Download TODAY Complications of Circumcision

FASCIITIS OF GENITALS.
COMPLICATIONS OF
CIRCUMSCISIONS.
AUTHOR: Dr. C. LOPEZ ST. LUIS
2nd.DEGREE SPECIALIST IN PLASTIC SURGERY
M Sc. Medical Emergency
Assistant Professor
COLABORATORS:SURGEONS FROM SURGICAL
DEPARTMENT. RUNDU HOSPITAL.
STAFF MEMBERS FROM SURGICAL W
Namibia 29 October 2016
INTRODUCTION
In the United States, circumcision is a commonly performed
procedure. It is a relatively safe procedure with a low overall
complication rate. Most complications are minor and can be managed
easily. Though uncommon, complications of circumcision do represent
a significant percentage of cases seen by pediatric urologists. Often
they require surgical correction that results in a significant cost to the
health care system. Severe complications are quite rare, but death has
been reported as a result in some cases. A thorough and complete
preoperative evaluation, focusing on bleeding history and birth
history, is imperative. Proper selection of patients based on age and
anatomic considerations as well as proper sterile surgical technique
are critical to prevent future circumcision-related adverse events.
Keywords: Penis, circumcision, complications, child, micropenis,
inconspicuous.
.
OBJECTIVES
1. To explain general elements about
circumcision.
2. To demostrate the complications can exist
after a circumcision operation.
3. To understand the need of circumcision by the
medical community and by the society.
BACKGROUND
Circumcision is one of the oldest surgical procedures and one
of the most commonly performed surgical procedures in
practice today. Descriptions of ritual circumcision across
cultures, and have been described in ancient Egyptian texts as
well as the Old Testament. Approximately, 1.1 million neonatal
circumcisions were performed in the USA in 2008 alone and
the incidence of this procedure appears to be rising. In a large
retrospective review of the Nationwide Inpatient Sample,
estimated rates of newborn circumcision have risen from
48.3% nationwide in the years 1988–91 to 61.1% of male
newborns from 1997–2001. This represents an increase in
incidence of approximately 6.8% per year.
Penis
Human Anatomy
The penis is the male sex organ, reaching its
full size during puberty. In addition to its
sexual function, the penis acts as a conduit for
urine to leave the body.
What is the foreskin?
The foreskin is a continuation
of the skin of the penis shaft
which forms a fold over the
glans of the penis. Shown to
the right are three views
labelling the various parts of
the foreskin and shaft skin.
Since it is a fold, the inner
foreskin (in green) and the
outer foreskin (in turquoise)
are continuous with each
other, and also freely mobile
with respect to each other.
Anatomy Male Foreskin
CIRCUMCISION
Circumcision is a common procedure in which the skin
covering the tip of the penis is surgically removed. Boys are
born with a hood of skin, called the foreskin, covering the
head (glans) of the penis. In circumcision, the foreskin is
removed to expose the head of the penis. It's a quick
procedure that causes very little bleeding and stitches
aren't needed. Older boys can be circumcised, but the
procedure is a bit more involved. After the circumcision,
a protective bandage may be placed over the wound, which
generally heals on its own within a week to 10 days.
TYPES OF CIRCUMCISION
Can be divided into two main categories :
1. Traditional
Has been practiced world wide before the
introduction of modern style surgery of suturing and
stitch. These type of circumcision found practiced in
Africa and Asia.
The foreskin is gripped by either fingers or
specially made object (eg. wooden pincers).
By using sharp knife, a cut is made through the
skin between the pincers and head of penis. When
the remain skin retracted, it produced a raw
circumferential cut area around the shaft of penis.
The active bleeding area is then rapidly covered by
powdered or herbs before applying clean cloth
wrapping around the cut area to prevent further
bleeding.
Almost all of the traditional method did not use any
anaesthetic agents.
Limitations
Glans penis may accidently cut
and injured.
Pain during the procedure and
few days to weeks after that.
Foreskin did not cut optimally. It
may be cut too little or too
much.
Bleeding,
unless
rapidly
controlled, it may cause a
profound significant blood lost.
Healing
time
prolonged
especially
those
of
older
children or adult.
