Complications following circumcision: Presentations to the emergency department – Gold

Gold reported on complications following circumcision presenting to the Emergency Department at the Royal Children’s Hospital, Melbourne, Australia, between 2012 and 2014.

Over a 29-month period, 167 children with a circumcision-related ED presentation. Mean age was 3 years. 54.5 of circumcisions had been performed for non-medical, 29.9% for medical reasons and 14.4% for reasons unknown. When location was known (n = 152), 60.5% were performed in the community and 39.5% in hospital. Reasons for presentation were: bleeding (53.9%), pain (38.3%), swelling (37.1%), redness (25.7%), decreased urine output (13.8%), fever (7.2%) and pus (6%). 29.9% were diagnosed as normal healing post circumcision. Patients were admitted in 39.1% versus 15% (P = 0.001) and re-operated in 18.5% versus 1.7% (P = 0.001) after community- versus hospital-operated circumcisions.

The authors concluded “Parents would have profited from better explanation of post-circumcision appearance of the penis”.  Joining the many authors who have failed to recognised that the way to avoid complications of unnecessary circumcision is to avoid unnecessary circumcision.

Background

Circumcision is the most common surgical procedure performed on boys in Australia. Patient presentations to the emergency department (ED) following circumcision are common; however, no Australian research has investigated acute care presentations.
Objectives

To identify reasons for presentation to the ED after circumcision and determine whether the setting (community vs. hospital) in which the procedure had been performed has any bearing on the sequelae seen.
Methods

Retrospective chart review of children presenting with circumcision related problems to the Royal Children’s Hospital, Melbourne, Australia, between 2012 and 2014. Descriptive and χ2 analysis included sequelae of community- versus hospital-performed procedures.
Results

Over a 29-month period, we identified 167 children with a circumcision-related ED presentation. Mean age was 3 years. A percentage of 54.5 had been performed for non-medical, 29.9% for medical reasons and 14.4% for reasons unknown. When location was known (n = 152), 60.5% were performed in the community and 39.5% in hospital. Reasons for presentation were: bleeding (53.9%), pain (38.3%), swelling (37.1%), redness (25.7%), decreased urine output (13.8%), fever (7.2%) and pus (6%). 29.9% were diagnosed as normal healing post circumcision. Patients were admitted in 39.1% versus 15% (P = 0.001) and re-operated in 18.5% versus 1.7% (P = 0.001) after community- versus hospital-operated circumcisions.
Conclusions

A range of reasons cause patients to seek help in the ED following a circumcision. Parents would have profited from better explanation of post-circumcision appearance of the penis. ED presentations after community-performed procedures required more re-operations than after hospital-performed circumcisions.

Read more at: Complications following circumcision: Presentations to the emergency department – Gold – 2015 – Journal of Paediatrics and Child Health – Wiley Online Library

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Update, 09 December 2015: A certain Brian Morris has written to say the answer to circumcision complications is, wait for it, more circumcisions:

The recent paper by Gold et al. on complications following circumcision [1] raises important issues.
Firstly, since circumcision based on parental choice is not currently permitted in public hospitals, the 54.5% performed for ‘non-medical reasons’ and a proportion of the 14.4% for ‘reasons unknown’ would have been ‘community procedures’. The circumcisions for medical need (29.9% overall) would have been prevented by neonatal circumcision.
Secondly, although the authors state that, ‘circumcision is the most common surgical procedure performed on boys in Australia’, there were only 167 children with a circumcision-related emergency department presentation during 29 months. All of the complications were minor and immediately and completely treatable with the expectation of complete resolution, and for 29.9% of community procedures were part of normal healing. The complication rate was not ascertained. Data from the Centers for Disease Control and Prevention (CDC) found that of 1.4 million circumcisions, 93.3% in newborns, incidence of complications was 0.4% in infancy, but 9.1% at ages 1–9 and 5.3% after age 10 [2]. Boys in the present study were aged 3.0 ± 4.3 standard deviation years. This implies most of the complications observed would have been avoided by neonatal circumcision.
Thirdly, failure to make elective circumcision available in public hospitals has the inevitable consequences of: (i) no back-up facility to deal with rare serious complications; and (ii) a decline in circumcision among the poor. A recent study found Medicaid defunding in 18 states in the United States was responsible for a decline in circumcision in populations most
adversely impacted by infections and conditions circumcision protects against [3]. While circumcision was maintained in families with health insurance, the authors attributed the decline in circumcision in these 18 states to the neutral American Academy of Pediatrics (AAP) policy statement in 1999. Similarly, negative Royal Australasian College of Physicians paediatric policy statements explain the axing of elective circumcision as an allowable procedure in all Australian public hospitals. Gold et al. should be aware that the 2012 AAP policy found bene ts exceed risks. The CDC recommendations reported a bene t–risk of 100:1.
Fourthly, the consequences of current barriers to elective circumcision in Australia and New Zealand will be higher costs to the health system for treatment of adverse medical conditions, infections and genital cancers able to be prevented or reduced were neonatal circumcision universal. This scenario has been documented in the United States [4,5].
We suggest current policies preventing in-hospital neonatal
circumcision are skewing the age towards later, more expensive,
medically indicated circumcisions.

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2015-07-31T12:16:11+00:00

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