Circumcision Procedure Results in Recurrent Urinary Tract Issues

This case involves the treatment of an eight-day-old child who underwent a circumcision that was performed at a substandard level. The patient sustained multiple complications including excessive bleeding, postoperative infection, and the removal of too much of the foreskin. The patient required a revision procedure at two years of age. The corrective procedure involved a urethral calibration, a release of a hidden penis, and a penoplasty. The patient still suffers from recurrent urinary tract issues due to the improper technique used during the urethral calibration procedure, and, as a result, he experiences urinary tract infections on an ongoing basis.

Question(s) For Expert Witness

1. What are the most common complications of circumcision and how are they normally handled?

Expert Witness Response E-001300

Bleeding is the most commonly encountered complication of circumcision. The expected blood loss during neonatal circumcision is just a few drops (easily handled with one 4 x 4 " gauze pad), so bleeding that exceeds this expectation is a complication. Fortunately, almost all cases of bleeding with neonatal circumcision are very mild. In many cases, bleeding can be controlled by applying direct pressure to the site for a minute or two. At times, the addition of a Gelfoam wrap can speed clot formation and stop the cut edge from oozing. Of the three commonly used techniques (Gomco, Mogen, and Plastibell), the Plastibell has the lowest incidence of bleeding, as the suture remains in place for a few days after the procedure. With both clamp devices (Gomco and Mogen), hemostasis is dependent on the adequacy of the crush injury. It should be noted that tissue edema puts increased stress on a crushed edge and can lead to oozing, so care should be taken during the procedure to minimize trauma of the sensitive foreskin. Keeping the instrument used to remove adhesions in the plane of tissue between the glans and the foreskin, and avoiding rubbing against the underside of the skin, is one useful way to minimize edema.