A Prospective Survey of the Indications and Morbidity of Circumcision in Children

Introduction

The British Medical Association (BMA)¹ and the American Academy of Pediatrics (AAP)² deplore neonatal circumcision and only recommend circumcision on medical grounds. There is no account of the indications and only a single report of the morbidity of the operation³. However, in the North American literature, the advantages and disadvantages of neonatal circumcision have often been reviewed^4,5. The indications and morbidity of circumcision in infants and children in Southampton was prospectively reviewed between February 1st and July 1st,1983.

Patients and Methods

140 boys were admitted to the Paediatric Day Care Unit for circumcision. After suitable pre-medication, the children were anaesthetised and, if over 12 months, had a pre-operative Marcain (bupivicaine 0.5%) caudal anaesthetic. A routine dissection circumcision was performed. Some children had no formal dressing, while others had a more complex dressing with tulle gras, 2.5 cm cotton tape and micropore, which was expected to stay on for 7 days. Postoperatively, the children were kept on the ward until they were fully awake and then allowed home. They were not required to pass urine before discharge.

The Paediatric Home Nursing Team visited each child in their area on the following morning, and as often as was necessary until the penis was healed and the parents and child happy. The nurses filled in a standard sheet on each visit. This asked if there had been any delay in micturition postoperatively, or any vomiting or bleeding at any time. The discomfort of the child was assessed, not by the amount of analgesia used, but by whether the child was prepared to wear pants. The state of the penis was assessed - redness, presence of pus, blisters. or scab formation. Although the indications and results of circumcision were documented for all 140, the details of the morbidity were only assessed in the 99 (70.7%) who lived within the range of our nurses. All the children were seen as out-patients at 3-5 weeks postoperatively, by which time no scabs were present, and all the children had been discharged by the district nurse. The penis was said to be healed when the family no longer required the services of the nurse, even if there were still scabs present, as this is a good measure of the medical and psychological healing of the child and his family after theoperation.

The mean age at operation was 4.3 years (range 3 months to 14 years; fig. 1).

Figure 1. Age distribution of boys.

Definition

Phimosis: This was defined as a foreskin that could not be retracted over the glans due to a tight band. In some patients, if it could be retracted, a paraphimosis would be the likely result. Obstruction to urinary flow may occur in severe examples of congenital or acquired phimosis. If the foreskin could not be retracted because of normal preputial adhesions, then it was termed non-retractile.

Fig. 2. Indications for operation. [pie graph]

The commonest reason for circumcision was phimosis - 112 Patients (80%). Pure congenital phimosis was present in 60 patients (42.8%). 14 patients (10%) had a tendency to paraphimosis, and 38 (27.1%) had an acquired phimosis, 7 boys (5%) had balanitis xerotica obliterans (BXO). In addition, there were 15 (10.7%) religious and 6 (4.2%) miscellaneous circumcisions.

39 children were circumcised when aged less than 3 years. Only 11 of 39 patients (28.2%) were circumcised purely for congenital phimosis, confirming that the diagnosis is unusual. 8 of 39 patients (20%) had a tendency to paraphimosis.

6 children aged less than 12 months were circumcised. 4 were religious circumcisions, of which 2 were initially inadequate. All the religious circumcisions were for Muslims and the foreskins were clinically and histologically normal. Only 7 of 15 (46%) circumcisions were performed when the child was out of nappies, despite medical advice to this end.

The 6 miscellaneous circumcisions comprised 1 severe balanitis, 1 true paraphimosis, 1 foreskin caught in a zip, and 3 inadequate circumcisions, 2 religious, and 1 medical.

Although there were 21 (15%) children with a history of ballooning, 12 (8.5%) with a history of dysuria and 56 (40%) with a history of balanitis, all of these children also had phimosis as the indication for operation.

Complications

4 children developed meatal stenosis requiring formal meatotomy under general anaesthetic. 2 had BXO, while the other 2 had normal foreskins histologically. 1 child had a repeat circumcision for an initially inadequate religious circumcision.

Morbidity of the Local Children (99 of 140)

Vomiting

None of the children under 2 vomited post-operatively. 46 children vomited either in hospital or within the first 24 h, and 1 child required re-admission for profuse vomiting.

Delay till Micturition

All the bovs were allowed home on the day of operation whether they had passed urine or not. 19 did not pass urine in the 12 h following surgery. 5 children had episodes of `hanging on' for several days (maximum: 3 days) before passing urine, 1 child was re-admitted for retention of urine, but then passed urine spontaneously 16 h post-operatively.

Significant Bleeding

36 circumcisions were noted to ooze at some time, though only 2 patients required re-admission for continued bleeding. In 9 boys, the post-operative bleeding was due to accidental trauma. Removal of the more complex dressing at 7 days, sometimes resulted in oozing from scabs which were inadvertently removed (5 of 23 = 21.3%).

Comfort of the Child

38 children were able to wear pants within the first 4 days, but 26 avoided wearing pants for 7 days or more. 12 children were in nappies which were replaced post-operatively.

