cyst. Post circumcision epidermal inclusion cyst is usually easy to diagnose from history and physical examination. Complete total excision is usually curative and prevents recurrence

    Picture of
    epidermal inclusion cyst

     

    Priapism caused by necrosis

    Zhonghua Nan Ke Xue. 2005 Jul;11 (7):544-7.

    [Integrated treatment for priapism caused by circumcision: a case report] [Article in Chinese]

    Jin BF, Huang YF, Shao CA, Xia XY, Guan FG, Li G, Wang J.
    Department of Andrology, Nanjing General Hospital of Nanjing Command, PLA, Nanjing, Jiangsu 210002, China. hexiking@126.com

    Priapism [permanent erection] is rare on clinical condition with complicated pathogenesis which is very difficult to cure. The paper reported a case of a long-time priapism complicated by local skin necrosis [tissue death], which was caused by circumcision. After the failure of routine therapy, we treated the patient with traditional Chinese therapy, such as TCM herbs combined with bone scraping and depletion therapy, and achieved the satisfactory effect.

    PMID: 16078678 [PubMed - in process]

     

    Gastric rupture

    Connelly KP, Shropshire LC, Salzberg A, "Gastric rupture associated with prolonged crying in a newborn undergoing circumcision," Clin Pediatr, Sept. 1992, 560-561.

     

     

    Oxygen deprivation

    1.

    The State
    Columbia, South Carolina
    July 10, 1992

    Boy in coma most of his 6 years dies

    A boy who was in a coma for more than six years while a legal battle raged around him has died ...

    Allen A. Ervin was born in July 1985 and had been on life support since December 1985, when his brain was damaged from oxygen deprivation during circumcision. He died at Spartanburg Regional Medical Center on Wednesday, three weeks before his 7th birthday

    ... The anesthesiologists who attended to Allen during the circumcision settled the case for $435,000 and agreed to lifetime payment of his medical bills.

     

    2.

    From the webpage of WILLIAM E. ARTZ, P.C.

    The infant Plaintiff, age 20 months, was scheduled for an elective circumcision on 5/18/92. Upon arrival at the hospital, the infant Plaintiff presented with a fever of 100.4 degrees, runny nose, and a dry cough for one week. Rather than cancel surgery, the anesthesiologists cleared the patient. Upon induction of anesthesia, the infant Plaintiff went into laryngospasm and required a paralyzing drug and intubation. Concern arose that the infant had developed pulmonary edema and might need transfer to a tertiary level facility better able to manage the airway. After 2 ½ hours of observation in the operating room, a discussion ensued as to whether the infant Plaintiff needed transfer at all. The pulmonary edema was largely resolved, the arterial blood gases were dramatically inproved, and the child's O2 saturation levels and lung function were close to normal. Nevertheless, a decision was made to transfer.

    Upon arrival at the second hospital, the child came under the largely unsupervised care of an anesthesiologist in his fellowship (one year after residency) on rotation from a neighboring hospital. The treatment plan called for continued intubation and periodic medication which both sedated and paralyzed the child. The arterial blood gases taken at 2:50 p.m. on 5/18 showed virtually normal lung function, making the child a candidate for extubation (tube removal). The anesthesiologist fellow nevertheless decided to continue with intubation and sedation. The sedation was being administered hourly, but the amount was effective for only 30 minutes. Thereafter, the child, by virtue of his agitation and thrashing about, self-extubated at approximately 6:00 p.m. As a result, O2 from the ventilator was delivered down the esophagus into the stomach, causing projectile vomiting at 6:10 p.m. With the tube out of the trachea and the child unsedated, the infant Plaintiff was able to breathe on his own. At 6:20 p.m., the anesthesiologist fellow administered sedation and a paralyzing drug. At 6:25 p.m., the child's heart rate dropped to 47, and then into the 30's. Instead of removing the endotracheal tube and reinserting a new tube, the anesthesiologist fellow administered atropine and epinephrine pharmacologically, causing the heart rate to rise and then drop again. At 6:40 p.m., he finally removed the tube and reintubated the child. Ventilation improved dramatically, but the infant Plaintiff sustained severe hypoxic brain damage as a result of the 15 minute delay in correcting the airway. The infant remained hospitalized for two additional months and was eventually discharged home, where he is cared for by his parents and three sisters.

    The infant Plaintiff's cognitive level will not develop beyond first grade level. He has cerebral palsy of the lower extremities, but is expected to be able to walk with tendon-lengthening surgery and a walker. As of age 4, he was not potty trained.

