Oct 18, 1993 - Abstract We report a rare compli- cation of ritual circumcision in an 8- week-old boy. He presented 1 week after the procedure with reduced.
Eur J Pediatr (1994) 153: 369-371 9 Springer-Verlag 1994
J. C. Craig W. G. Grigor J. F. Knight
Received, accepted: 18 October 1993
J. C. Craig (N~) 9j. F. Knight Department of Nephrology, The Royal Alexandra Hospital for Children, Pyrmont Bridge Road, Camperdown, Sydney, NSW 2050, Australia W. G. Grigor Department of Paediatrics, The Royal Alexandra Hospital for Children, Pyrmont Bridge Road, Camperdown, Sydney, NSW 2050, Australia
Acute obstructive uropathya rare complication of circumcision
A b s t r a c t We report a rare complication of ritual circumcision in an 8week-old boy. He presented 1 week after the procedure with reduced urine output, a grossly distended bladder and marked bilateral hydroureteronephrosis on ultrasonography. The acute partial urinary obstruction was due to the dressing which was applied after surgical removal of the foreskin and to oedema of the glans. He had abnormal renal function (creatinine 85 gmol/1, urea 8.5 mmol/1) and a hyperkalaemic metabolic acidosis with hyponatraemia (Na 127 mmol/1, K 6.9 mmol/1, HCO 3 16 mmol/1), which were attributed to
Introduction Circumcision remains one of the most commonly practised surgical procedures world-wide [12]. Opinion is divided on whether circumcision should be performed routinely on all newborn boys, or only on a sub-group of older boys who fulfill certain medical criteria such as recurrent balanoposthitis. Advocates for routine neonatal circumcision contend that it prevents urinary tract infections in infants, sexually transmissible diseases (including HIV infection), balanoposthitis, and cervical and penile cancer in adult life [14]. Opponents of routine neonatal circumcision assert that many of these benefits are unproven, and that the procedure itself carries with it certain risks that are not outweighed by the putative benefits [11]. The exact incidence of complications from circumcision is unknown. All published series are retrospective and the data presented is often incomplete. The reported incidence varies from 0.2%-38%, with haemorrhage and infection the most common [5, 10]. Generally the infections are
obstructive uropathy. Because of prolonged secondary bladder dysfunction he required urinary catheterisation for 1 week. There was significant post obstructive diuresis and parenteral fluid therapy was given for 7 days. Whilst urinary retention is a well recognised complication of circumcision, this is the first report of significant obstructive uropathy and renal impairment due to surgical excision of the foreskin. K e y words Circumcision Urinary retention Acute renal failure
local, but bacteraemia, meningitis, necrotizing fasciitis, scrotal abscess, disseminated staphylococcal and group B streptococcal sepsis have been reported [12]. Other complications include phimosis, concealed penis, skin bridge, urethrocutaneous fistula, penile necrosis, meatitis and meatal stenosis, chordee, inclusion cysts, lymphoedema, bivalve penis, hypospadias, epispadias, anaesthetic complications, gastric and bladder rupture, and death [3, 5, 9, 10, 12, 15]. We report a rare complication of circumcision, acute obstructive uropathy.
Case report An 8-week-old boy was referred with a 4-day history of diarrhoea that had commenced on the day following a circumcision, performed by a local doctor for religious reasons. The foreskin had been removed by surgical excision and a gauze bandage had been applied to achieve haemostasis. He had been commenced on oral flucloxacillin chemoprophylaxis. On examination, at that time, there was no evidence of urinary obstruction and he was discharged with a diagnosis of antibiotic
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Table 1 Plasma electrolyte values and renal function estimation after admission [all values given in retool/1 except Cr (gmol/1), and GFR (ml/min)] Time after admission (hours)
Calculated Cr
Urea
GFR
Na
K
HCO 3
6 12 24 48 56 69 93 114
70 85 67 49 44 37 40 40
7.8 8.9 8 5.6 4.6 4.6 2.1 1
34 28 36 49 54 65 60 60
127 126 128 129 129 127 135 139
6.2 6.9 5.9 5.7 6.7 5.6 4.7 3.7
16 17 18 22 19 13 19 21
