Early complications of circumcision performed in the community

British Journal of General Practice, Volume 53, Issue 496, Pages 887-888. November 2003.

HJ Corbett, GME Humphrey

Many circumcisions of male children are performed in the community by a variety of people, including some general practitioners.¹ The complication rate for community circumcisions is reported to be higher than that for those performed in hospitals.¹ This is supported by an increase in the rate of complications when hospital circumcision rates reduce.^2,3 The most frequent complication of circumcision is any setting is bleeding.⁴

Between August 2001 and April 2003 we saw 31 children with complications because of community performed circumcision. Their age range was from 4 weeks to 9 years (median 3 months). Nineteen boys had been circumcised with a Plastibell® ring. Twenty-five children presented with bleeding from 4 hours to 6 days post-circumcision. Haemoglobin (recorded in 21 patients) ranged from 6.2-15.2 g/dl. Five patients received a blood transfusion. Ten children needed surgical intervention under general anaesthesia to secure haemostasis. Four children presented from 8-30 days post-circumcision with the Plastibell® ring still in situ. Each had marked swelling of the glans and skin-mucosal dehiscence requiring recircumcision. A neonate presented 12 hours following Plastibell® circumcision with a completely displaced ring; bleeding was minimal and so management was conservative. One child presented 5 days post-circumcision with a purulent infection that settled with oral antibiotics.

Over 21 months, at least 31 children presented with complications of community circumcision. Most children with bleeding were managed with compressive dressing alone, but a significant number required surgical haemostasis. Some of the infants had life-threatening blood loss requiring blood transfusion, which is not in itself without risk. The Plastibell® ring, made by Hollister Incorporated, is used with good results.¹ One source of bleeding was due to failure to tie the string tightly enough.¹ This problem was the cause of bleeding in one infant that we saw and was probably to blame in the case where the ring fell off prematurely. Vigilence when tying the string may prevent such complications.¹

Our report highlights some of the complications of circumcision in children, which all GPs should be aware of. Such complications are not unique to circumcisions performed in the community and some were reported by Shah et al. from their pioneering circumcision service in Bradford Hospitals NHS Trust.¹ What is crucial is that the practitioner should be suitably experienced, give suitable analgesia, counsel the patients, and provide appropriate aftercare.^1,6 We recommend that parents should be advised to seek medical attention if bleeding post-circumcision has filled the nappy or continues frommore than 1 hour.

Note:

Post-circumcision bleeding is an extremely serious matter. Infants have very little blood in their tiny bodies, so cannot tolerate blood loss. Bleeding can lead to exsanguination, followed by hypovolemic shock, followed by death. Post-circumcision bleeding requires immediate medical attention.

References

Shah T, Raistrick J, Taylor I, et al. A circumcision service for religious reasons. BJU Int 1999; 83: 807-809
Madden P, Boddy SM. Should religious circumcisions be performed on the NHS? (Letter). BMJ 1991;302:47
Ahmed A, Mbibi NH, Dawam D, Kalayi GD. Complications of traditional male circumcision. Ann Trop Paediatr 1999;19:113-117 [ Abstract]
Williams N, Kapila L. Complications of circumcision. Br J Surg 1993;80:1231-1236
Poland RL. The question of routine neonatal circumcision. N Engl J Med 1990; 322:1312-1315
The General Medical Council. Guidance for doctors who are asked to circumcise male children. London: The General Medical Council; 1997

Citation:

Corbett HJ, Humphrey GME. Early complications of circumcision performed in the community. Br J Gen Pract. 2003-11;53(496):887-8.

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