    The medicals incurred as of settlement were $175,000, and the lost wage claim totalled $713,000. Cost of future care, were the infant to be placed in a full service school, exceeded $5.6 million by projection, although defense experts felt the child's needs could be fully met with a present value annuity costing $3 million.

    The defendants were two hospitals and an anesthesia group, plus two individual anesthesiologists.

     

    Brain Damage

    Click here for the settlement in the case of the brain damage to Jacob Sweet in Anchorage, Alaska.

     

    Clamp injuries

    Tuesday August 29 2001 5:34 PM ET
    US warns of circumcision clamp injury risk

    WASHINGTON (Reuters Health) - Reports of complications associated with certain kinds of circumcision clamps have spurred the US Food and Drug Administration (FDA) to issue a letter to physicians warning them of the potential for injury if the clamps are misused.

    In the letter, doctors are advised not to substitute or interchange clamp components and to ensure that clamps appropriately fit the patient.

    "Although research suggests that circumcision is generally a safe procedure, we are concerned that some serious device-related complications have occurred," the FDA said in the letter. Between July 1996 and January 2001, the agency has received 105 reports of injuries involving the clamps, including cuts and bleeding, penile amputation, and urethral damage.

    Clamps are used during circumcision to protect the penis while the foreskin is being removed [implying that the foreskin is not part of the penis].

    "The use of...clamps that have been reassembled by users with parts from different manufacturers, or that have bent parts or mismatched components, has led to clamps breaking, slipping, falling off during use, tearing penile tissue or failing to make a tight seal," the FDA said.

    The agency points out that "although...clamps may appear to have interchangeable parts, these parts may not always be safely interchanged because they may vary slightly in dimensions."

    The injuries associated with other types of clamps, meanwhile, stem from the use of clamps "that have jaw gap dimensions greater than those in the manufacturer's specifications, or use of clamps inappropriately sized for patients." This may "allow too much tissue to be drawn through the opening of the device, thus facilitating the removal of an excessive amount of foreskin and in some cases, a portion of the glans," the FDA said.

    For this type of clamp, the agency recommends that surgeons "ensure that the clamp being used is appropriate for the patient size," noting that "some manufacturers have two sizes of clamps, one for adults and the other for infants."

     

    NYTimes
    Oy! Did You Hear the One About the Overzealous Mohel?

    11/13/06
    11:59 AM
    Court Reporter

    Plaintiffs: L.G., a minor, by and through his parents and next friends, Dror Gerges and Sivan Gerges

    Defendants: Daniel J. Krimsky; Mogen Circumcision Instruments Ltd.

    Accusation: An Oceanside, Long Island, rabbi is accused of lopping off the head of an 8-day-old's penis during a Bris on December 16, 2004.

    According to the federal complaint filed last week in Central Islip, New York, not only was Daniel Krimsky unqualified to perform a Bris, but the circumcision tool he used — called a "Mogen clamp" for the overly curious — was faulty, and instructions failed to warn against the (seemingly obvious) risk of severing. What's worse, the rabbi then tried to hide his error, and the boy's injuries only came to light when a physician attending the Bris noticed something was wrong and spoke up.

    "L.G. was required to undergo corrective surgery ... which was not entirely successful," reads the complaint, which is a delicate way of saying doctors were unsuccessful in reattaching the boy's penis. " (He) has been permanently disfigured and mutilated, and will suffer forever from a disfigured and mutilated penis, and from the loss of sexual feeling and function."

    So, what price for a partial penis? [implying a circumcised penis is not "partial"] Plaintiffs seek $150,000 in damages from the rabbi and another $150,000 from the makers of the "Mogen clamp." Only time will tell if the boy will consider that a fair trade when he grows up.

    Disposition: Awaiting response from the rabbi and the clamp manufacturer, who will likely seek to have the case tossed like poor little L.G.'s foreskin.

    You can read the complaint here.

    — Nick Divito

     

    Plastibell™ Ring injury

    Journal of Pediatric Urology Volume 6, Issue 1, Pages 23-27 (February 2010)

    Penile injuries from proximal migration of the plastibell circumcision ring

    C.O. Bode and A.O. Ademuyiwaa
    Pediatric Surgery Unit, Department of Surgery, College of Medicine University of Lagos / Lagos University Teaching Hospital, PMB 12003 Lagos, Nigeria

    Abstract
    Background
    Although circumcision is the commonest surgical procedure performed on male neonates, complications still arise from all methods used by operators.

