Post Traditional Circumcision Penile Skin Degloving in a Five Year Old Boy: Short Discussion

Abstract

Circumcision is the surgical removal of the prepucial skin of the penis, some of the complications of traditional circumcision includes; sepsis, genital mutilation, redundant prepuce, gangrene of penis, excessive bleeding, penile amputation or urinary retention, others include loss of penile sensitivity, metal stenosis, and urethrocuteneous fistula. Among the documented complications we did not come across complete degloving of the penile skin, as we found in this 5-year-old patient, who had traditional circumcision with application of some concoction on the penis leading to sloughing of the entire penile skin. A case report of 5-year-old Hausa Muslim boy who after penis skin avulsion presented with a 5 days history of a penile swelling and pain with discharge of purulent material, following a traditional circumcision and application of a concoction on the penis. Examination revealed acutely ill looking boy who was crying warm to touch, he has a degloved penis with sloughs and purulent discharge, the external urethral meatus was partly covered by crust and blood clots, no active bleeding and a diagnosis of post-circumcision degloved penis was made and patient was admitted. Patient was planned for reconstruction and penile coverage with split thickness skin grafting which he had on 5th day of admission, he was placed on parenteral antibiotics, analgesic, and intravenous fluids and graft site was dressed with Vaseline gauze and he was discharged on 7th day post-operative.

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32 International Journal of Dental and Medical Specialty Vol 2 ● Issue 2 ● Apr-Jun 2015
Post Traditional Circumcision Penile Skin Degloving
Post Traditional Circumcision Penile Skin Degloving
in a Five Year Old Boy: Short Discussion
in a Five Year Old Boy: Short Discussion
Muhammad Ujudud Musa1, Abdulkadir Abubakar2, Bashir Yunusa2
Department of Surgery, Urology Unit, 1Federal Medical Centre, Katsina State,
2Aminu Kano Teaching Hospital, Kano State, Nigeria
ABSTRACT
Circumcision is the surgical removal of the prepucial skin of the penis, some of the complications of traditional circumcision
includes; sepsis, genital mutilation, redundant prepuce, gangrene of penis, excessive bleeding, penile amputation or urinary
retention, others include loss of penile sensitivity, metal stenosis, and urethrocuteneous fi stula. Among the documented
complications we did not come across complete degloving of the penile skin, as we found in this 5-year-old patient, who
had traditional circumcision with application of some concoction on the penis leading to sloughing of the entire penile skin.
A case report of 5-year-old Hausa Muslim boy who after penis skin avulsion presented with a 5 days history of a penile
swelling and pain with discharge of purulent material, following a traditional circumcision and application of a concoction on
the penis. Examination revealed acutely ill looking boy who was crying warm to touch, he has a degloved penis with sloughs
and purulent discharge, the external urethral meatus was partly covered by crust and blood clots, no active bleeding and a
diagnosis of post-circumcision degloved penis was made and patient was admitted. Patient was planned for reconstruction
and penile coverage with split thickness skin grafting which he had on 5th day of admission, he was placed on parenteral
antibiotics, analgesic, and intravenous fl uids and graft site was dressed with Vaseline gauze and he was discharged on
7th day post-operative.
Key words: Degloving, graft, penis, traditional circumcision
INTRODUCTION
Circumcision is a surgical method in which portion
of the foreskin (removal of preputial skin) is removed
leaving the glans penis uncovered commonly
done in Muslims, Catholics Jews and some other
communities.[1,2] It is most widely believed that, if a
person is circumscribed in childhood, the foreskin of his
penis can sprout up again. If a person is circumscribed
in early age, his body will be stunted though it may
get bigger. This allows for repair and healing of
damaged tissues and reduces the risk of infections. The
procedure can be performed as preventive measures
where there is chance or potential for infection of the
penis due to poor hygiene. The penis is sumptuously
supplied with blood, and the potential post-operative
problems are hemorrhage and infections.
Traditional circumcision (initiation) is an essential part
of the Xhosa-speaking communities. Circumcision
is the first step toward manhood. It involves some
cultural, legal, religious and ethical issues and are rights
that must be protected in terms of the Constitution of
the Republic of South Africa.[3,4]
Circumcision is one of the oldest surgical procedures
performed, and the early Egyptian mummies were fund
to be circumcised. In rural Sub-Saharan Africa surgical
circumcisions are generally safe performed mostly in
the urban centers, whereas traditional circumcision of
Address for correspondence:
Dr. Muhammad Ujudud Musa, Department of Surgery, Urology Unit, Federal Medical Centre, Katsina P.M.B 2121,
Katsina State, Nigeria. Phone: +2348036005365, E-mail: ujudud@gmail.com
Submission: 02 Apr 2015; Revision: 21 May 2015; Acceptance: 30 May 2015
Short Discussion
Access this article online
Publisher
Website:
www.renupublishers.com
DOI:
10.5958/2394-4196.2015.00015.1

