The first cut is the deepest? Medicolegal aspects of male circumcision
‘Complications of circumcision should be few and rare’ [ 1 ];
‘When the surgeon pays less than complete attention to the details of this common and straightforward procedure, misadventures are inevitable.’ [ 2 ].
Male circumcision is a common procedure used for medical, prophylactic and ritual reasons by health professionals and surgical amateurs, thus creating a situation that is unique in urological surgery. The enormous variation in circumcision rates throughout the world (USA 70–80%; Great Britain 5–6%) causes significant differences in the medicolegal and economic implications of the procedure in different countries and/or cultural systems. Although circumcision is technically simple and has a low complication rate (with most of the untoward effects occurring during or shortly afterward), the operation must not be regarded as trivial.
In 1980, Prucha wrote of the prepuce: ‘The history of these few millimetres of skin is utterly epochal and fascinating.’ That continues to be true. During the last three decades, few topics within urology have generated as much scientific and emotional controversy as the question of routine neonatal circumcision. This is reflected by the unusually high proportion of editorials and comments in the extensive literature (1889 hits in Medline with the keyword circumcision; 403 hits with the combined keywords circumcision and complication) and an overflowing correspondence section whenever this or similar issues are raised .
Clearly indicated in only six definite conditions (balanitis, posthitis, phimosis, paraphimosis, localized condyloma acuminata and localized carcinoma) circumcision is mostly performed for religious and prophylactic reasons. Once advocated as a simple and proper means of preventing genitourinary diseases and genital cancers, the justification for routine neonatal circumcision began to be questioned by a strong anti-circumcision movement in the late 1960s. Circumcision was discussed with regard to its associated risks and morbidity, producing psychological, sexual and medicolegal difficulties. Although the pros and cons continue to be assessed extensively (see ) the debate is unlikely to be resolved.
This article focuses on those aspects of male circumcision that may be relevant in a medicolegal context. The objective of this review was to identify key publications that provide a firm scientific background for assessing medicolegal cases related to male circumcision. The specific issues addressed included definitive and poten-tial medical benefits, contraindications, complications (nature, severity, frequency) and preoperative counselling.
As this particular procedure and its implications cannot be fully understood without the sociocultural context (most of the major complications occurred at the hands of lay persons during ritual circumcisions), the historical aspects are briefly outlined.
The literature was searched using the National Library of Medicine Medline ( http://www.ncbi.nlm.nih/pubmed) and the search confined to papers in English and German. Only peer-reviewed data were considered. Abstracts were classified for their scientific value (review, original work, retrospective, prospective). The Medical Defence Union in the UK was consulted about the medicolegal issues that have been raised related to circumcision. The combination of the keywords ‘circumcision’ and ‘complication’ resulted in 403 references. Most of these articles had a specific emphasis (carcinogenesis, sexually transmitted diseases, female/ritual circumcision, anaesthesia, dermatological diseases, hypospadias) and were of limited significance for the present review. The keyword combination ‘circumcision’ and ‘litigation’ resulted in 62 references, most of which dealt with female circumcision (female genital mutilation). All relevant articles were retrieved.
Circumcision, probably one of the oldest of all surgical procedures, almost certainly began as a religious ritual. The Egyptians depicted circumcision in bas-relief on the tombs of Ankh-Mahor. The first mummies examined were found to have been circumcised. For many the centuries Jewish communities have circumcised young boys; as described in the Bible in Genesis, ritual circumcision (bris milah) is performed when the boy is 8 days old. Religious circumcision is also practised by Muslims, black Africans, Australian aborigines and other ethnic groups in different parts in the world. Currently, about a sixth of the world's male population can be considered to be circumcised, mostly on religious grounds.