    Patients and method
    This was a prospective study of penile injuries resulting from proximal migration of the Plastibell device in neonate boys referred to the Lagos University Teaching Hospital, Lagos, Nigeria. The parameters measured were patients' biodata, presentation, management and treatment outcome.

    Results
    Twenty-three injuries resulting from circumcision with the Plastibell device all occurred from prolonged retention of the ring. In each case, the ring was retained and had migrated proximally. There was extensive skin loss in 17 (74%) babies. Urethrocutaneous fistulae were the result in nine (39%) of these cases, while partial necrosis of the glans penis occurred in four (17%). These complications resulted from the use of wrong-sized Plastibell kits, lack of follow-up by the medical staff, and inadequate maternal knowledge of ring fall-out time.

    Conclusion
    Proximal migration of the Plastibell ring can result from employment of an inappropriate size, causing grievous penile injury. Adequate information should be provided to mothers of circumcised babies about possible complications of the Plastibell kit when employed. There is a need to redesign the Plastibell kit to eliminate its migration up the penile shaft.

    These pictures appeared on the web about the time this study came out, and may refer to it. (Not for the squeamish)

     

    Ingrown Plastibell

    - BabyCenter, October 18, 2014

     

    Loss of glans

    Savage Love
    by Dan Savage
    [Village Voice] October 26th, 2004 1:00 PM

    Q. I am 24 years old and lost my entire glans penis, the head of my dick, in a botched circumcision. Basically I have a shaft but there's no head at the end. Unfortunately, I was left with my balls so I still have a sex drive, but it's nearly impossible for me to climax. When I was much younger, around 14 to 16, I could sometimes masturbate to a climax, but after a couple of years I stopped being able to do this. Some of the women I've been with never saw the condition of my penis, and failed to notice when I didn't come. Others have seen my condition before intercourse and refused to have sex with me, while still others found out afterward, after I wasn't able to come, and then never wanted to have sex with me again. Of course I never dare to ask anyone to suck me, although this might provide the necessary extra stimulation and actually help me climax. So my problem, Dan, is twofold: I can't come and I can't get anyone to stick around and help me try to come. Can you suggest any special techniques for someone in my condition? Any help would be appreciated. I'm very miserable, frustrated, and lonely. —MUTILATED AND COMELESS

    A. OK, A.Z., after reading MAC's letter, and after insisting your husband read MAC's letter, is circumcision really something you want to risk? I know, I know, "complications," as it's delicately put, are rare after circumcision. But even if the odds are low—even if they're infinitesimal—the thought of having to look your glans-less son in the eye one day and say, "We're awfully sorry about that botched circumcision, son, but your father and I used to know this woman who once dumped a guy because he was uncircumcised, you see, and we didn't want to risk that ever happening to you . . . and . . . so. Sorry." Speaking parent-to-parent, A.Z., and speaking as a contentedly circumcised adult male who likes his dick just the way it is and has no truck whatsoever with hysterical anti-circumcision activists (whew!), I would rather teach my son to wash under his foreskin than assume even the tiniest risk of him losing the head of his penis in a botched circumcision.

    OK, MAC, on to you. Jesus, Jesus, Jesus. Rarely am I left speechless or bereft of any suggestions at all after reading a letter, but Christ almighty, I haven't the faintest idea what to tell you. But I ache for you, kiddo, and so I'm throwing open the switchboards here at Savage Love HQ and putting out a call for advice from my resourceful readers. If anyone out there has any expertise on headless dicks or knows of any special techniques for people in MAC's condition, please write in. Write in right now.

     

    As an infant, I underwent the usual (then) curcumcision procedure. ... I'm from the upper-midwest US area where this was common practice. ... It seems something went wrong during the suposidly "simple" procedure. My glans was sliced off. Apparently there was an attempt to re-attach it with out success. So I was left without the usual head on the end of my member. ... Apparently the doctor who performed the mis-hap, felt a bit guilty about the whole affair (as he well should have) and at some point later in my infancy modified my ramaining foreskin, (which was apparently fairly long) so that I would appear to have a normal intact penis. ... The skin at the tip of my penis had a small opening, so I was not able to retract it at all. ... I didn't have the usual bulge at the end. There seemed to be a few bumps at the end, suggesting the remnants of a coronal ridge, but that is all.

    - Bostel's blog, July 8, 2006

     

    Another case, in Alameda, CA, in 2006.