Ujudud, et al.: Penis skin degloving
International Journal of Dental and Medical Specialty Vol 2 ● Issue 2 ● Apr-Jun 2015 33
males is common amongst many rural societies where
it is seen as a rite of passage to manhood.[5]
Among the documented complications of both
orthodox and traditional circumcision we did not come
across complete degloving of the entire penile skin, as
we found in this 5-year-old patient, who had traditional
circumcision with application of some concoction on
the penis leading to sloughing of the penile skin.
Injury to penis or degloving of the penis, scrotal skin or
both are rare, often requiring reconstruction and occurs
mainly due to trauma (industrial and/or agricultural
machinery), sports injury, fight or can be iatrogenic.
Such type of injury to the penis is incapacitating and
has a devastating psychological impact.[6]
Toddlers and young persons are usually victims.
Degloving describes a potential severe injury in which
an unrestricted area of skin is torn from its underlying
attachments consequently depriving it of its blood
supply.[7]
The treatment options commonly employed includes are:
• Degloved skin either as flap or as free skin graft
• Free split skin graft
• Free full-thickness skin graft (Wolfe Graft)
Various surgical management of penis:
• Sub-coronal degloving incision
• Direct incision over the defect
• Inguino-scrotal incision
• Corporoplasty or plication procedures
• Plaque incision or excision with grafting
• Penile prosthesis insertion with plaque modeling or
incision with or without grafting.
CASE REPORT
A 5-year-old Hausa Muslim Child, who resides with his
parents in Hotoro with no underlying illness, presented
a history (given by their parents) of a penile swelling
and pain with discharge of purulent material and of
offensive odor. History reveals a 5 days back traditional
circumcision of the child penis and application of
a concoction on the penis that was focused only on
achieving hemostasis.
By the description given by their parents, the patient
was said to be crying a day after the circumcision
excessively, and the mother noticed the swelling of
the penis. Two days prior to presentation the mother
noticed a mucopurulent discharge from the swollen
penis with associated foul smelling and the child was
also crying on micturating.
On the 5th day post-circumcision, the penile swelling
ruptured and was bleeding unhealthy granulation
tissue and the child was crying excessively necessitating
them presenting to the hospital. There was no previous
history of crying on micturation’ or abnormal, excessive
bleeding, no history of trauma to the penis and sickle
cell anemia.
Physical examination revealed acutely ill-looking boy
who was crying warm to touch (temperature 37.8°C)
no pedal edema, the abdomen was full moving with
respiration no renal angle or suprapubic tenderness,
he has a de globe penile with sloughs and purulent
discharge oozing, the external urethral meatus was
partly covered by crust and blood clots, there was no
active bleeding, both testicles was intra scrotal and
non-tender, a diagnosis of post-circumcision degloved
penis was made, and patient was admitted as shown
in Figure 1a.
On routine blood investigation and laboratory findings
which includes blood, urine analysis, etc. we found
that packed cell volume was 34%, urea, creatinine
and electrolytes were essentially normal, wound
swab microscopic/culture/sensitivity (M/C/S) culture
Escherichia coli that was sensitive to augmenting.
Patient was commenced on BD dressing intravenous
antibiotics and analgesics he was also catheterized
with size 6F Foleys urethral catheter for intermittent
bladder drainage. No history of urethral catheterization
was found.
On the 3rd day of hospital admission the fever subsided,
purulent discharged was reducing, and the patient’s
general condition improved as shown in Figure 1b.
Repeat wound swab M/C/S showed no organism
isolated on the 4th day of admission and the wound
Figure 1: (A and B) Showing degloving of penis
b
a