Immobility, patient was unable
to freely moved as movements
or
activities
may
caused
bleeding and pain.
Cannot taking bath for some
time until wound closure or
partial healing occurred.
TYPES OF CIRCUMCISION
Can be divided into two main categories :
Benefits
2. Clinical
reduced rate of injury to glans
Has been practiced world wide before the
introduction of modern style surgery of suturing and
stitch. These type of circumcision found practiced in
Africa and Asia.
The foreskin is gripped by either fingers or
specially made object (eg. wooden pincers).
By using sharp knife, a cut is made through the
skin between the pincers and head of penis. When
the remain skin retracted, it produced a raw
circumferential cut area around the shaft of penis.
The active bleeding area is then rapidly covered by
powdered or herbs before applying clean cloth
wrapping around the cut area to prevent further
bleeding.
Almost all of the traditional method did not use any
anaesthetic agents.
penis and infections.
minimized and controlled bleeding
better.
less pain or no pain at all with
introduction of anaesthesia.
 shortened the healing period.
a decreased risk of urinary tract
infections.
A reduced risk of some sexually
transmitted diseases in men.
Protection against penile
cancer and a reduced risk
of cervical cancer in
female sexpartners.
Prevention
of balanitis (inflammation of the
glans) and balanoposthitis
(inflammationof the glans and
foreskin).
Prevention of phimosis ).
METHODS OF CIRCUMCISION
• the Gomco clamp. The most commonly
utilized techniques used in the newborn
• the Mogen clamp.
• the Plastibell clamp.
• the “free-hand circumcision” using either the
sleeve technique or the dorsal-ventral slit
technique is most commonly used.
The Gomco Clamp method
Consists of 4 pieces:
the bell, platform,
hooking arm, and
screw.
These
are
assembled
after
placing
the
bell
completely over the
glans and the skin
drawn through the
hole in the platform.
The Mogen Clamp method
The Mogen clamp is
used by drawing the
skin to be removed
into the V and then
providing hemostasis
followed
by
amputation.
The Plastibell Clamp method
The Plastibell is placed
over the glans and a
suture is secured over
the skin. After several
days, the skin will
slough
and
the
Plastibell falls off.
The “sleeve” method
The
“free-hand
circumcision”
is
accomplished in the
operating room and
involves excising the
skin
as
marked,
hemostasis
using
electrocautery
and
then reapproximation
of the skin edges using
absorbable sutures.
The dorsal-ventral slit method
The dorsal-ventral slit
technique
of
circumcision involves
making these incisions
and then removal of
the
skin
between
them. Sutures are most
commonly used to
approximate the skin
edges.
TIMING OF CIRCUMCISION
• Complications occur more frequently with
increasing age of the patient. Bleeding becomes
more common during the “minipuberty” of
infancy that begins at 4 weeks of age and extends
to 3 months of age. This is thought to be due to
hormonally mediated increase in penile and
prepuce size and vascularity
• Based on use of the Neonatal Infant Pain
Scale the ideal timeframe for a “pain free”
circumcision is during the first week of life.
Complications during circumscision
•
•
•
•
•
injury to the glans or amputation.
excessive skin removal.
Bleeding and Hemorrhage
Buried, Concealed, and Hidden Penis
insufficient drawing up of the skin will lead to an
incomplete circumcision.
• insufficient tightening of the screw results in
inadequate compression of the skin and
subsequent bleeding.
Early circumscision complications
•
•
•
•
•
•
•
•
•
bleeding
pain
inadequate skin removal
surgical site infection tend to be minor and quite treatable.
However, postcircumcision bleeding in patients with
coagulation disorders can be significant and sometimes
even fatal
Chordee
iatrogenic hypospadias
glanular necrosis
glanular amputation
The latter, of course, requires prompt surgical intervention.