     

    Another case, in Mattoon, Ill, in 2007.

     

    >

    Loss of glans after Plastibell circumcision

    Lana writes [to "Hey LLL: Circumcision Affects Breastfeeding! Tell moms the truth!" on Facebook, November 26, 2013

    Yesterday we had an appointment at the women's and childrens hospital ... in the bathroom ... a little boy came running out of the stall pants-less ... he didn't have a whole penis. It looked as though someone had taken a guillotine and chopped it off. There was a catheter in the stump and the stump was about 1cm long. It was obvious, hideous and very sad to see.

    Then mom feels the need to explain. When he was 8 days old he had a plastibell circumcision. The ring cut the blood supply to his glans off and it went black, the tissues died and by the time they rushed him to hospital the head of his penis was in the diaper unattached to the shaft and even more of the shaft tissue was necrosing. The surgeon had to remove all the dead cells right up into the good tissue to save his life. leaving him with a stump and the need for a catheter in order to urinate.. he would be having many many surgeries to reconstruct his penis as he grows up ...

     

    Ablation (removal) of the penis

    The tragedy of David (initially named Bruce) Reimer of Winnipeg, Manitoba, is seldom blamed on circumcision, as it should be.

    Bruce was born one of normal identical twin boys in Winnipeg in 1965. Seven months later, his mother noticed that "their foreskins were closing, making it hard for them to urinate," a doctor told her that they had phimosis, and both boys were scheduled for circumcision at St. Boniface Hospital. .

    (In fact foreskins do not normally close, and true phimosis is not diagnosable in boys as young as seven months, since the foreskin has usually not yet separated from the glans. The facts as given do not stack up. One probability is that the mother had been wrongly instructed to retract their foreskins, and that this caused tearing and scarring, leading to the closure. This is a common excuse for circumcision.)

    A power surge in the electocautery needle (used to seal blood vessels by heat) burnt off Bruce's penis, and it was decided to reassign his genitals surgically and raise him as a girl, Brenda. There is a strong suspicion that his being an identical twin was a factor in the decision, and the case was widely used by Dr John Money for the next 15 years to demonstrate that gender is completely malleable, under purely social control.

    Brenda was subjected to castration at the age of 22 months, but she was a troubled tomboy throughout her childhood. From the age of eight onward, she steadfastly refused further surgery, and at puberty she resisted taking hormones. Her sexual desires, closely monitored by Dr Money, were towards females, and her parents were made to face the possibility that their daughter was a lesbian.

    At 14 she refused to live as a girl any longer and was told the truth about his gender.
    David Reimer
    At 16 he had a penis reconstructed, but the outcome was unsatisfactory and teasing by his peers led to two suicide attempts. At 21 he had another reconstruction with a better outcome. He met a woman with three children, abandoned by their three biological fathers, who was somewhat disillusioned with men's pride in their penile prowess. For some years he was a happily married adoptive father, but he said:

    "It was like brainwashing. I'd give just about anything to go to a hypnotist to black out my whole past. Because it's torture. What they did to you in the body is sometimes not near as bad as what they did to you in the mind - with the the psychological warfare in your head."

    - The true story of John/Joan
    by John Colapinto
    Rolling Stone December 11, 1997
    (David was called "John/Joan" in the medical literature.)

    "It only added to the young couple's misery that [brother] Brian's phimosis had long since cleared up by itself, his healthy penis a constant reminder that the disastrous circumcision on Bruce had been utterly unnecessary in the first place."

    Colapinto also discusses another very similar case, also reassigned as female by Dr Money.
    - As Nature Made Him
    by John Colapinto
    Read reviews and order
    from Amazon.com:
    cover
    Amazon.com

    Order the paperback

    In March, 2004, David Reimer committed suicide.
    Colapinto has written a feature article for Slate analyzing his motives. (email here if this article becomes unavailable.)

    A more detailed, scientific account of the case of "John/Joan/John" is at the CIRP library. It refers to his circumcision as "phimosis repair by cautery".

    David was not born intersexed (hermaphrodite). For issues of intersexuality, see the Intersex Society of North America website. Nor was he transsexual (having a gender identity different from his physical gender at birth). Intactivists in general have no objection to voluntary sex-change surgery performed on adults.

    It seems gender identity (what sex we think we are) is laid down in the brain, as is sexual orientation (what sex we are attracted to), and each is distinct from biological gender (XX, XY or other chromosomal makeup, and/or the appearance of the genitals or secondary sexual characterisics) - though all three may be affected by environment, including upbringing.

