Wednesday, November 04, 2009

Massive Infection Takes Over Body After Plastibell Circumcision

This pediatric urology crisis occurred after a routine circumcision as a result of the Plastibell method -- one which some advertise as being 'less traumatic' than other methods of genital cutting. For more on the Plastibell method, see here.

PEDIATRIC UROLOGY

  • John H. Ngan, F.R.C.S.
  • Michael Mitchell, M.D.

"I think this child has an infected penis after neonatal circumcision..."

  • Authors: John H. Ngan M.D., J Waldhausen M.D., Richard Santucci M.D.

CASE REPORT


A 6 day old male was circumcised uneventfully using the Plastibell technique in the pediatrician's office. Two days later the patient developed penile shaft swelling and blistering accompanied by a temperature of 38.3 degree celsius. Intravenous Ampicillin and Gentamicin was started by the pediatrician. Gram stain of the blister aspirate revealed no inflammatory cell or organism. The patient improved the next day and antibiotics were changed to intramuscular ceftriaxone.

On post-circumcision day 4, urologic consultation was obtained as the penile swelling had extended into the scrotum and the penis started to blister. The Plastibell ring was removed without difficulty and the blisters drained. An ultrasound was obtained which revealed scrotal edema with normal testicles bilaterally. Provisional diagnosis of necrotizing fasciitis was made and the patient was transferred to Children’s Hospital Medical Center by helicopter.

On arrival, examination revealed a swollen scrotum with induration and erythema extending to the lower abdominal wall (See Figures One and Two below). A coin-sized patch of purplish discoloration was also evident on the right hemi-scrotum. The circumcision wound was covered with yellowish granulation tissue. His temperature was 37.6 deg Celsius, heart rate 160-170/min and blood pressure 80/60 mmHg. WBC was 27,000/cmm with 12744/cmm polys and 1296/cmm bands.

Figure One
Figure Two

Fluid resuscitation with adminstration of broad spectrum antibiotics using vancomycin, gentamicin and clindamycin. The child was brought into the operating room for debridement of necrotizing fasciitis. The infective process had involved the upper thighs, the lower abdominal wall and posteriorly to the perineal body. Wide excision of scrotum, penile skin, and lower abdominal wall was carried out. Deep tissue layers including the penile shaft, testicles, and abdominal musculature appeared normal. (See Figure Three)

Figure Three


Post-operatively, the child underwent second-look surgery and further debridement to the level of the mid-abdomen and the superior thigh on post-operative day 2. (See Figure Four)

Figure Four

In addition, 7 hyperbaric oxygen treatments were given. On post-operative 15, split-thickness skin autografts were applied to the lower abdomen, penile shaft, thighs and testicles.

DISCUSSION 

 

Technique of Neonatal Circumcision.


Neonatal circmucisions are commonly performed by obstetricians and pediatricians in the first week of life in their offices in Washington. In general, either the plastibell or the Gomco clamp techniques are used. While both techniques should give reasonable cosmetic results, the plastibell alows better visualization of the circumcision. With the plastibell, a ring is left to assist coaptation of the wound edges after the circumcision. Upon healing, the ring will be released from the wound. The Gomco clamp leaves no foreign body on the wound but has the risk of wound edge separation. Moreover, the Gomco clamp does not allow an accurate estimation of skin to be excised and can remove excess skin when the location of the penoscrotal junction is misjudged. It is important that electro-coagulation (in place of the scalple) is not used on the Gomco clamp during circumcision. The Moyal clamp performs the circumcision on the same principle as the Gomco clamp. There is no device to hold the wound edges together. Most pediatric urologists prefer using the free-hand technique.