Late circumscision complications
•
•
•
•
•
•
•
•
•
•
Epidermal inclusion cysts
Suture sinus tracts
Inadequate skin removal resulting in redundant foreskin
Penile adhesions
Phimosis
Buried penis
Urethrocutaneous fistulae
Meatitis
Meatal stenosis
Infections
The fearmost complication:
INFECTION
Severe infections following
circumcision,
including necrotizing fasciitis. Presenting signs
and symptoms as erythema, induration, pain out
of proportion to physical findings, coupled with
tachycardia, leucocytosis, or bandemia. Is usually
a polymicrobial infection. Empiric broad spectrum
antibiotics to cover Gram-negative, Grampositive, and anaerobic organisms are essential. A
suggested regimen is an aminoglycoside, nafcillin,
or vancomycin and clindamycin and aggressive
debridement of necrotic tissue is required.
NECROTIZING FASCIITIS
• Commonly called a "flesh-eating bacteria" rare disease can
be caused by more than one type of bacteria. These include
group
AStreptococcus
(group
A
strep), Klebsiella, Clostridium, Escherichia coli,Staphylococcus
aureus, and Aeromonas hydrophila, among others. Group A
strep is considered the most common cause of necrotizing
fasciitis.
• Usually, infections from group A strep bacteria are generally
mild and are easily treated. But in cases of necrotizing
fasciitis, bacteria spread rapidly once they enter the body.
They infect flat layers of a membrane known as the fascia,
which are connective bands of tissue that surround muscles,
nerves, fat, and blood vessels. The infection also damages the
tissues next to the fascia. Sometimes toxins (poisons) made by
these bacteria destroy the tissue they infect, causing it to die.
When this happens, the infection is very serious and can
result in loss of limbs or death.
FOURNIERS GANGRENE or
FASCIITIS OF GENITALS
Fournier gangrene was first identified in 1883,
when the French venereologist Jean Alfred
Fournier described a series in which 5 previously
healthy young men suffered from a rapidly
progressive gangrene of the penis and scrotum
without apparent cause. This condition, which
came to be known as Fournier gangrene, is
defined as a polymicrobial necrotizing fasciitis of
the perineal, perianal, or genital areas.
Male Circumcision and HIV
With the publication of several promising studies on the protective
effect of Male Circumcision (MC), an additional tool was added to the
HIV prevention toolkit. In three ground-breaking studies, in South
Africa, Kenya, and Uganda, MC, was shown to reduce the risk of HIV
infection in men by up to 60%. Although this protection is not total –
and offers no protection against HIV to women – the World Health
Organization (WHO) and the Joint United Nations Programme on HIV
and AIDS (UNAIDS) have both recommended MC for countries, like
Namibia, where the population prevalence of HIV is high and few
men are circumcised. Following this recommendation, the potential
impact of a national MC campaign on future HIV incidence rates in
Namibia was modeled. According to these estimates, scaling up MC
to reach 80 percent of adult and newborn males in Namibia by 2015
would avert almost 35,000 adult HIV infections between 2009 and
2025. With only 21% of Namibian men currently circumcised,
reaching 80% coverage nationally will be a challenge.
Does circumcision of the penis reduce
the risk of HIV transmission?
• For men who have sex with women: Penile
circumcision does provide protection for HIVnegative men who are at risk of HIV infection
through vaginal sex with women. Research
studies in East and South Africa found that
circumcised
heterosexual
men
were
approximately 50% to 60% less likely to
become infected with HIV than uncircumcised
men. The circumcised men were also at
reduced risk of herpes, syphilis and human
papillomavirus (HPV).
• For women who have sex with men: Penile
circumcision does not provide protection for
HIV-negative women who are at risk of
infection through vaginal sex with men.
Although an HIV-negative circumcised man is
less likely to become infected with HIV through
vaginal sex, an HIV-positive circumcised man is
not less likely to pass HIV to others.
• For men who have sex with men
(MSM): Penile circumcision does not provide
protection for HIV-negative men who are at
risk of HIV infection through insertive and
receptive anal sex (topping and bottoming)
with other men. However, some studies
suggest that circumcision of the penis may
protect HIV-negative men from HIV if they
engage only in insertive anal sex (topping).
Epidemiology
• A prevalence of 1 case in 7500 persons. A
retrospective case review revealed 1726 cases
documented in the literature from 1950-1999,
with an average of 97 cases per year reported
from 1989-1998.
• In Rundu Intermediate hospital, since 2010 has
been received 8, 1 died, representing 12.5%
Case # 1
•
•
•
•
•
•
•
•
Male. 31 years old
Referal from Nankudu.