    Other cases of penis ablation from circumcision (commonly through the use of unipolar electocautery) are reported by Williams and Kapila and Bradley

     

    (This article comes via Snopes, because the picture was used to illustrate an urban myth)

    Severe Burn of Penis Caused by Excessive Short-Wave Diathermy


    Jiang, Jun et al. (Department of Urology, Third Military Medical University, Chongqing)
    Asian Journal of Andrology. 6 December 2004.

    A 38-year-old man was admitted to this Hospital for severe penile burn caused by excessive short-wave diathermy. Five days ago, the patient visited a clinic for recurrent genital herpes simplex. Circumcision was performed and local short wave diathermy given immediately. The frequency of short wave source was 13.56 MHz with a penile exposing time of about 2.5 hours. Blisters and extravasation at the penile skin were seen 1 day and became black 3 days after short-wave diathermy. The patient could micturate [i.e., urinate] without hematuria [i.e., blood in the urine]. The whole penis was burned black and became indurated [i.e., hardened] with a clear margin with the normal skin at the base of the penis. He felt no pain in the penis even with needle puncture. Doppler sonography revealed no blood flow in the penis and severe burn and penile gangrene was diagnosed.

    At day 31 after the treatment, the necrotic part of penis was resected with only about 1 cm of the penile stump left. Thrombi were found in the two deep arteries of the corpora cavernosa and deep dorsal arteries and the veins beneath Buck's fasica. Scrotal skin was mobilized and shifted to repair the penile stump. Pathological examination showed necrosis of the penis tissue and thrombi formation in the corpora cavernosa.

    Convalescence was uneventful. The patient could micturate in standing position by pushing skin around the stump of the penis backward.

    P the diathermy ablation (not for the squeamish)

     

    FELICE v. VALLEYLAB, INC.No. 86-1018.

    520 So.2d 920 (1987)

    Terry W. FELICE, Sr., Individually, et al., Plaintiffs-Appellees,
    v.
    VALLEYLAB, INC., et al., Defendants-Appellants.

    Court of Appeal of Louisiana, Third Circuit.
    November 4, 1987.
    Writs Denied January 8, 1988.
    Brame, Bergstedt & Brame, David A. Fraser, Lake Charles, for plaintiffs-appellees.
    Camp, Carmouche, Barsh, Gray, Hoffman & Gill, David Frohn, Lake Charles, McGlinchey Stafford, Mintz, Cellini & Lang, Colvin G. Norwood, Jr., New Orleans, for defendants-appellants.
    Before GUIDRY, FORET and YELVERTON, JJ.

    YELVERTON, Judge.

    This case involves a surgical accident to a two year old child. During a circumcision operation the child's penis was burned off by an electrosurgical device. The father, ... filed suit against Valleylab, Inc., the manufacturer of the unit, and the State of Louisiana, ... The trial judge found the State defendants to be 100% at fault and returned a verdict in favor of the plaintiffs, ... individually, against the State in the amounts of $18,968.01 for past medical expenses and $100,000 in general damages, and in favor of ... on behalf of the minor child ... in the amount of $1,730,000. The jury returned a verdict in favor of the plaintiffs against Valleylab, Inc. in the amount of $2,750,000. The jury found Valleylab to be 30% at fault. Judgment was rendered according to the two verdicts. The defendants have appealed and the plaintiff has answered the appeal. We conclude that the jury was clearly wrong in finding Valleylab at fault. We agree with the trial judge that 100% of the fault lies with the State and its agencies. We reconcile the conflict in the award by finding the jury's assessment, $2,750,000, the more reasonable.

    ... Dr. William Goodger and Dr. Cynthia Glass were residents training at Moss Regional Hospital. ... Neither doctor was a board certified general surgeon.

    ...

    FACTS

    In late January 1984 Jeffery's parents noticed that he complained of pain when he urinated and that the foreskin of his penis had difficulty retracting. He was examined by a physician and his condition was diagnosed as phimosis. [At two years old, he could not have had true phimosis. It was normal for his foreskin not to retract.] Circumcision surgery was recommended, and Jeffery was admitted to Moss Regional Hospital. The surgery was performed on February 2, 1984 by Dr. William Goodger, a first year family practice resident at the hospital, under the supervision of Dr. Cynthia Glass, a third year surgical resident. The two residents were the only doctors present during the surgery. Dr. Glass instructed Dr. Goodger to perform a circumcision technique known as the guillotine technique. In this technique the foreskin of the penis is stretched past the end of the penis and clamped with a hemostat to hold the foreskin in a position to be cut off. After the excess foreskin is cut away, the bleeding is controlled and the edges of the foreskin are sutured together. Generally the cutting in circumcisions is performed with a scalpel.