Whether the type of techniques used is related to a higher incidence of infection is not entirely clear. Gee and Ansell compared the use of Plastibell and Gomco in 5521 children between 1963 and 1972. In the Plastibell group, 19/2625 (0.72%) infections encountered. In the Gomco group, 4/2896 (0.14%) circumcisions infected. The incidence of infection following Plastibell circumcision was significantly more frequent than that following Gomco circumcision (p<.005). Moreover, 4/19 Plastibell infections developed irritability and required antibiotic treatment while all Gomco infections were successfully treated with topical agents. The other patient with Fourniew's gangrene developed after circumcision reported in teh literature also had a Plastibell circumcision (Woodside JR, 1990). Of all the serious infections that are known at this center, the plastibell has been used.
Care after circumcision.
The wound more often than not will look edematous and even red. However, the erythema should not spread to penile shaft skin. Erythema in the shaft skin should raise the concern for spreading wound infection and impending faciitis if not treated promptly. Though WBC in the neonates can be as high as 30,000/mm3, neonates with faciitis in general will demonstrate leukocytosis with bandemia and WBC higher than 20,000/mm3. Normal neonates do not show bandemia. Admission for observation and broad spectrum antibiotics is warranted. However, there is no consensus on whether the plastibell should be removed at this point. The plastibell is an external device and it is not unreasonable to leave it on if the circumcision is only recently performed. Surgical intervention is indicated when faciitis is suspected.
Surgical management.
High index of suspicion, prompt diagnosis, immediate fluid resuscitation and institution of broad spectrum antibiotics followed by debridement is the key successful treatment of Fournier's gangrene. The disease is extremely lethal. In adults, the recent mortality has improved to 18% (Clayton et al, 1990). In children, the overall mortality rate is 9% and can be as high as 30% in infants younger than 3 month (Adams JR et al, 1990), the time when neonatal circumcision is performed. Faciitis caused by streptococcal infection and Chicken pox on the face has been successfully treated by raising skin flaps for subcutaneous drainage without excision. In this way, skin can be preserved and cosmesis preserved. At present this technique should not be extrapolate to use in Fournier’s gangrene which is polymicrobial in nature. Wide excision should be the rule followed by frequent re-examination.
It is important that the testes should be preserved as necrotising faciitis almost never involves the testes. The tunica vaginalis should remain intact during dissection so theat the testes will not dessicate. Retraction of testes occur secondary to wound contraction. Tagging the testes in their orthotopic position after debridement may decrease the extent of proximal migration.

REFERENCE

  1. Woodside JR: Necrotizing fasciitis after neonatal circumcision. Am. J. Dis. Child, 134:301, 1980.
  2. Gee WF and Ansell JS: Neonatal circumcision: A ten year overview. With compariison of the Gomco clamp and the plastibell device. Pediatrics, 58:824, 1976.
  3. Adams JR Jr., Mata JA, Venable DD, Culkin DJ and Bocchini JA Jr.: Founier’s gangrene in children. Urology, 35:439, 1990.
  4. Clayton MD, Fowler JE Jr, Sharifi R, Pearl RK: Causes, presentation and survival of 57 patients with necrotizing fasciitis of the male genitalia. Surgery 170:49-55,1990.

 

THE CONFERENCE


This conference was conducted on February 15, 1996 at 7.00 am by the Department of Surgery at the Children’s Hospital and Medical Center, University of Washington, Seattle, Washington. Attendance: D. Tapper, M.D. R. Sawin M.D., E. Hatch M.D., J Waldhausen M.D., D. Bliss M.D. (pediatric surgery fellow), P Healey M.D.(pediatric surgery fellow), R. Woods M.D. Ph.D. (R3), B. Plaskon M.D.(R3), L. Kawamura M.D.(R1), M. Burns M.D.(Urology), M. Carr M.D. (Urology), C. Close M.D.(pediatric urology fellow), J. Ngan M.D.(pediatric urology fellow), R Santucci M.D.(R5-urology), S. Manning M.D.(ENT), D. Cara M.D. (ENT fellow).


For further information on circumcision morbidity and mortality rates see:

Cirp.Org/Library/Death

Increased Dangers of Circumcision Report


Circumstitions.com/Complications

NoHarmm.org/complicationsUS

Death From Circumcision

Cut vs. Intact Outcome Statistics

The Perils of Plastibell Circumcision: A Mythical "No Cutting, No Risk" Method

Related News Briefs:

Baby Dies in South Dakota

New York Baby Dies

Baby Dies After Brit


More newborn baby boys die from circumcision surgery each year in the United States than from choking, from auto accidents, from suffocation, from SIDS, from sleep positioners and from (the recently banned) drop-side cribs.

Books:

