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
Adhesions to the Glans
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
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.
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
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
These are removed though a small incision under general anesthesia.
Excess Skin
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.
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.
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
Too Much Skin Removed
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
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.
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.