In western societies, circumcision is mostly performed for medical reasons, the most common of which is phimosis. However, circumcision of newborn boys is a subject of great debate. From the early 1940s until the mid-1970s, circumcision of newborn boys was accepted in the USA as a simple procedure that promoted genital hygiene and prevented genital diseases (and genital cancers). In the late 1960s a strong anti-circumcision movement developed which focused the public's interest on the potential risks of circumcision and its consequences for these boys. Preston's article  serves as an impressive example of numerous pleas against routine neonatal circumcision. In 1975, the American Academy of Pediatrics (AAP) declared: ‘There is no absolute indication for routine circumcision of the newborn.’ This standpoint was supported by the American College of Obstetrics and Gynecologists. In 1983, the statement was reiterated.
In the late 1980s the attitude towards circumcision changed. Evidence mounted for the medical benefits of this procedure, particularly in preventing UTI in infant boys, and sexually transmitted diseases (STDs) in adolescents and young men. Wallerstein's article  is a meticulous dissection of the conflicting evidence for the prophylactic benefits of circumcision. In view of this discussion, the AAP reviewed their policy and published an updated scholarly report on neonatal circumcision , covering penile hygiene, local infections, cancer of the penis, cervical carcinoma, UTI, STDs, pain and behavioural changes, surgical techniques and local anaesthesia. Only a brief paragraph is dedicated to complications. The authors concluded: ‘Newborn circumcision has potential medical benefits and advantages as well as disadvantages and risks. When circumcision is being considered, the benefits and risks should be explained to the parents and informed consent obtained.’
Schoen  undertook to define the status of circumcision in newborns at the beginning of the 1990 s, exclusively focusing on the prophylactic aspects of the procedure. His discussion is a thoughtful reflection on the changing attitudes towards the routine use of circumcision. He concluded that ‘the benefits of routine circumcision of newborns as a preventive health measure far exceed the risks of the procedure, although some may question its cost effectiveness and priority in the delivery of health care’.
Indications and medical benefits of circumcision
The common medical indications for circumcision are usually seen in adults. Inflammation of the preputial skin (balanitis) or of the glans penis (posthitis) is often associated with diabetes. Obstinate and frequently recurring forms not responding to antimicrobial ointments usually require surgical intervention. Phimosis is stenosis of the preputial ring with resultant inability to retract a fully differentiated foreskin. The primary scarring of the distal margins of the foreskin often is a sequel of chronic balanitis. The circumferential fibrosis may make retraction of the foreskin impossible and occasionally create a pinpoint opening that, in the worst case, interferes with micturition. Urinary obstruction and UTI may be the consequence. Notably, only 4% of boys have a retractable foreskin at birth, increasing to 15% at 6 months and by 3 years the foreskin can be retracted in 80–90% of uncircumcised boys.
Paraphimosis is retention of the preputial ring proximal to the coronal sulcus, creating a tension greater than the lymphatic pressure. This constellation may result in subsequent oedema of the prepuce distal to the ring and the glans. A potentially disturbed perfusion may lead to ischaemic pain, cyanosis and, if left untreated, skin loss and gangrene. Either manual reduction or dorsal incision of the oedematous preputial skin are adequate measures to relieve paraphimosis. Circumcision is advisable after the inflammatory process has resolved.
When conservative therapy is futile or fails, circum-cision is the treatment of choice for a variety of dermatological conditions confined to the foreskin. The most common of these disease entities are condyloma acuminata or malignant basal or squamous cell carcinomas, with only low-stage tumours suitable for circumcision alone.
Routine neonatal circumcision has been advocated as a means of preventing genitourinary diseases and genital cancers. Special attention to this issue is paid in the clearly structured review article by Niku et al.. Circumcision of newborns facilitates genital hygiene throughout life under varying environmental conditions. It prevents preputial colonization with uropathic bacteria in infancy and childhood. Compared with circumcised children, uncircumcised boys have a 5–89-fold higher risk of acquiring UTI with the possibility of subsequent development of bacteraemia and meningitis .
Circumcision appears to have protective effects against certain STDs; uncircumcised men may be more susceptible to STDs that disrupt the epithelial surfaces, e.g. genital herpes, syphilis, condyloma acuminata, cancroid and even HIV .