Traumatic injury through the rectum
7 days later:
Pain, swollen testis, fever 39dg.
DOA:01/02/14
DOD:30/03/14
Septic shock . H. C. Admision
Case 1
Significant finding on examination of genitalia and perineum
Case 1
Debridement under general anaesthesia
Case 1
Necrotic tissue removed
Case 1
Debridement under general anaesthesia
Case 1
Abdominal wall incisions
case1
Secondary closure of abdominal incisions not enough scrotal sac for
closure
Case 1
recovering
Case 1
Recovering
Case # 2
Male. 28 years old
Referal from Katima.
Circumcized 02/16
7 days later:
Pain, swollen testis, fever 38dg.
DOA:18/03/16
DOD:30/04/16
Swab: multibacterial
On HAART
Surgical+chemical debridment
Case # 2
Case # 2
Male 28 years old
File: 4656
DOA: 20-04-16
DOD: 13-0516
Case # 3
Male. 34 years old
Referal from Katima.
Circumcized
10 days later:
Pain, swollen testis.
DOA:02/12/15
DOD:24/12/15
Swab: multibacterial
On HAART
Surgical+chemical debridment
Case # 3
Case # 4
Male. 28 years old
Referal from Katima.
Circumcized
More a week later
swollen penis.
Swab: multibacterial
No reactive
Surgical+chemical debridment
Case # 4
Case # 5 dehiscense. 3 days
later.casualty at one week later
Male. 18 years old
from Kavango.
Circumcized
More a week later
swollen penis,septic wound.
Swab: multibacterial
No reactive
Surgical+chemical debridment
Case # 5
Case # 5
Case # 6
Male. Adult. Looks more than 40 years old
from village near Katima.
Not circumcized
More than 15 days with pain and swollen
testis
Treated by a traditional healer.
Swab: multibacterial
reactive
Surgical+chemical debridment
Case # 7
Male. Adult. 54 years old
from rundu
Not circumcized
More than 7 days with pain and swollen
testis, open septic wound
Well known diabetic patient
not reactive
Swab: multibacterial
Surgical+chemical debridment
Passed away 1 week after debridment.
Caso # 8
Male. Adult. 38 years old
from a village
Not circumcized
Many days with pain and swollen testis, nothing
remarkable
not reactive. Trauma pulling a cow.
Swab: multibacterial
Surgical+chemical debridment
Passed away 1 week after debridment.
Case # 9
Male. Adult more than 30 years old.
Not circumcized
Many days with pain and swollen testis.
On HAART.
Swab: multibacterial
Surgical+chemical debridment
CONCLUSIONS
• The general factors inducing genitals fasciitis in this
presentation are the following: imunodepression, Diabetes,
trauma, lack of hygiene.
• Circumcision does not affect male sexual drive or functioning.
• When a guy is not circumcised, moisture can get trapped
between his penis and the foreskin, which creates an ideal
environment for bacteria to grow. This means there’s a higher
risk of infection and it’s easier to spread viruses to others.
• Being circumcised reduces your female partner’s risk of
cervical cancer.
• By getting circumcised, you not only reduce your HIV , but
your partner’s too.
•
RECOMMENDATIONS
To increase the educative promotion using
social media, about the need and importance
of the circumcision in communities, homes,
schools, jobs, neighborhoods, towns, HIV
institutions, hospitals, clinics.
• To increase the health promotion about the
importance of a good personal hygiene.
• To increase the circumcision programmes.
• To promote exchange of experiences and
knowledges about circumcision between
differents hospitals in events and conferences.
REFERENCES
1. Circumcision: A History of the World's Most
Controversial Surgery. By Dr. David L. Gollaher.
• 2. Male Circumcision Reduces Risk of HIV
Acquisition for as Long as Seven Years.
By Dr. Thomas, J.
3. Male Circumcision: A Gender Perspective.
By Dr. Zoske, Joseph
4. Ministry of Health and Social Services. Policy
on male circumcision for HIV prevention.
5. http://www.webmd.com/sexualconditions/guide/circumcision.
RUNDU HOSPITAL
THANKS