    Dr. Goodger, under the supervision of Dr. Glass, was instructed to cut the foreskin with a cutting instrument known as the Valleylab Electrosurgical Unit, known as an ESU. This unit operates by applying a high frequency electrical current through a "surgical pencil" to the cutting area. The electronic cut of the ESU reduces bleeding at the cutting area and eliminates the necessity of "tying-off" the vessels. The unit has two modes: cut and coagulation. The surgery in the present case was begun in the cut mode on a setting of one on the power dial, and raised to two-and-one-half when the initial setting failed to make a cut. Dr. Glass instructed Dr. Goodger to cease cutting after he had cut approximately one-third of the distance across the foreskin. Dr. Glass observed that something was wrong because the penis had retracted and was very pale. Dr. Glass then became aware that the penis had sustained a full thickness burn. The ESU never touched the clamp during the surgery. The record is clear the penis was burned by excess electrical current running through the penis. Dr. Glass then removed the rest of the foreskin with scissors and sutured it by hand. A burn ointment, Silvadene, was applied to the burned area.

    On February 8, 1984 the child was sent home. Several days later he began running a high fever and was taken back to the hospital where he was transferred to New Orleans Charity Hospital. Eventually his external penile tissue sloughed away leaving him with no visible penile tissue. Put in simpler terms, his penis was gone.

    Because of this injury Jeffery has suffered from physical problems with his urethra, the channel between the bladder and the penis, and has undergone four additional surgical procedures.

    ...

    At trial the expert testimony agreed that the accident occurred as a result of the introduction of too much electricity to the cutting area. Dr. James Brennan, a professor of electrical engineering, explained the general principles. Electricity has the ability to generate heat through any form of conductor. However, the heat will be concentrated more where the conductor is smaller; this principle is known as current density. On the cut mode the generator is on, constantly generating a continuous stream of electricity. In the present case the conductor of electricity was a very small penis of a two year old child.

    Dr. Leonard Knapp, a general surgeon, did some research for purposes of his testimony and explained that when too much electricity goes through a small area the heat causes the blood vessels in an appendage to thrombose. ...

    In the present case the ESU was intended to be used in most surgical procedures either to cut the tissue or to be used to stop the bleeding. The obvious, or ordinary, user of these machines are the surgeons who manipulate the "surgical pencil". We find that using the ESU to cut on a small appendage is a foreseeable use of this machine. The evidence is clear that most physicians are unaware of the dangers inherent in using the ESU to cut upon small appendages, such as a child's penis. ... the danger in the present case was not a danger which a surgeon should be presumed to know through his familiarity with the machine.... there are no warnings or instructions on how to use the ESU in a routine circumcision. There were not adequate warnings placed on the machine itself. The machine merely indicated that the device produces "hazardous electrical output". It is clear that Valleylab failed to give adequate notice of the danger inherent in using the ESU in making a cut in a circumcision, or other surgeries involving small appendages. This failure resulted in the product being unreasonably dangerous in normal use.

    We find, however, that the absence of warning was not a cause-in-fact of Jeffery's injury....

    By Dr. Glass' own testimony she admitted that she had never read the warning label on the device itself, and that she had never read the manual. An adequate warning or instruction would have been futile under the circumstances.

    We accordingly hold that the jury's finding of liability on the part of Valleylab was clearly wrong, ... Dr. Goodger had never performed a circumcision with an ESU or in a surgical suite. Dr. Glass was in charge of the surgery and instructed Dr. Goodger on the technique to be used. Dr. Glass instructed Goodger to use the guillotine technique with the use of an ESU to cut the foreskin. Dr. Goodger assumed Dr. Glass had experience and had been trained to perform the circumcision in this method. However, Dr. Glass testified that she had been trained to perform a circumcision with a scalpel in medical school and that she had not been instructed on the use of an ESU in circumcisions. She had always performed circumcisions with a scalpel until one week before the Felice surgery. On that occasion one week earlier, she and Dr. Boustany, another resident, discussed the possible benefits in using an ESU for a circumcision. Dr. Glass was also in charge of that surgery. They believed the ESU would control the bleeding, so they performed a circumcision with an ESU, with no ill effects. Dr. Glass never inquired of her supervising doctors as to whether the use of an ESU was proper for circumcision surgery. She did not inspect the literature or the manual to see if there would be any dangers in the use of ESU in circumcision. Dr. Glass merely decided to try it and see what effect the ESU would have upon the surgery, since she considered it an improvement upon well-established technique. Dr. Glass also admitted that she had never held the ESU "surgical pencil" in her hand to cut the foreskin in a circumcision. She twice had instructed two residents on a procedure she had never performed herself. Dr. Glass also admitted that it was a precept of medicine that any modification of a learned technique would never be done without a full appreciation of all the risks involved in the modification.