associated diarrhoea. He was re-admitted 3 days later with a 2-day history of reduced urine output and a poor urinary stream. There was a clear history of a previously normal urinary stream. His bladder was percussible and palpable to the level of the umbilicus, the foreskin dressing was still in place and there was moderate oedema of the glans. His back, spine and neurological examination were normal. His weight was 560 g less (5.37 kg) than at the time of his first admission. An ultrasound examination confirmed a distended bladder with moderate bilateral hydro-ureteronephrosis. The circumcision bandages were removed after soaking and he voided. Later on the day of admission his voiding remained poor and his bladder was still clinically enlarged. An indwelling catheter was therefore inserted. Attempts at removing the urinary catheter over the following week were unsuccessful due to recurrence of urinary retention. A suprapubic bladder tap excluded an associated urinary tract infection and a plain X-ray of his lumbo-sacral spine was normal. Renal tract ultrasonography confirmed gradual resolution of his dilated upper tracts. His plasma biochemical abnormalities (Table l) were typical for partial obstructive uropathy. Hypoadrenalism was excluded (17-OH progesterone 11 nmol/1 (normal < 24 nmol/1), ACTH 8.8 pmol/1 (normal 2.0-11.0 pmol/1)). Plasma renin activity was markedly raised (> 7920 fmol/1/s (normal 2000 +/- 930 fmol/1/s)). A micturating cystourethrogram was normal apart from demonstrating incomplete bladder emptying. In addition to bladder drainage, management consisted of replacement of post-obstructive diuresis losses with half normal saline. Our patient was discharged on day 10 with normal plasma biochemistry, a persistently distended bladder on examination, but non-dilated upper tracts on ultrasonography. He was reviewed 2 weeks after his discharge, At this visit there was no abnormality on clinical examination or renal tract ultrasonography and he was discharged from further follow up.
Discussion We report an unusual case o f partial urinary obstruction due to circumcision, resulting in significant g l o m e r u l a r and tubular impairment, dehydration, and s e c o n d a r y bladder dysfunction in a n e w b o r n infant. Hyponatraemia, hyperkalaemia, metabolic acidosis and d e h y d r a t i o n are well r e c o g n i s e d c o m p l i c a t i o n s o f acute renal failure due to urinary obstruction, particularly when the obstruction is acute and partial. R e l i e f o f the obstruction often corrects the h y p e r k a l a e m i a , but m a y result in clinically significant post-obstructive diuresis with seco n d a r y renal salt wasting and excessive water loss [8]. The exact m e c h a n i s m s for these abnormalities are unclear. The clinical course o f this case was influenced b y his y o u n g age. The n e w b o r n k i d n e y has a l o w e r g l o m e r u l a r filtration rate, a r e d u c e d p r o x i m a l reabsorption o f sodium, and a r e d u c e d urinary concentrating ability c o m p a r e d with the mature kidney, resulting in a relative predilection for these electrolyte abnormalities [6]. The syndrome, which m i m i c s h y p o a l d o s t e r o n i s m , is well r e c o g n i s e d in the n e w b o r n child, and usually the p r o b l e m is hydronephrosis with or without infection [13]. In our case the urine was sterile and the obstruction was secondary to a c i r c u m c i s i o n dressing and o e d e m a o f the glans. Currently there are three m e t h o d s for c i r c u m c i s i o n in w i d e s p r e a d clinical use: the G o m c o clamp, the Plastibell device, and surgical excision [10]. A c u t e urinary obstruction has been reported as a c o m p l i c a t i o n o f the latter two methods only [1, 2, 4, 5, 7, 9, 10]. In m o s t cases r e m o v a l o f the dressing or the Plastibell d e v i c e was all that was required to relieve the obstruction. The r e m a i n d e r required a single urethral catheterisation. Escherichia coli sepsis c o m p l i c a t e d one case [7]: a 5 - y e a r - o l d b o y d e v e l o p e d acute renal failure and a ruptured b l a d d e r due to c o m p l e t e urethral obstruction f o l l o w i n g ritual c i r c u m c i s i o n using the Plastibell device [9]. We report the first case o f obstructive uropathy due to a c i r c u m c i s i o n p e r f o r m e d b y surgical excision. W h i l s t unc o m m o n and usually easily treatable, urinary retention p r o g r e s s i n g to obstruction with bilateral hydro-ureteronephrosis and renal dysfunction, is a potential significant c o m p l i c a t i o n o f circumcision.
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7. Horowitz J, Schussheim A, Scalettar J (1976) Abdominal distension following ritual circumcision. Pediatrics 57 : 579 8. Hsu CH (1990) Fluid and electrolyte abnormalities in obstructive uropathy and following urinary tract diversion. In: Kokko JP, Tannen RL (eds) Fluids and electrolytes, 2rid edn. WB Saunders, Philadelphia, pp 781-812 9. Jee LD, Millar AJW (1990) Ruptured bladder following circumcision using the Plastibell device. Br J Urol 65 : 216-217
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