Case Report Highlights Risks of Iatrogenic Hypospadias Following Traditional Circumcision in Young Child

Traditional circumcisions may cause complications such as hemorrhage, infection, amputations of the penis, meatal stenosis, and urethro-cutaneous fistula. In addition to all these complications, iatrogenic hypospadias, as in our case, is a rare condition. In general, complications are mild and preventable, especially in children, but when the procedure is carried out by unskilled providers, in unsterile conditions, or with inadequate equipment and supplies, severe complications are more likely to occur. Several degrees of urethral erosion, including iatrogenic hypospadias, might result from further injury. Particularly in intensive care facilities, the ventral male urethra can undergo this kind of trauma.

The case described involves a 4-year-old child who underwent circumcision at the age of 3 and subsequently experienced significant bleeding. Four months later, his parents took him to the hospital. Upon examination, the glans appeared normal, but there was an opening near the glans at the distal urethra, located at the subcoronal level.

After a thorough pre-operative evaluation, the child was prepared for elective surgery. During the procedure, an incision was made to expose the fistula tract, with marker sutures placed around the edges for guidance. The fistula opening was then repaired using 6/0 PDS (polydioxanone) sutures, and a second layer was created over the repair before closing the skin with 4/0 Vicryl (polyglactin) sutures.

Shukri Said Mohamed, Mogadishu Somali Turkey Recep Tayyip Erdoğan Training and Research Hospital, Mogadishu, Somalia, and colleagues emphasize that circumcision remains the most commonly performed procedure on children worldwide. However, injuries to the penis can occur, with a complication rate of approximately 1%. One of the leading causes of fistulas is a poorly placed suture at the frenulum, which aims to achieve hemostasis. This can result in strangulation and necrosis of part of the urethral wall, ultimately leading to the formation of a sub-glandular fistula. Prompt identification and treatment of any potentially life-threatening injuries to the urethra are crucial.

The authors conclude that circumcision, as a medical procedure, requires careful execution and should only be performed by qualified surgeons in sterile hospital environments. Most injuries associated with circumcision occur during clamp procedures, such as Mogen or Gomco, and can vary in severity from minor loss of penile skin to more severe injuries affecting the glans, distal urethra, or penile shaft.

Reference:

Mohamed SS, Sheikh OA, Adam MK, Ali AY, Mohamed AH, Mead A. A presentation of iatrogenic hypospadias after traditional circumcision: A case report. Ann Med Surg (Lond). 2022 Nov 12;84:104872. doi: 10.1016/j.amsu.2022.104872. PMID: 36582869; PMCID: PMC9793154.