Doctors Re-examine Circumcision

Circumcision: An American Health Fallacy

Circumcision: The Painful Dilemma

Circumcision: A History of the World's Most Controversial Surgery

Questioning Circumcision: A Jewish Perspective

What Your Doctor May Not Tell You About Circumcision

Circumcision: What Every Parent Should Know

Marked in Your Flesh: Circumcision from Ancient Judea to Modern America

Circumcision: The Hidden Trauma

Circumcision: The Rest of the Story

Circumcision Exposed: Rethinking a Medical and Cultural Tradition

40 Compelling Reasons Why You Should Respect His Birthright and Keep Your Son Whole


Children's Genitals Under the Knife


Complete resources on the prepuce organ, intact health and circumcision can be found at: Are You Fully Informed?


~~~~

32 comments:

  1. How sickening. This left me in tears. Why Why Why do so many people allow this to continue taking place?

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  2. OMG that poor little man :( This practice needs to be stopped.

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  3. those pictures were truly disturbing. How can anyone think this is ok to do to our babies?

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  4. That is disgusting!!!!!!!!!!!!!!!!!

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  5. This is crazy, and just heartbreaking for that little boy. Why do parents think this is okay? I've gotten into heated debates with moms who feel it is their "right" to decide.....and I don't understand that mentality, nor can I accept it. I know I'm not the only one who feels that RIC is child abuse. I have a hard time understanding how anyone can do that to their own son.

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  6. Very compelling. I'm sure most viewers thought circumcision was only dangerous when done in some African hut. Kids get very sick and sometimes even die in Western cultures.

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  7. Horrible... what gets me is that even after being admitted to hospital and seeing the infection, the plastibel was not removed until the next day..... poor baby.

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  8. Thank you for posting this. More parents need to be made aware that this horrendous practice is not only unnecessary, it is dangerous.

    I posted on circumcision not long ago and was shocked by some of the facts I discovered in my research.

    Did you know that:
    circumcision began in the United States during the Victorian era to punish boys for masturbating;
    46% of new parents are not provided circumcision information by a doctor; and
    circumcised penises are actually more prone to infection.

    Keep speaking out! It is posts like this that can help parents reconsider. Too often the topic is seen as taboo and our baby boys are mutilated out of ignorance.

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  9. This is why we keep on keeping on.

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  10. I feel so sorry for that little boy!! I hope he recovers as well as can be, but his parents will have some serious explaining to do when he is older, I'm sure.
    I sincerely hope this practice is abolished soon, it makes me so sad to think of all the people who don't know better, and the children of said people.

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  11. hi i am sandy i been look for more imfo about circumcision, because my son doctor say that my 8 year boy need it, i take him to the hospital 3 days ago and now i regreat because i do not know if is imfected i call his doctor he say evething is normal my son is in terrible pain please parents think twice, i think i should find mero imfo before.

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  12. This is sad. But I am more concerned about how/why it got to this state. This did not happen instantly. Like any wound, a circumcision needs to be cleaned and tended to until it is healed. I think the ignorance/neglect of the parents is the issue in this case.

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  13. Wow, anonymous, you can't be serious. There are antibiotic resistant bacteria around these days that can produce a horrible result like this while parents and medical professionals stand by and can't do a thing about it.

    Blaming the parents for improper care would be highly inappropriate.

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  14. This is horrifying. I cannot believe it got that bad on a poor defenseless infant. I already decided against circumcision and this definitely has added to my reasons for not doing it.

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  15. THIS is why we don't cut babies!!

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  16. Fasciitis is caused by a strain of staph that can be kept at bay with proper wound care.

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  17. I wish there was a way to require that blown-up full color copies of these photos be displayed on consent forms. What parent would sign them looking at this?

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  18. Fellow anonymous - it is sometimes fair to say that parents ought to know better, but we don't know what information these parents were given - we don't know if they realised their son was ill until too late.

    Redness on a circumcision wound is probably what they were told to expect - if they were first time parents, they may have overestimated the "acceptable" extent of redness.

    Without more information, it's simply improper to pass judgement regarding post-circumcision care.

    What is fair to say is that they should never have been letting anyone cut away part of another individual's body.

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  19. Results that are this bad are rare but, since there is no medical need for circumcision, in the first place, even one result like this should be enough for parents to leave their babies' healthy genitals alone, and for physicians to refuse to perform them. More minor infections are quite common in circumcised babies, while infections in intact babies whose foreskins haven't been mistreated are extremely rare. The parents of this little boy probably had no idea that this was a possibility. They may have even been told that the Plastibell method doesn't involve any cutting! It is total madness that Americans keep this awful practice going.

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  20. my son was circunzized a year ago he described it was painful,coudnt move,and shocking....he still told me he want hes old private back...he was 8 years old and he can described so please think before torture someone that you really love...

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  21. ugh, this makes me so sad. dear parents question circumcision, its not YOUR penis. leave it alone. poor babies.

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  22. This is so sad. Does anyone know whatever happened to him? Will he have full use of his penis?

