Paediatr Child Health Vol 12 No 4 April 2007 Coroner's Corner Circumcision: A minor procedure? Paediatric Death Review Committee: Office of the Chief Coroner of Ontario A male infant at 37 weeks' gestation was born ... weighing 3.9 kg, with Apgar scores of seven at 1 min and nine at 5 min, Prenatally mild bilateral dilation of renal pelvises and ureters was noted on ultra­sound. A urology consultation at 36 weeks' gestation sug­gested a possible normal variant ... The baby was bottle-fed and was reported to he doing well when he was circumcised using a PlastiBell ring (Hollister, USA) at 10:00 on the seventh day of life (Figure 1).

Figure 1. (Click to enlarge) Local anaesthetic was not used. Some slight ooz­ing was noted during the procedure but it was not a problem at discharge. Five hours later, the parents returned to their family doc­tor with the infant, reporting that he was very irritable and had blue discolouration below the umbilicus [navel] when he cried. The doctor confirmed this observation and noted that the penis was slightly swollen. ... He had several loose stools, and it could not be determined with certainty whether he had voided [emptied his bladder]. ...The baby was subsequently discharged home. The infant was brought to a different hospital 14 h after the circumcision. He was now noted to be extremely irrita­ble, with marked swelling of the penis and with marked swelling and cyanosis [blueness] of the scrotum and perineum [region behind the scrotum]. He had grunting respirations and was cyanotic below the umbilicus ... He was transferred to a tertiary care centre, where the bladder was identified as being distended to the level of the umbilicus, The PlastiBell ring was removed 16 h after the circumcision and a catheter was passed. The bladder was drained and the bluish coloration below the umbilicus sub­sided. Urine volume was not recorded. Over the next few hours, the infant went into septic shock with purpura fulminans, and went on to develop multiorgan failure and dis­seminated intravascular coagulopathy [a state of increased propensity for blood-clot formation] ... He died seven days after his circumcision from hypoxic-ischemic encephalopathy [damage to cells in the brain and spinal cord from getting too little oxygen]. ... Complications of meatal obstruction [blockage of the urinary opening of the glans] with the PlastiBell technique have been previously described in the literature (1,2). Necrotizing fasciitis as a complication of circumci­sion is rare, and all cases reported seem to be associated with the PlastiBell technique (2,3) The finding of cyanosis below the umbilicus after circumcision due to meatal obstruction caused by a misplaced PlastiBell ring resulting in bladder distension and obstruction of venous return has also recently been described (1). A review of circumcision complications suggest that these may occur mote frequently than is conventionally believed (2,4) The members of the Paediatric Death Review Committee of the Office of the Chief Coroner of Ontario were collectively aware of complications from their own institutions, including two children with necrosis of the glans, two infants requiring transfusion, one infant with a buried penis secondary to circumcision, numerous cases of retention of a PlastiBell ring, one infant with a slipped PlastiBell ring causing a penile tourniquet, and one infant with meatal obstruction due to a misplaced PlastiBell ring (Figures 2A and 2B).

Figure 2. (Click to enlarge) None of these complications were reported in the medical literature and are therefore not available in a retrospective literature review. It is concern­ing that none of the initial three physicians who saw this infant, including the physician who performed the procedure, identified this problem as a meatal obstruction, although they were all concerned about, a possible link with the recent circumcision. In this infant, there was no description of the glans by the physician removing the PlastiBeil ring. If the foreskin is pulled too tight, then there will be considerable tension pulling the ring against the glans, thus compressing the ure­thra and making urination difficult or impossible. This is the mechanism described in the case report by Ly and Sankaran (I) We propose the mechanism shown in Figure 2B, given the rapid onset of symptoms, suggesting a complete obstruction. These coukl be differentiated clinically. In Figure 2A, the meatus would be visible in the mid­dle of the ring and a catheter would be difficult or impossible to pass. In Figure 2B, the meatus would not be visible. The management of both complications would be the immediate removal of the PlastiBell ring. Perhaps a prospective surveillance study by the Canadian Paediatric Society of the complications of circumcision is warranted. Such a study would provide more accurate information for the ethical requirement of informed consent. [Perhaps a ban on non-therautic neonatal circumcisions by members of the Canadian Paediatric Society is warranted. As the headline implies, this is not a minor procedure.]