It was once a nearly universal practice in the United States to circumcise male infants at birth (i.e., to perform “neonatal circumcision). While there has been somewhat of a trend away from male circumcision in recent years, it is still a very common practice in this country.

The vast majority of neonatal circumcisions take place without any difficulty and result in a penis that has a normal circumcised appearance and function. The most common complications that can take place can be grouped into three categories: 1) Too much skin removed.  2) Too little skin removed. 3) Remaining foreskin that is stuck to the head or glans of the penis (adhesions).

Too Much Skin Removed
It is fortunately very rare for too much skin to be removed in a circumcision, since this complication is the most difficult to correct. Pediatricians and other physicians who perform neonatal circumcisions know this, and so they tend to err on the side of leaving a little more skin when in doubt (and gauging exactly the right amount of skin to remove is not as easy as it might seem).  

Removal of too much skin can result in a deformed penis, and can, in a worst-case scenario, require reconstruction using skin grafts. I have seen perhaps only one or two of these cases in nearly 20 years of practice, which gives an indication of how rare it is. Such cases are quite serious, and require the services of a university-based pediatric urologist with extensive experience in penile reconstructive surgery. Even then, outcomes can be less than ideal.

Too Little Skin Removed
By far the most common scenario is that of “redundant foreskin”-also often referred to as an “incomplete circumcision.” This is a cosmetic issue, since an incomplete circumcision can result in the penis having neither a normal uncircumcised appearance nor a normal circumcised appearance, but rather something that is in between. It is also usually a functional issue as well, since the remaining foreskin (prepuce) can have a tendency to have a buildup of smegma (an otherwise normal secretion) under the redundant portions of foreskin, can tend to become irritated or infected easily, and can have a tendency to form adhesions.

Adhesions
Preputial (foreskin) adhesions usually happen in the setting of redundant foreskin, but can also happen even when the circumcision has been complete. While many of these adhesions are mild and break spontaneously as the penis grows, many of them need to be addressed by an urologist.

The easiest way to deal with preputial adhesions is to manually break them in the office. While this is uncomfortable for the child, the pain is very brief, and lasts only a couple of seconds. I usually reassure parents that the pain in a “lysis of adhesions” is far less and far briefer than is the pain caused a child by an ordinary immunization. The urologist quickly retracts the redundant foreskin to break the fine adhesions, and then applies a greasy antibiotic ointment such as a triple-antibiotic compound. It is vital that the parents retract the redundant foreskin and apply antibiotic ointment (or even plain petroleum jelly) to the head of the penis several times a day for several weeks to prevent the areas of raw skin to stick back to one another. Once the areas have completely healed, then the risk of adhesions forming again is largely gone.

Surgical Repair for Adhesions
There are several reasons why redundant foreskin or preputial adhesions might require a formal repair by an urologist in an operating room under general anesthesia.

First, if the distribution of redundant foreskin is uneven, with one part of the remaining foreskin being significantly longer than other parts, or if the amount of foreskin left is particularly large, then normal penile growth will not result in the child “growing out of it” in the way that can happen when the foreskin is evenly redundant all the way around. Whether surgery will ultimately be necessary is a judgment call for the urologist evaluating the child.

Second, if preputial adhesions have completely fused to the point where they cannot be easily broken by hand in the clinic, then a formal operation under general anesthesia will be required to cut these adhesions, remove any redundant foreskin, and suture the skin together again.

Third, if the redundant foreskin is so difficult to keep clean and free of smegma that there is recurrent irritation and inflammation, then surgical intervention is needed. A related problem that requires surgery is when the redundant foreskin cannot be kept from forming adhesions in spite of the parents’ best efforts at proper care.

Fourth, sometimes the penis will be a “buried penis,” where it retracts into the fat pad of a child’s pubic area. The cause of a buried penis is a congenital absence of normal definition of the skin angle between the penile skin and scrotum below, and between the penile skin and the pubic skin above. If a child is uncircumcised, he will usually grow out of the buried penis as the “baby fat” of the pubic area is lost over time. But in a circumcised child, a buried penis more often than not leads to adhesions and irritation. Repair of a buried penis is a more complicated circumcision revision, and involves placing sutures at the base of the penis to fix the penile skin to the shaft of the penis itself.

Conclusion
While the vast majority of circumcisions performed at birth go perfectly and without any complications, there are a small number of cases that will require an urologist’s attention in the first couple of years of life to revise the original circumcision. Once the circumcision has been revised, it is extremely rare for any further problems to take place. Consultation with a urologist experienced in evaluating and treating these conditions is ultimately the only way to determine for certain whether your child’s circumcision needs to be revised.

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From issue: 28/07-08