One of the most striking arguments in support of circumcision is that in the newborn it almost completely eliminates the risks of developing cancer of the penis. It may also lessen the risks to female partners of circumcised men from having uterine cervical cancer. This effect appears to be a consequence of a lower incidence of infections with human papilloma virus and herpes simplex virus type 2, which are suspected to play a role as cofactors in the aetiology of genital cancers.
The most recent analysis of the health benefits and risks of circumcision was published by Moses et al., arriving at the balanced view that ‘for individuals and their families to make an informed decision they should be provided with the best available evidence regarding the known benefits and risks of circumcision’.
Contraindications to circumcision
Contraindications to circumcision are congenital or acquired abnormalities that require the availability of preputial skin for surgical repair. Such abnormalities include hypospadias, epispadias, megalourethra, webbed penis and chordee. As the hypospadias complex is the most common of these conditions, it must always be excluded by careful inspection of the penis.
Methods of circumcision
The aim of circumcision is to excise enough shaft skin and inner preputial epithelium so that the glans is sufficiently uncovered to prevent or treat phimosis and render the development of paraphimosis impossible. Although there are many different techniques of circumcision they can be broadly classified into four types: dorsal slit, shield, clamp and excision. Although many of the methods are not used in urological practice the urologist will occasionally be faced with their complications. He must therefore be familiar with the different techniques, their specific advantages and pitfalls.
To prevent complications with whatever technique is preferred, four principal factors should be strictly adhered to; attention to aseptic conditions, adequate but not excessive excision of outer and inner preputial layers, meticulous haemostasis and protection of the glans penis and the urethra.
Complications of circumcision
According to the literature, a realistic complication rate for circumcision appears to be 1.5–5%, although extremes of 0.06% and 55% have been reported. Complications can be regarded as immediate or delayed ( Table 1); at their most severe, some complications can cause loss of the entire penis. There are two excellent articles that extensively reviewed the complications. Williams and Kapila  provided the landmark paper on circumcision, and this should be mandatory reading for those involved in a medicolegal case. The review considers the whole spectrum of common and rare, trivial and exotic complications, and discusses the possible aetiological mechanisms in depth. After a brief history of circumcision they provide a comprehensive description of operative and non-operative complications. One section is dedicated to psychological and sexual complications, compensating for a major weakness in most of the other reviews. In their conclusion the authors hope that ‘a greater awareness of the incidence and scope of associated complications will encourage a more carefully considered decision on whether or not to circumcise’.
Table 1. Immediate and delayed complications of circumcision
|Urinary tract infection |
|Skin bridges||frequent, but no|
After outlining penile development and the natural history of the uncircumcised penis (‘Forcible retraction is completely unnecessary because separation will occur physiologically without such manoeuvres’) Kaplan's review  provides another detailed discussion of complications (‘ranging from the insignificant to the tragic’). He concluded that virtually all of the complications are preventable with only a modicum of care. He noted that most complications occur at the hands of inexperienced operators who are neither urologists nor surgeons, and that it is left to the urologist to consult in the management of these complications.
Wiswell and Geschke  compared the risks from circumcision during the first month of life with those for uncircumcised boys. The records of 136 086 boys born in US Army hospitals from 1980 to 1985 were reviewed for indexed complications related to circumcision status. For 100 157 circumcised boys, there were 193 complications (0.19%). These included 62 local infections, eight with bacteraemia, 83 with haemorrhage (31 requiring ligature and three requiring transfusion), 24 instances of surgical trauma (too much or too little skin removed in 15, injury to the urethra requiring plastic repair in one, circumcision in a child with hypospadias, wound dehiscence in seven) and 20 UTIs. In contrast, the complications in the 35 929 uncircumcised infants were all related to UTIs.
Wiswell et al. presented detailed data on 476 boys who were circumcised beyond the neonatal period. Complications occurred in eight patients (1.7%), and included excessive bleeding (three, one requiring transfusion), malignant hyperthermia (two, both survived), aspiration pneumonia, large haematoma development and postoperative fever.
