A 39 4/7 week gestation healthy male infant was born without complications to a mother with a negative maternal history. He underwent circumcision at 44 hours using the Gomco surgical clamp technique and dorsal penile nerve block for anesthesia. The patient was discharged home 6 hours later. He comes to the emergency room now 2 days later after his parents noted that his penis, scrotum and lower abdomen had become extremely swollen and red. The pertinent physical findings reveal the penis, anterior 1/3 of the perineum and the scrotal sack are red, swollen, and have ulcerations and eschar of some involved areas. A skin leading edge of redness was noted. He is afebrile with normal vital signs. The laboratory evaluation later showed the leading edge and skin cultures growing Group A Beta hemolytic streptococcus thus the diagnosis of necrotizing fasciitis was made. The patient’s clinical course had no other concurrent invasive disease. He required only a small amount of skin tissue removal. The patient had good cosmetic results and was expected to have no urological functional problems in the future.
Necrotizing fasciitis is a severe, yet insidious, invasive soft tissue infection that may be polymicrobial but is often caused by Group A Beta hemolytic streptococcus, Staphylococcus aureus and Haemophilus aphrophilus. The organisms spread along the fascial planes. Deep infections can cause ischemia, tissue necrosis and vascular occlusion. Bacteremia, sepsis and other systemic problems may occur. The incidence is higher in infants and older persons and mortality can be as high as 25%. It requires emergent treatment including aggressive debridement, IV antibiotics and treatment for other invasive disease such as sepsis.
Circumcision is one of the most common surgical procedures performed in the United States. Routine infant circumcision is not recommended by many professional societies but many parents will choose to have it done because of religious, social, cultural or medical reasons.
The risks of infant circumcision include pain, bleeding, infection, cosmetic deformity (too little or too much of the foreskin is removed, partial amputation), and adhesions. As with any other surgical procedure, informed consent should detail the risks and benefits. Detailed instructions on how to take care of the circumcised penis consistent with the technique should be given. The parents should know whom to contact for questions. They should call if the child does not urinate normally in the first 6-8 hours of life, or if there are more than a few spots of blood on the diaper. They should also be told about the signs of infection such as swelling, redness, and/or foul-smelling discharge. A slight yellow coating around a reddened penis is normal for about the first week of life, but parents may not know this and should be told before going home.
Questions for Further Discussion
1. What patient care instructions should parents receive for an uncircumcised male infant?
2. What are the potential benefits of male infant circumcision?
3. What anesthesia is recommended for circumcision?
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Circumcision.
American Academy of Pediatrics. Circumcision: Frequently Asked Questions. Available from the Internet at: http://www.medem.com/medlb/article_detaillb.cfm?article_ID=ZZZ13FOPIUC&sub_cat=549 (rev.2001, cited 8/30/04).
American Academy of Pediatrics. Circumcision Policy Statement Pediatrics Volume 103, Number 3 March 1999, pp 686-693. Available from the Internet at: http://www.medem.com/medlb/article_detaillb.cfm?article_ID=ZZZ6HG9QE8C&sub_cat=549 (cited 8/30/04).
Peleg D, Steiner A. The Gomco Circumcision: Common Problems and Solutions. American Family Physician. 1998 Sep 15;58(4):891-8. Available form the Internet at: http://www.aafp.org/afp/980915ap/peleg.html (cited 8/30/04).
Schwartz RA, Kapila R. Necrotizing Fascitis Available from the Internet at: http://www.emedicine.com/derm/topic743.htm (rev. 3/11/04, cited 8/30/04).
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
September 30, 2004