    ...

    2) The LSU Medical School

    The trial judge also found the LSU Medical School independently negligent for failing to instruct its students in the proper use and dangers of the ESU unit.... Dr. Glass was properly instructed on how to perform a routine circumcision using the guillotine technique and making the incision with a scalpel and scissors.

    We find, however, that the medical school was negligent in its supervision of Dr. Glass in her residency training. At the time of the Felice surgery, the residency program had in effect the following regulation:

    "No third year resident is to do an elective operative procedure without staff present in the operating room. This rule is good for twelve months of the year."

    Dr. Isodore Cohn, Chairman of the Department of Surgery at the LSU Medical School and a professor of surgery, ... stated that the rule was followed and applied only in major surgeries, not minor surgeries as in circumcisions. ...

    DAMAGES

    ...

    Dr. Aretta Rathmell, Jeffery's psychiatrist, testified that the child will need intermittent psychiatric counseling to help him cope with crises as they occur. She said that there is a high possibility his loss will affect his self-identity. She said that Jeffery will undoubtedly experience anger and frustration as he grows older and probably will direct that anger against his parents.

    ... Sexual pleasure, procreativity, marriage in any normal sense, these things will never exist for him. The suffering of deprivation, both physical and mental, that will accompany him throughout his life can be only vaguely imagined. What will his puberty be like? Where will he go to escape the cruel and ribald jokes of his comrades? For that matter who will be his comrades? Into what corner of his dark cell will he seek refuge when the natural urgings of his body wage battle?

    There is a suggestion in the evidence that he can be changed into a woman. As a means of mitigating damages in this case, we view this prospect as pure speculation. If it is realistic to imagine he may one day find a new life in this way, it is just as realistic to speculate that after the sex change, he may wish it had never been done. [He may very well wish the circumcision had never been done.]

    ...

     

    A partial ablation is reported from New York in 1995. A three-year old Jewish Russian immigrant child was circumcised by a mohel in a urologist's outpatient clinic. Consent had been given for the urologist to perform the circumcision. Instead, the mohel negligently amputated the head of the boy's penis. The urologist attempted to reattach the head and transferred the boy to Bellvue hospital by ambulance. Four-fifths of the head of the penis necrosed (died) and came off. After a one-month long trial, the family was awarded a total of $1,000,000. The mohel declared bankruptcy.
    Bronx County N.Y.
    Plaintif Nozik #20875/90
    November 22 1995

     

    Ouch! Boys Lose Too Much in Circumcision Slip

    Updated 3:22 PM ET June 9, 2000 ANKARA (Reuters)

    Health workers carrying out a mass circumcision on more than 200 children in western Turkey cut off more than they should have when they got to the last two on Friday.

    "Whether it was because of their anatomy or through carelessness, too much was cut off," Anatolian news agency quoted Manisa health service chief Ismet Nardal as saying.

    Doctors in the hospital where the two-day circumcision marathon was carried out immediately operated on the pair to try to rectify the error.

    "The children's stitched organs have held, the operation was successful," Nardal said. "They appear to be alright, but it will only become apparent later if they have lost their sexual function."

    Young boys are circumcised in overwhelmingly Muslim Turkey before they reach puberty, according to Islamic tradition.

    [This item - about a lifetime catastrophe for the two boys involved - was widely reported in the "joke" sections of papers, as the headline suggests. That in itself is part of the psychopathology of circumcision, helping as it does to prevent questioning of the operation itself.]

     

    Jerusalem Post
    Monday, August 14 2000 12:48 13 Av 5760

    Baby recovers from 'brit mila' amputation

    By Judy Siegel

    AFULA (August 14) - A baby whose penis was accidentally amputated below the corona by the mohel (ritual circumciser) and reattached by microsurgery a month ago was declared fully recovered yesterday at Ha'emek Hospital in Afula.