Ujudud, et al.: Penis skin degloving
34 International Journal of Dental and Medical Specialty Vol 2 ● Issue 2 ● Apr-Jun 2015
was granulating well as shown in Figure 2. Patient was
planned for split thickness skin grafting that he had
on 5th day of admission, he was placed on parenteral
antibiotics and analgesia and intravenous fluids and
graft site was dressed with Vaseline gauze as shown in
Figure 3. Immediate post-operative was uneventful,
and the vital sign were within normal range patient was
commenced oral feeds 24 h post-operative.
On the 5th post-operative day the graft site was
inspected and found to have about 95% graft take
with no evidence of infection, the child did remarkably
well and was discharged on 7th day post-operative.
Daily dressing with povidone iodine wrung gauge was
commenced.
DISCUSSION
The penis comprises three erectile columns, namely the
corpus spongiosum and paired corpora cavernosa. It is
surrounded by facial layer, nerve, lymphatics, and blood
vessels and covered by skin. The penis is supported at
its base by the penile suspensory ligaments.
Rashid and Sarwar reported the classification of male
genitalia injury by anatomical location.[8] Type I injury
includes a distal portion of the penis with the proximal
part of the penis being preserved. Type II injury includes
severe injury on the shaft of penis with penile crush
being preserved. Type III injury includes the injury
when urethral catheterization is necessary with the
external urethral part being preserved. Type IV injury
includes the injury when suprapubic cystostomy is
needed.[4] However, this classification could not reflect
the nature of injury mechanism such as penetrating or
strangulation injury.
Superficial or partial penile injury can be treated
with suturing and wound dressing after exploration.
More extensive injuries including urethral and corpus
cavernous can be treated by free transfer flaps and
different grafts. Penile amputation, whether it is partial
or total, requires complex and skilled reconstructive
techniques including phalloplasty.[9-11]
Expeditious and prudent post-operative care is needed
to avoid delayed complications such as infection,
curvature, erectile dysfunction, unrecognized urethral
injury, and chronic pain. Severe penile injury might
be associated with adjacent comorbidity involving
the scrotum, pelvis, buttocks, and thighs. In these
scenarios, delicate surgical skill with staged treatment
is needed.[12]
The aim of the reconstruction in penile injury is
to embody an esthetically acceptable shape, to
obtain normal or near normal functional outcomes
including erection and sensation, and to minimize
the post-operative sequel including fistulae or urethral
strictures.
Circumcision is one of the most common surgeries in
urology, which is usually a safe and simple procedure
with low morbidity. However, serious complications
can occur because unprofessional practice performs
it.[13] The penile injury from circumcision is diverse:
from infections to disfigurement or partial to total
amputation of the penis.
Our patient presented with a unique presentation
which is complete degloving of the penile skin
following a traditional circumcision and application
Figure 2: Showing the Skin Graft
Figure 3: Post operative image showing placement of skin graft