Infection

22 children had persistent hyperaemia, but there was no case of proven infection. 12 of 140 (8.5%) children were prescribed antibiotics. 6 children had wounds which were noted to be 'infected' and so were started on antibiotics by their general practitioner. 3 children were seen on the ward and given antibiotics. 2 children had antibiotics for an intercurrent otitis media and 1 had a chest infection.

Healing

The mean length of time for healing after circumcision was 10.4 days. 76 patients were fully healed 14 days after operation. None of those with a complex dressing were healed in less than 8 days, because the dressing was not taken off till 7 days post-operatively. A few of the others were healed earlier than that, as the parents were confident and the glans was dry. Scab formation was normal, and they usually took from 2 to 3 weeks to fall off. Many of the children had scabs on the penis at the time of discharge, but this did not prevent the child and his mother from leading an otherwise normal life. Of the 7 children with BXO, only 4 were visited by our district nurses. They took 11-18 days to heal (mean 14.2) and 3 of them developed large scabs on the glans, especially around the meatus. 2 of the 7 boys developed meatal stenosis requiring meatotomy (28.5%).

Re-Admissions

Four children required re-admission: 1 for difficulty with micturition; 2 for bleeding, and 1 for vomiting (4 of 140, 2.7%). The boy with retention of urine was admitted after 12 h, but passed urine spontaneously at 16 h. The boys who bled had both sustained accidental trauma, and settled on bed rest and analgesia. I boy began vomiting profusely at home and was re-admitted. He required intravenous fluids for 24 h and was dischargedhome within 2 days.

Discussion

The proponents of routine neonatal circumcision^4,5 extol the advantages of preventing cancer of the penis⁵, facilitating penile hygiene⁶, decreasing the incidence of sexually transmitted diseases (specifically genital herpes)⁷ and a reduction in the incidence of cancer of the cervix⁸. Circumcision in adult life is painful⁹, and is often indicated for difficulties with intercourse^10-13.

Following neonatal circumcision there is an appreciable morbidity of 0.06¹⁴ to 55%¹⁵. This discrepancy reflects differences in the definition of terms in the various studies. Haemorrhage is the most common complication and occurs in about 1% of cases¹⁶. Infection is more common with the Plastibell device than with the Gomco Clamp¹⁷. Major complications like septicaemia, life-threatening haemorrhage, denudation of the penile shaft, circumcision of hypospadiacs, osteomyelitis and lung abscess have all been reported⁴. There is a negligible mortality of 1 in 1,000,000¹⁴. Thus neither the BMA¹ nor the AAP² support neonatal circumcision and both recommend delay until circumcision is required for medical reasons.

As one might expect, 80% of children in Southampton requiring circumcision had phimosis, and the majority of these were congenital. 17 patients (11%) had circumcision for non-medical reasons (15 religious + 2 cosmetic). No child was circumcised if it had a non-retractile foreskin due to preputial adhesions. Over the same period, freeing of preputial adhesions was performed 36 times under both general and local anaesthetic.

Contrary to Rickwood et al.¹⁸, who suggested that 95% of phimoses were caused by BXO, we found that only 7 of 140 patients (5%) had this confirmed by histological examination of the excised prepuce.

The average age of circumcision (4.3 years) is in line with the recommendation of the BMA that circumcision should be performed between the ages of 3 and 5 as the child is usually out of nappies by this age and the psychological trauma of the operation is decreased¹. The HIPA for 1979¹⁹ shows that only 30% of circumcisions in England and Wales are performed under 5 years of age. The average stay in hospital is 1.7 days for those under 4 years, and 1.9 days for children up to 14 years old. Day surgery is of value in reducing the psychological trauma of circumcision and should be the system of choice.

Only children who had had omnopon (Papaveretum) as a part of thepre-medication vomited post-operatively.

In view of this, a separate survey of vomiting was started omitting omnopon from the pre-medication, and we expect to be able to eliminate post-operative vomiting.

The overall major morbidity of the 140 circumcisions comprising admission to hospital or further surgery, was 6.4%. In addition. closer study of 99 boys by our district nurses showed that 46% vomited, 36% oozed, 74% were wearing normal clothes within 7 days and the mean time to healing was 10.4 days. Healing was delayed for longer than 14 days in 23%. All the operations were performed by an experienced surgeon: either the consultant, senior registrar, or post-fellowship registrar. One might expect the morbidity to be higher in more junior hands.

In Southampton, 200 circumcisions a year are performed in adult life for paraphimosis, intractable balanitis and sexual problems. It seems likely that most of these adults should have been circumcised as children, thus avoiding an extremely painful experience.

Acknowledgement

We wish to acknowledge the work of Sister Peggy Gow and her Paediatric Home Nursing Team who carefully collected all the morbidity data.

Dr. D. Mervyn Griffiths,
Research Fellow in Paediatric Surgery,
 John Radcliffe Hospital
Headington,
GB-Oxford OX3 9DU (England)

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