    Hospital spokesman Danny Brenner said the baby is now able to urinate normally, and the penile blood vessels and nerves are fully functioning. The hospital reported the highly unusual incident to the Health Ministry, but Ha'emek still doesn't know the identify of the mohel, as the family refused to give his name and have not yet filed a complaint.

    The parents rushed the baby to the hospital four weeks ago carrying a plastic bag with the glans penis kept in ice. Dr. Ya'acov Rosenman, deputy head of the urology department, and Dr. Boris Lachman performed the painstaking operation, which took more than eight hours.

    Rabbi Yosef Weisberg, the ministry's national supervisor of ritual circumcisers, had not yet been informed of the case. "If asked, our committee will investigate.

    Such a thing is extremely rare, but I have heard of one or two other cases here over the year. Any mohel who does such a thing must be blind, have taken a drink, or been pushed while performing the brit mila," he said.

    The fact that there is no circumcision law, "due to pressure from American Conservative, Reform, and female circumcisers who are afraid they'll be left out," means there are unlicensed mohelim, Weisberg said, but he could not estimate how many there were out of the total of several hundred practicing mohelim in the country.

    Brenner said that it was possible the family would complain to the police or sue the mohel for damages now that the child had recovered, "or maybe they received payment from the circumciser to keep quiet about the incident."

    Although amputation of the penis is rare in children, said Brenner, the world's top medical experts in reconnecting adult penises are in Thailand, as nearly every day, disgruntled wives cut off their husband's organs in a fit of anger or jealousy.

     

    J Sex Med. 2007 Dec 14 [Epub ahead of print]

    Restoration of the Penis Following Amputation at Circumcision: Shaeer's A-Y Plasty.
    Shaeer O. Department of Andrology, Faculty of Medicine, Cairo University, Egypt.

    Introduction. Male circumcision is one of the most commonly performed procedures worldwide. It has an estimated complication rate ranging from 0.1% to 35%. Amputation of the shaft is one of the most devastating complications reported, resulting from entrapment of the phallus between the blades of the clamp or from thermal injury due to the application of unipolar diathermy.
    Aim. In this work, I describe the guidelines I adopted in the management of 32 male patients afflicted with amputation of the shaft of the penis upon circumcision.
    Methods. "Shaeer's A-Y plasty" was performed for all patients, whereby the proximal corpora and crura were released from their attachment to the pubis and were advanced forward by insetting a specially configured fat flap into the resultant cavity. Skin grafts were used to cover the released penis.
    Results. In all 32 cases, the released penis was within the normal range of penile length, and was cosmetically and functionally acceptable.
    Conclusions. "Shaeer's A-Y plasty" is capable of restoring the native phallus [No, it replaces it with a facsimile] following amputation, with preservation of both gender identity and physiological characteristics of the penis to a large extent.

    PMID: 18086176 [PubMed - as supplied by publisher]

     

    Urology. 2014 Jun 11. pii: S0090-4295(14)00390-2. doi: 10.1016/j.urology.2014.04.021. [Epub ahead of print]

    Complete Penile Amputation During Ritual Neonatal Circumcision and Successful Replantation Using Postoperative Leech Therapy.

    Banihani OI, Fox JA, Gander BH, Grunwaldt LJ, Cannon GM.

    Abstract
    Circumcision is the most common surgical procedure in males in the United States, and minor complications are not uncommon. Major complications like partial penile amputations have been reported with successful replantation. Complete penile amputations in adult males have been described, and successful replantation has been reported with increasing success. We report a case of complete penile amputation at the penopubic junction using a Mogen clamp in a 7-day-old neonate with replantation using postoperative leech therapy. To our knowledge this is the first time leech therapy has been used postoperatively for neonatal penile amputation.

    Copyright © 2014 Elsevier Inc. All rights reserved.

     

    Death

    Deaths from circumcision are now on a page of their own. The autopsy report on Ryleigh McWillis, who died of blood-loss, is on yet another page.


     

    Here are references for more than 25 other mishaps, mainly ablations.

    The Circumcision Information and Resource Centre has a further compilation of complications.

    A controversial webside, Ulwaluko shows botched Eastern Cape tribal circumcisions - contains graphic images.

    Stating the obvious, Robert Darby, PhD writes To avoid circumcision complications, avoid circumcision in the July-August 2014 issue of the Canadian Urological Association Journal | Journal de l'Association des urologues du Canada

     

     

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