In a retrospective analysis Özdemir  compared the complications from circumcision caused during mass and single circumcisions performed by medically trained or untrained operators. Traditional (medically untrained) circumcisers were responsible for 85% of the complications and almost all the disastrous ones. The frequency of complications from mass circumcision was significantly higher than that from circumcisions performed singly in operating room conditions.
Griffith et al. reported a prospective survey of the indications and morbidity of circumcision in 140 boys in a paediatric day-care unit. This article provides a realistic insight into routine practice. The authors concluded that ‘childhood circumcision has an appreciable morbidity, and should not be recommended without a medical reason’.
The specific medicolegal issues raised by the Medical Defense Union in the UK relating to circumcision are haemorrhage, meatal stenosis and amputation of the glans; these are addressed below.
Bleeding is the most common complication associated with circumcision, being reported in 0.1–35% of cases. Most of these bleeding episodes are minor and respond to gentle pressure. Excessive bleeding may be caused by inadequate haemostasis, blood coagulopathy or the existence of anomalous blood vessels. Bleeding is rarely dramatic enough to require blood transfusion or substitution of clotting factors.
In most instances, the application of pressure alone is sufficient to control local haemorrhage but other methods of haemostasis may be required. One of the most commonly used aids to obtain haemostasis is electrocautery. This normally safe and effective method has the potential for damage when used uncritically. The use of unipolar diathermy must be considered obsolete because of the danger of current-induced extended penile necrosis; bipolar diathermy is safer. When electrocautery is used in conjunction with the Gomco clamp, catastrophic and irreparable injuries leading to extended penile necrosis have occurred .
As an alternative to electrocautery, bleeding may be stopped by suture ligation. Most problems are caused by poorly placed sutures. Bleeding from unsecured or insufficiently ligated vessels within the loose areolar tissue can produce significant subcutaneous haematomas. To evacuate the haematoma and to identify and ligate the responsible vessel, several sutures must be removed. A small Penrose drain may be placed through the suture line and removed after a few days.
One of the most common sites for persistent bleeding is at the frenulum. Sutures placed in the area of the frenulum to control bleeding may lead to strangulation and necrosis of parts of the underlying urethra. This can result in the development of a urinary fistula.
To obtain haemostasis a sterile circumferential dressing may be applied with an antibiotic salve. To avoid the development of iatrogenic paraphimosis care must be taken not to apply the dressing too tightly. Urethral obstruction may lead to urinary retention predisposing to UTI. Rare instances of penile necrosis have resulted from tight dressings.
Vasoconstrictive agents may be used to stop minor bleeding. The application of pharmacological agents has the potential for systemic side-effects. Tachycardia and heart failure are the most striking symptoms of systemic absorption of locally applied adrenaline solution.
Meatitis and meatal stenosis
Meatitis or meatal ulcer is a frequent complication of circumcision with an incidence of 8–20%. The removal of the prepuce exposes the glans to ammoniacal substances present in urine-soaked nappies. This may lead to irritation and injury of the external urethral meatus. Subsequent scarring of the meatus may result in meatal stenosis predisposing to UTI. Upadhyay et al. assessed 50 patients who underwent meatotomy to treat meatal stenosis 3 months to 13 years after circumcision (mean 48 months); 16 patients were diagnosed incidentally and 34 presented to the clinic with symptoms caused by meatal stenosis. In all symptomatic patients meatotomy alleviated the symptoms. There were no recurrences within the study period. It was concluded that meatal stenosis is an under-recognized complication of circumcision in neonatal and infant boys still using nappies, and that presentation can be very late.
While it is rare, glans amputation is the most serious complication. In case reports, Gluckman et al., and Özkan and Gürpinar  describe the re-attachment of the glans and distal penile shaft amputated by lay operators during circumcision. They suggested that amputation injuries should be treated using the standard principles of grafting in reconstructive surgery. As the distal glans tissue is well vascularized a good ‘graft take’ is common.