Ujudud, et al.: Penis skin degloving
International Journal of Dental and Medical Specialty Vol 2 ● Issue 2 ● Apr-Jun 2015 35
of a traditional concoction, as opposed to 3 cases of
partial penile skin deglobing reported by Sotolongo
et al. secondary to ritual circumcision by Mohel[12]
[A mohel is a Jewish man trained in the practice of Brit
milah (circumcision)].
Gearhart and Rock[14] reported the post-operative
complication rate as 0.2-0.6%, which ranges from
bleeding, lymphedema, fistula formation, and
iatrogenic hypospadias to the partial or complete
amputation of the glans penis.[15,16] El-Bahnasawy and
El-Sherbiny[12] reported the largest series of pediatric
penile injury. Sixty-four boys with penile injury were
hospitalized over 20 years and among them 43 boys
(67%) had a penile injury caused by circumcision.
Although circumcision is regarded as a minor surgical
procedure, it is not free of complications. Urologists
have to pay more attention to reducing the complication
by circumcision. Penile injury by circumcision also can
have lifetime functional, psychological, and cosmetic
sequel.
Although in a study by Williams et al.[17] they described
penile skin denudation in medical circumcision as
a result of failure to break down the ventral foreskin
adhesions to the glans penis completely, as such they
advocated that the inner preputial epithelium be
completely free from the glans such that the entire
coronal sulcus can be visualized while in a study by
Gee and Ansell reported one child with complete
denudation of the penile skin, which was treated
initially by burying the penis in a scrotal skin tunnel
and a complete denudation in adult male was managed
by split thickness skin grafting. Hemorrhage and sepsis
are the commonest complications and are considered
in greater detail below.[17] The nature of circumcision
dictates that errors of omission and commission,
i.e. too little or too much, is assessing how much
foreskin to remove are likely to happen, and one of
the most common complaints is of an unsatisfactory
cosmetic result. If the insufficient foreskin is removed
the cosmetic appearance is such that the penis does
not appear to be circumcised; phimosis may still
subsequently develop.[17]
The actual active ingredient contained in the
traditional concoction used for our patient is not
known however some of the traditional concoctions
include maize leaves, neem tree leaves or eucalyptus
tree others use back of some trees while some use a
mixture ash and ghee and sometimes animal dungs
with its attendant risk of infection. They also have a
higher risk of testicular torsion and trauma or it may be
a harbinger to a more serious congenital anomaly such
as ectopia vesicea, prunebelly syndrome or disorder of
sexual development and differentiation.[18]
Our patient presented septic necessitating parenteral
antibiotics, analgesics and daily wound dressing with
remarkable improvement as evidenced by healthy
granulation tissue and negative wound swab microscopy
culture and sensitivity 5 days on admission and we also
catheterized the patient to divert the urine.
We prepare the patient and he had split thickness skin
graft using the medial aspect of the thigh skin of the
patient as a donor the graft take was excellent about
96% and our patient did well and was discharged
home and at follow up the wound has healed without
sequel.
The aim of penile circumcision is to surgically cut
enough shaft skin and inner preputial epithelium so
that the glans is sufficiently uncovered to prevent
or treat phimosis and render the development of
paraphimosis impossible.[19] Although there are many
different techniques of circumcision, they can be
broadly classified into four types: dorsal slit, shield,
clamp, and excision. Although many of the methods
are not used in urological practice, the urologist
will occasionally be faced with their complications.
POINT TO NOTICE
Nurses should do a thorough abdominal and scrotal
examination of new born male infants from birth upto
age of atleast one to two years for early detection of
undescended testis and any infection in penis.

Ujudud, et al.: Penis skin degloving
36 International Journal of Dental and Medical Specialty Vol 2 ● Issue 2 ● Apr-Jun 2015
He must, therefore, be familiar with the different
techniques, their specific advantages, and pitfalls.[19]
To prevent complications with whatever technique
is preferred, four principal factors should be strictly
adhered to; attention to aseptic conditions, adequate
but not excessive excision of outer and inner preputial
layers, meticulous hemostasis and protection of the
glans penis and the urethra.[19]
CONCLUSION
The cultural practices which are harmful to life
contravene the norms of society, and must be changed
sooner. In terms of the Constitution of the Republic
of South Africa, everyone has a right to life. That right
to life cannot be sacrificed at the altar of culture and
politics. There is a serious health crisis that is going on
in South Africa in relation to the ritual of circumcision.
The government or traditional leaders, or both must
take bold steps to resolve the problem and prevent
these avoidable deaths and disabilities among Xhosa-
speaking boys in these areas. It is always dangerous to
mix culture with politics.
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How to cite this article: Musa MU, Abubakar A, Yunusa B. Post traditional
circumcision penile skin degloving in a fi ve year old boy: Short discussion.
Int J Dent Med Spec 2015;2(2):32-36.
Source of Support: None; Confl ict of Interest: None