Problems After Circumcision

Problems After Newborn Circumcision

Newborn circumcisions are done using various devices (Gomco, Plastibell, Mogen) to remove the foreskin. All leave a small remnant of the foreskin as a collar around the penis just under the head.
The reason newborns with abnormal foreskin, such as those with hypospadias and chordee without hypospadias, should not be circumcised is because these devices do not function properly when part of the foreskin is missing.

These devises are very reliable when used by experienced practitioners. In most cases when parents become concerned that not enough skin was removed, the appearance is due to the fat pad that normal infants develop and the skin will look more “normal” with time. Revision of a circumcision is rarely needed.

A variety of minor skin issues can occur after newborn circumcision. Rarely, more severe injuries to the head of the penis and even the urine opening, occurs during the circumcision. These are all discussed below.

Secondary Phimosis

Adhesions to the Glans

Skin Bridges

Skin Tags after Plastibell Circumcision

Epitheliomas

Excess Skin

Too Much Skin Removed

Meatal Stenosis

Injury to the Head or Urine Opening

Secondary Phimosis

The skin edges are not sutured after newborn circumcision. Occasionally, early after the circumcision, these edges will separate and heal over the head of the penis, forming a scar that hides the head. Most often, steroid cream applied twice daily for 6 to 12 weeks will soften the scar and allow the skin the return to a normal position without corrective surgery.

Adhesions to the Glans

The “collar” of inner foreskin that remains under the head of the penis after circumcision can “stick” back to the edge of the head, as shown here. This is not scarring, and it will resolve on its own. Smegma typically builds up between the head and the foreskin to separate them, and care-givers will see small white dots at the ends of the adhesion.

Adhesions do not mean the parents failed to “pull back” the skin after newborn circumcision, which is not necessary to do. These can be separated by force, but tend to come back. These adhesions cause no health problems and can be ignored.

Skin Bridges

Sometimes a part of the penis skin will heal attached to the head of the penis, creating a skin bridge.

These are usually at 12 o’clock and short, as shown in the first picture. However, they can extend for a longer distance, or even go completely around the penis.

Smegma collects under the bridge, and boys may play with these by inserting various items under the bridge as though they have been pierced.

For smaller bridges, topical anesthesia cream can be applied and then the bridge cut open with scissors painlessly, in the outpatient office. More extensive bridges are best opened under general anesthesia. They do not recur.

Skin Tags after Plastibell Circumcision

A small bump of skin at 12 o’clock after circumcision indicates a Plastibell device was used for the procedure. This method involves tying a string tightly around a plastic ring protecting the head. Sometimes, the skin right under where the knot was tied does not slough as expected, but instead creates this bump.

Topical anesthesia cream can be applied to this area in the outpatient clinic, and then the skin tag can be removed. It is usually not necessary to sew the wound, which heals spontaneously.

Epitheliomas

An occasional infant will develop a lump under the skin in or near the line of the newborn circumcision. This will gradually grow larger over time, but is not painful. These are called epitheliomas, and are small bits of skin that somehow end up under the incision and then grow. Why they occur in a very small percentage of boys after newborn circumcision, but are very rare after circumcision or other penis surgery done in infants and older patients, is not known.

These are removed though a small incision under general anesthesia.

Excess Skin

Many parents express concern that their son’s newborn circumcision did not remove enough skin. As mentioned earlier, the devises used to do these procedures function reliably, and in most cases the skin length is correct.

Penis skin is relatively loose, to allow erections. When normal baby fat appears around the penis at approximately 6 months of age, the penis appears shorter and the skin is pushed outwards, sometimes hiding the head and giving the impression of too much skin.

Here is a typical example showing the penis nearly completely hidden by baby fat. Realizing the penis in infants is only one and a half inches long, it does not take much to hide it! In this case, when that fat is pushed away, it is immediately clear that there is no excess skin.
Some pediatric urologists and surgeons will recommend a “phalloplasty” to place a few stitches at the base of the penis to tack the skin so that the fat does not hide it. However, the normal chubbiness of these infants goes away as they become toddlers.

Parents should also know that teens do not have problems with fat hiding the penis as they progress through puberty, unless they are obese – which is the same situation as in adult men.

In this case, that same maneuver to push back the fat shows there is excess skin that completely covers the head. Circumcision revision is an option to remove this half inch of skin.

Too Much Skin Removed

Occasionally, too much skin is removed during newborn circumcision. When this occurs, most often nearly all the skin on the underside is missing. Usually, the practitioner recognizes the situation and stitches the skin edges back together.

Although a large part of skin has been removed (arrow), skin revision with skin grafting or a skin flap is almost never required. Rather, the available skin appears to regenerate or stretch and the final appearance usually is quite normal.

Meatal Stenosis

During toilet training, some boys pee with the stream deviated upwards, shooting over the top of the toilet when they are aiming directly into it. These boys then push their penis down between their legs trying to hit the toilet.

The urine opening in these boys appears small, but calibrates to a normal size, so there is no “stenosis”. Rather, there is a web of skin across the bottom half of the opening (“meatus”) that deflects the urine up.

Textbooks suggest this is a consequence of irritation at the urine opening following circumcision, in part because uncircumcised boys do not have this problem. However, uncircumcised boys rarely pull their skin back as they pee, and so any deviation is likely re-directed as the urine exits the opening in the foreskin.

Furthermore, it is very unusual for a teenager to complain of upward deviation of the stream, suggesting that this problem resolves itself at puberty. Nevertheless, the difficulty aiming so that the urine goes into the toilet can be managed in younger boys with a simple, painless, snip in this skin as a brief office procedure using topical anesthesia cream. The problem almost never recurs afterwards. “Meatotomy” or “meatoplasty” under general anesthesia can almost always be avoided.

A better term for this condition would be “meatal webbing”.

Injury to the Head or Urine Opening

Fortunately, injuries to the head of the penis are very rare during newborn circumcision. Nearly all result from the Mogen clamp, especially when it is used by a relatively inexperienced practitioner, such as a trainee.

When it happens, usually only the very tip of the head is cut off, and the urine opening is not injured. But more extensive injuries can occur, which include both the head and the urine opening. In the most extreme case, the entire head can be cut off.

When the injury is recognized, the piece of tissue can be placed on ice and promptly sewn back into place by a pediatric urologist or surgeon.
Given that Gomcos and Plastibells do not cause this injury, it is a reasonable recommendation that medical professionals not use the Mogen.

Here is an example of an injury from a Mogen that removed part of the head and urine opening, requiring several reconstructive operations.