The report by Hanukoglu et al. serves as a sad example of the ultimate ‘worst case’ scenario. In a neonate, a tight circular bandage applied to the circumcision area led to urinary retention and consequent hydroureteronephrosis. The entire necrotic glans penis sloughed off. The authors concluded that those carrying out circumcision should be aware of the potential dangers. Proper dressing and bandage care, and instructions for the parents to closely observe voiding after circumcision, may prevent serious complications.
Urethrocutaneus fistula is a rare complication after circumcision that may occur for several reasons, but mostly as a consequence of mechanical injury to the urethra. Strangulation of parts of the urethral wall and resultant necrosis and fistulation may be produced by the use of a clamp, or by a poorly placed suture to obtain haemostasis. Other forms of fistulae occur as a result of sepsis or unrecognized penile anomaly, such as megalourethra. Baskin et al. reported the surgical repair of subcoronal urethrocutaneous fistulae and urethral deviation that had occurred secondary to circumcision in a small series (11 patients) collected over 7 years. In four patients the glans was split and a Mathieu-style skin flap used. In four patients the urethral defect was bridged by an onlay island flap from the dorsal or ventral penile skin. In three patients with a scarred abnormal (hypospadiac) urethra after partial glans amputation the urethra was tunnelled into a new position. The repair was successful in all patients.
Infection is the second most common complication of circumcision, occurring in up to 10% of patients; in most cases it is usually mild and manifests by local inflammatory changes. Most infections are of little consequence and respond to local therapy. However, in some cases the circumcision site serves as the portal of entry for severe bacterial infections. Microbial contamination, bacterial invasion and metastatic infection are mechanisms which may lead to necrotizing fasciitis (Fournier's syndrome), staphylococcal ‘scalded-skin’ syndrome, impetigo, osteomyelitis, bronchopneumonia and meningitis. Despite their apparently low incidence, these complications must be considered because of their potential to cause significant morbidity and even mortality.
Surgical trauma and operative complications
Inadequate excision of foreskin and improper surgical techniques are the main reasons for an unsatisfactory outcome of the operation. Loss of penile skin (penile denudation) can occur as a consequence of complicating severe infection, the use of electrocautery or negligent surgical technique. Excision of too much skin can result from pulling too much of the skin over the glans during the procedure. The remaining skin slides back, leaving a denuded shaft. Another reason for penile denudation may result from the failure to break down all glanular adhesions. Most of these cases can usually be treated conservatively; only in the worst does penile denudation require split skin grafting or treatment with scrotal skin flaps.
A rare consequence of excision of excess preputial skin is the so-called ‘concealed penis’, i.e. a normally developed penis that becomes camouflaged by the suprapubic fat pad. On inspection, the contour of the penile shaft and the glans cannot be seen but careful palpation reveals that the penile shaft is concealed and normal in size, rather than a microphallus. It has been assumed that although an excess of skin is removed, not enough inner preputial epithelium is excised. As a consequence, as healing and fibrosis occur, the penile shaft is forced into the suprapubic fat, with the resultant preputial ring at the level of the skin of the mons pubis. Prevention of this complication depends on appropriate skin excision and complete dissection of the inner preputial epithelium from the glans. The treatment of this condition is surgical correction.
Webbed penis is a condition in which the scrotal skin extends onto the urethral aspect of the penis. Excessive removal of ventral penile skin may have produced this complication. Although the webbed penis is usually asymptomatic, the cosmetic appearance is often unacceptable. This condition may be corrected by incising the web transversely, which separates the penis from the scrotum, and closing the skin vertically.
Phimosis after circumcision
Insufficient excision of foreskin may lead to an unsatisfactory outcome or even result in the persistence of the former pathological condition. Phimosis may subsequently develop as the healing process is combined with wound contraction and cicatrization of the distal foreskin. This may produce a fibrotic ring which can cause urinary obstruction. Re-circumcision might be required; repeat circumcision rates because of inadequate skin excision at the initial procedure are 1–10%.