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  23. my mind goes to terrible scarring and that poor baby trying to heal how did they diaper im sure once he left the hospital he still needed to heal. staph is very sneaky what looks like typical swelling can be a whole lot worse. like moles can be just a spot or cancer its easily misjudged

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  24. I was told by someone involved with legal cases like the type discussed above that the boy will be a sexual cripple and sterile. The skin of the scrotum is unique tissue, which contracts and expands with change in temperature. The scrotum expands when hot and contracts when cold. There is also some effect on the cremaster muscle, but I don't know what it was. As for the penile skin that was lost, one should read about Shane Peterson from Australia. Penile skin is very different from other skin on the body and when this other skin is grafted to the penis it doesn't stretch as well. I think I remember in Shane's case that the graft of leg skin adhered to the underlying membrane making an erection extremely painful. The tunica albuginea is an important internal penile sheath. I can't tell if it was removed in the photo above. Please don't get fooled by most doctors comments about complications being rare because these studies about complications were conducted at really good hospitals. Essentially it's like going to the richest town in your state to determine the average wealth in your state. It's simply not accurate. Besides 1% or 2% complication rate on the half a million boys cut each year is a lot.

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  25. Oh Dios mio... no deberían permitir ésto!

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  26. Risks are completely underplayed when it comes to circumcision. Everyone seems to be under the misguided notion that it is a quick, safe, harmless procedure with no negative consequences. It is not true. This post shows a REAL possible consequence of a routine circumcision. DEATH is another possible outcome. How is it worth it to people to put their newborn sons at risk like this so unnecessarily? The human mind is a mystery to me.

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  27. Leave your perfect baby boys INTACT-- this poor infant suffered horribly (and will continue to suffer) for NO REASON AT ALL.

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  28. There is NO medical reason to amputate the foreskin; a healthy, functional body part, in males or females. The argument that it may have slight benefits is highly flawed. For one thing, it's not more hygenic. The foreskin is a self cleaning mechanism, just as the labia, and requires no special care. Cleaning it is as easy as cleaning a finger. Legally, circumcisions on non-consenting minors is actually illegal, it's just not enforced because there is BIG money to be made. Forcibly amputated tissues are sold to cosmetic and pharmaceutical companies and can fetch up to $100,000.

    Proxy consent (parental consent) is only valid in life threatening situations. Having a prepuce is hardly life threatening. On the minuscule chance that an infection does occur, antibiotics are all that is needed. If a female child has a urinary tract infection, her prepuce (clitoral hood) is not amputated, she is given medication, and females are actually MORE likely to get an infection than males. It shouldn't be different for males. No other body part is amputated for supposed "prevention". That would be like removing the tonsils at birth on the CHANCE of tonsilitis later in life. Or removing any other body part that COULD become infected with something at some point. It's ridiculous.

    Circumcision has actually evolved over thousands of years. When it was first practiced, the procedure was a blood sacrifice, and only involved pricking the foreskin to allow a single drop of blood. Then, the foreskin was slit. Next, a small amount of tissue was removed. Circumcision as we know it today was actually "perfected" by Dr. Kellog to curb masturbation and hinder sexual pleasure.

    The foreskin contains about 20,000 nerve endings and is the most sensitive body part of humans. About 50% of the tissue is amputated, and amounts to about 15 square inches of tissue.

    Probably the most important issue is the fact that the male child is unable to provide informed consent. It's his body, it's his choice. There is NO medical organization on the planet that recommends routine infant circumcision. And worldwide 90% of males are intact. The United States is the only country to practice routine circumcision of male infants.

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  29. When I gave birth to my son 36 years ago, I asked my ob/gyn and my daughter's pediatrician about circumcision. I basically was told, that it was better for the baby and it was NOT painful. I was sooo stupid and I have such regret to this day. I had my baby circumcised to "match" daddy, that was also spewed to me by these two doctors. I beg parents to watch these videos and then decide. I cannot believe this barbaric butchering is still allowed to be done. If a man wants to be circumcised, then he should be able to decide that when he is of a legal age. Also, to the doctors and nurses and whoever else talks about circumcisions to parents, DO NOT say it is not painful..orrr that babies dont feel pain...this is NOT true. Sorry for my rambling, this is such a painful thing I did to my precious precious baby. I almost lost him when I was 6 months gestation, and here I did this to him once he was born. He also had colic, problems sleeping, he had problems keeping his food in his stomach. I think this is attributed to the horrific thing I subjected him to...

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  30. I cried when i saw this.. i pray for this child.. i pray for this child's parents.. i pray that god fixes everything and helps the healing.. and the future of this family.. it would be nice to see other folks comment with their prayers..

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  31. Yes, we can pray that this child be healed of the nightmarish consequences of his parents' misguided decision to circumcise. But our prayers should not end here. Let us pray that mankind will awaken from the irrational obsession with maiming our children without medical necessity, violating their bodily integrity without their consent. Let us pray that we won't have to pray for repairs and healing after the fact when child genital mutilation finally ceases.

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  32. I had no idea what was involved in circumcision (both of my sons were circumcised before I ever even saw either of their intact p3nises. I never thought to research it because "it is just what you do to prevent infections, and it would be so much harder on them later in life"). No wonder the doctors do not allow parents to be present to comfort their children during this "procedure" My poor sweet babies. They thankfully did not have any complications. If I ever have any more boys they will remain intact.

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