Complications arising from ritual circumcision: pathogenesis and possible prevention

Much has been written about circumcision^1-4. An increasing awareness of the complications and possible mortality following the procedure has contributed to a decline in its frequency in Western society. Nevertheless, Jewish infants all over the world continue to be circumcised. The biblical instruction (mitzvah) concerning circumcision on the eighth day of life is faithfully observed by most Jews^5,6. The circumcision is usually performed by a ritual circumciser (mohel) who is not a physician; if complications occur, they are often ignored or just accepted. Death following circumcision⁷ was discussed in Talmudic times and let to codification of specific laws in the code of Jewish Law (Shulhan Arch)⁸. Problems associated with ritual circumcision (brit milah) continue to be reported in medical^5,6,9-13 and nonmedical⁷ literature. Complications may be due to technique^6,7,9, or to a lack of awareness of problems that may arise.

In this report, four of five infants referred over a six-year period with complications following ritual circumcision are described. Three had systemic infections and in one, the glans was partially amputated, leading to hemorrhage. The infants were all health at the time of circumcision, and were being cared for in a maternity hospital.

CASE REPORTS

Case 1. This baby was born after a normal pregnancy (birthweight, 2,830 g) and was circumcised on the eighth day of life. After the procedure, there was some oozing and over the next 24 h the infant became increasingly lethargic and fed poorly. When the baby was referred on the 10th day, he was unresponsive and would not eat. He was desperately ill, in shock, febrile and more than 5% dehydrated. There was a tight dressing on his glans, which was swollen, inflamed and almost black. The bladder was distended and percussible¹². Removal of the dressing was followed by a free flow of urine¹¹, which was probably the first urine passed for 48 h. Escherichia coli was isolated from the urine, blood and infected site of circumcision. Administration of i.v. fluids and parenteral penicillin and kanamycin was begun, together with antiseptic dressings to the penis. The infant had some difficulity voiding for a few days because of a scab over the urethral orifice, but the subsequent course was satisfactory and at six-week follow-up, he was healthy.

Case 2. This baby was born after a normal pregnancy and delivery (birthweight 3,830 g). He had a cleft lip and palette, but was other wise normal and was circumcised on the eighth day of life. The nex day, he fed slowly and was rather sleepy and lethargic, developed diarrhea, and had a temperature of 38 C and some tachypnea. The infant was pale and mildly jaundiced, with abdominal distension and excoriated perineum. The tip of the penis was almost gangrenous and the penile shaft was elongated by a tight dressing. When this was removed, an infected offensive wound was seen. The bladder was full on percussion but not palpable and after the dressing was removed, the infant voided. Multiple organisms were cultured from the circumcision and Proteus was grown from the blood and urine. A lumbar puncture showed early signs of meningitis and a chest X-ray revealed patchy consolidation at the bases of both lungs. Treatment with i.v. fluids and parenteral penicillin and kanamycin, together with antiseptic dressings, led to rapid improvement and recovery over the next few days.

Case 3. This baby, delivered by cesarean section, was born after a normal pregnancy (birthweight 3,180 g). Mild jaundice appeared on the third day of life but, decreased spontaneously by the fifth. He was circumcised on the eighth day and the next day developed a mild fever and the jaundice worsened. The penile shaft was elongated by a tight dressing. When the bandage was removed, an offensive, infected wound was observed and the infant voided. Multiple organisms were isolated from the penis, but not from the blood and urine. The infant was treated with parenteral penicillin and kanamycin and antiseptic dressings. Recovery was uneventful.

Case 4. This baby was born one week post term (birthweight, 3, 400 g). He was circumcised on the eighth day of life and continued to bleed over next few hours despite application of a second dressing by the mohel. Examination 6 h after circumcision revealed a somewhat pale, irritable infant. The penis was tightly bound and both the shaft and the glans were elongated. Despite severe compression, blood oozed continuously. When the dressing was removed, the glans was found to be partially lacerated. The undersurface of the shaft had also been denuded and there were a number of arteriolar bleeding points, which were oversewn. The glans was treated conservatively with local petrolatum-gauze dressings and oral trimethoprim. Recovery was uneventful.

DISCUSSION

Complications of varying severity, including occasional fatalities, have been described following all forms of circumcision^14-17. It is important to consider measures that will improve the safety of ritual circumcision. The cases presented here do not present a complete picture of the complications that have resulted from ritual circumcision. Despite reports in the literature^6,7,9-12,16, it is difficult to obtain a clear picture of the true incidence of complications following circumcision, as there is no comprehensive documentation. Weiss⁷ suggests that the morbidity and mortality may be substantially higher in ritual than in non-ritual circumcisions.