Another adverse result of circumcision is the formation of cutaneous bridges between the glans penis and the penile shaft. These synechias develop as consequence of incomplete preputial adhaesiolysis at the time of circumcision. Prominent skin bridges are aesthetically disturbing and may lead to tethering of the erect penis, with pain or penile curvature. In addition, smegma may be retained under these bridges. Usually the skin bridges can be corrected by simple surgical division.
As a rare complication, inclusion cysts develop if the skin edges are inverted as the wound is closed. Cysts may also be caused by implantation of smegma in the circumcision wound. As these cysts show a tendency to grow large or to become infected, the treatment is surgical excision.
Chordee is a rare complication of circumcision when performed during an acute episode of balanoposthitis. Formation of a dense band of scar in the area of the frenulum may cause chordee and impair erection. A dorsal slit rather than circumcision at the time of inflammation may prevent this complication.
In some cases the penis may swell from lymphoedema; the treatment must be individualized.
Older children are usually circumcised under general anaesthesia, but neonatally it is traditionally carried out with no anaesthesia. There is no doubt that newborns undergoing circumcision with no anaesthesia experience pain and physiological stress. To reduce pain and stress, a complete sensory blockade can be produced by infiltrating the dorsal penile nerves at the base of the penis, and by circumferential infiltration of tissues lying between the tunica albuginea and Buck's fascia. A 1.0% lidocaine or 0.5% bupivacaine solution with no adrenaline is recommended because the latter may cause arterial spasm and clinically significant penile ischaemia. This dorsal nerve block has also been shown to provide pain control for as long as 6 h after circumcision.
Psychological effects of circumcision
Despite the prevailing assumptions and prejudices about the serious psychological effects of circumcision in the young child, firm scientific data on this important issue are scarce. Some authors state that circumcision, performed around the phallic stage, is perceived by the child as an act of aggression and castration. Circumcision is said to have detrimental effects on the child's functioning and adaptation, particularly on his ego strength. Cansever's article  on the psychological consequences of circumcision was published when the Freudian school of psychoanalysis was more influential than it currently is. As this paper is still cited in contemporary debates, those using it should be aware of the methodology and that few individuals were enrolled in the study. Serious assumptions about the devastating psychological sequelae of circumcision were based on a study of 12 children from different socio-economic levels and from a cultural background (Turkey) that may not be representative of other countries. A more recent review  on the medical benefits and risks of circumcision clearly showed that there is little evidence of adverse effects on sexual, psychological and emotional health.
Informed consent and mandatory requirements of documentation
As in all surgical procedures, the key to high patient (parent) satisfaction with the results of circumcision is realistic and comprehensive preoperative information, ideally provided by the attending surgeon. Informed consent must be obtained by signature, if available on a standardized form, illustrating the surgical technique and listing all potential complications of the operation. The patient's/parents' approval of circumcision must be based on a clear understanding of the indication(s) for circumcision in the individual case, the surgical technique, its potential hazards and what can be done if there is a complication. Christensen-Szalamski et al. showed that replacing the ‘physician’s policy of partial disclosure with a comprehensive disclosure of unbiased information of possible risks and complications' had no effect on the mother's decision to have their son circumcised. If the procedure is performed under local anaesthesia administered by the surgeon, the risks of this must also be discussed. If a child is to be circumcised, it is desirable to obtain his assent, explaining the procedure in a way that is appropriate to his cognitive abilities.
The operative notes must include the indication for circumcision, a concise description of the procedure with particular reference to specific features of a case (e.g. frenulum breve) and intra-operative complications. The text should reflect all precautions taken by the surgeon to prevent complications (e.g. meticulous haemostasis). The notes must be signed by the surgeon and kept in the patient's records with the consent form. Especially in day-case surgery, the patients/parents must be instructed about the correct procedure after circumcision and what to do if there is a complication.
E.W. Gerharz, MD, Staff Urologist.
C. Haarmann, Senior House Officer.Correspondence: Dr med. E.W. Gerharz, Department of Urology,Julius-Maximilians-University Medical School, Josef-Schneider-Str. 2, 97080 Würzburg, Germany.e-mail: firstname.lastname@example.org