The mohel is strictly governed by Jewish halachi law¹⁸. The first step in the ritual procedure is cutting off the prepuce, which has been drawn forward off of the glans from about the level of the corona. A shield or metal guard with a fine slit⁶ is slid over the prepuce and directed downward and forward to protect the glans from the cutting knife and to reduce the risk of damage to the vessels of the frenulum. The forward direction of the guard also prevents denuding of the undersurface of the shaft. The second step involves tearing back the adherent preputial mucosa to expose the corona of the glans^6,19. This usually done with the nails of the thumb and forefinger. The final step is drawing blood from the cut penis before a dressing is applied. This step is regarded in religious writings as essential for the safety of the infant, is still sometimes done by mouth. An awareness of the risk of cross infection⁷ has read many reputable rabbinic authorities to recommend that the oral drawing of blood be performed only with a sterile glass tube placed over the cut penis^18-20. However some authors suggest that saliva may have special healing qualities.

Slight bleeding during the first few hours after circumcision is common and may be explained by the lack of close approximation of the cut edges of the skin, which are usually brought together by a dressing and only rarely by a suture. Capillary, venous or, at times, arteriolar bleeding may occur; the former usually settles with a firm dressing, but the latter types may lead to exsanguinations if they are not treated promptly²¹.

The amount of bleeding depends on how much raw area is left between the cut edges. If an ex [lacuna]. This occurred in case 4. The amount of prepuce removed depends on the experience of the operator because with the ritual technique the amount can only be approximated⁵. Undue emphasis is often placed on the speed with which the procedure is performed.

Because sutures are not used during ritual circumcision, a tight dressing may be applied to control bleeding. This can lead to urethral compression, the retention of urine and to the complications illustrated in the first three cases.

Many mohels apply antiseptic and coagulative powders to the wound to reduce the risk of bleeding; this was done in all our cases⁶. The dressing is often left undisturbed for many days⁹, again to reduce the risk of bleeding. However, the presence of a foreign body may increase the risk of infection, particularly if the circumcision is performed without adequate aseptic technique and with instruments and dressings that are inadequately sterilized. Oral contact may also introduce foreign organisms to an already traumatized area⁷, causing healing by second intention over days or weeks^7,9. Scarring of the preputial remnants, the occasional development of chordee and even meatal ulceration and stenosis have been described^5,9,13.

Additional complications may arise from faulty technique, as described by Schulman et al.⁹ In case 4, part of the glans was partially amputated and the undersurface of the shaft was denuded. There is no substitute for proper technique, which can come only from adequate training, supervision ad experience⁷. The small number of infants circumcised by some operators may contribute to the morbidity described. The use of a shield or guard to separate the prepuce from the glans^6,19 protects the glans when the prepuce is cut, unless the tip of the glans is caught in the slit of the guard, as occurred in case 4.

If the wound is contaminated (often with local perineal organisms) and tightly dressed, compression of the urethra and tightly dressed, compression of the urethra and resultant urinary retention^9-12 may lead to an ascending urinary tract infection and septicemia²². The compression [lacuna] There may also be a tendency among nursing and medical attendants to remain uninvolved when ritual circumicision is performed by a nonmedical person⁵ and vital signs of infection or other complications may be ignored. It is essential that a nonmedical mohel be able to recognize abnormal signs and seek appropriate medical attention for the infant. This is of even greater importance when the circumcision is performed at home.

The excellent blood supply of the penis and healing powers of the neonate were demonstrated in our cases. Once the situation was recognized and appropriate treatment wascommenced, recovery was rapid and complete.

CONCLUSION

Despite the awareness of medical and religious authorities of the problems that may follow ritual circumcision, it is difficult, if not impossible to fully supervise the practice⁷.

If a dressing is applied too tightly to a contaminated and infected wound and left on for too long, it can lead to compression of the urethra with resulting ascending urinary tract infection and the development of septicemia, meningitis, or pneumonia. The causative organisms are usually those found in the perineal area¹⁵. It is suggested that voiding subsequent to circumcision be carefully observed by the mohel and other attendants. In addition, removal of the original dressing on the day following the circumcision is highly desirable A second dressing with less tension may be applied if necessary, although application of 1% aqueoeus merbromin (MERCUROCHROME®) or povidone-iodine (BETADINE®) to any raw area may be all that is required.

The London Initiation Society has shown in its publication¹⁹ that ritual circumcision can be carried out according to the strictest Jewish halachic law, and yet utilize aseptic surgical techniques with minimal morbidity, no mortality and primary healing.

Received for publication 18 June 1980

The author thanks Mr. Peter G. Jones and Mr. Max W. Jotkowitz for reviewing the manuscript.

Address for correspondence and reprints: Dr. S. Menahem, Royal Childrens Hospital, Flemington Road, Parkville 3052, Australia

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