Ch. 4: Immediate Complications of Circumcision (DOC Genital Integrity Statement)

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Chapter Four: The Immediate Complications of Circumcision

The immediate complications of circumcision may be classified as hemorrhage, infection, surgical mishap, other miscellaneous complications, and death.


The foreskin is highly vascularized,1 so hemorrhage is a particular problem and risk when the foreskin is cut. An artery that passes through the frenulum to provide blood to the glans penis is in danger of being severed.2 Williams & Kapila (1993) report bleeding to be the most common problem associated with circumcision.3

Special clamps are used to crush the skin to provide hemostasis. Old clamps may be worn, deformed, and fail to provide adequate crushing and hemostasis.4 When using the Plastibell® device, failure to tie the string tightly may result in bleeding.5

When a newborn is circumcised, there is great danger from bleeding because the prepuce is highly vascularized and because an infant’s body contains only 85ml/kg of blood.6 With so little total blood volume, a small loss of blood may cause exsanguination, hypovolemia, hypovolemic shock, and death.7-9 The coroner of Dade County, Florida reported the death of an infant from hemorrhage.7 Hiss et al. reported a hemorrhage followed by death.8 The coroner of British Columbia reported the death of a one-month-old infant from bleeding, exsanguination, hypovolemic shock, and multiple organ failure.9


Infection may range from the trivial to the life-threatening systemic infection.3

Life-threatening infections, includind septicemia and meningitis,10,11 tuberculosis,12,13 wound diphtheria,14 staphylococcus,15 and streptococcus,16 pyoderma17, impetigo,18,19 and scrotal abscess with salmonella infection,20 also have been reported. Scurlock & Pemberton (1977) reported a death from meningitis.11 The coroner of Ontario reported the death of a two-week-old infant from infection with Escherichia coli, intravascular coagulopathy, and hypoxic-ischemic encephalopathy.21

There are several reports of a significant increase in urinary tract infection (UTI) after ritual circumcision.22-24

Necrotizing fasciitis25-27 and Fournier’s gangrene (gangrene of the scrotum) have been reported.28 Such infections require extensive debridement (surgical excision) of infected tissue, if the patient is to survive.25-28

Circumcision infections may be spread by hospital workers.16,29,30,32,33 Hospitals are increasingly infected with antibiotic-resistant pathogens. St. Catherines’s Hospital on Long Island experienced an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) among circumcised boys in the hospital nursery.31 Any invasive procedure increases the risk of MRSA infection in the newborn nursery.32 Boys who are circumcised have a twelve-times greater risk of CA-MRSA infection.33

Surgical Accident

Circumcision is an imprecise surgical procedure. It is difficult to judge the amount of skin to excise. One problem is the removal of excess skin,3 which may denude the entire shaft of the penis and require an immediate corrective operation by a urologic specialist.34-36 Circumcision may also result in injuries to the urethra, including urethral fistula,37-39 which requires corrective surgery by a urologic specialist. A case of bivalving the glans penis caused by inserting the scissors into the urethra has been reported.40

Due to the difficulty in judging the correct amount of skin to excise, sometimes so little skin is removed that the penis does not appear to be circumcised. This may generate parental complaints and requests for a re-circumcision, although there is no medical indication for the second circumcision. Leith (1970) reported that, in his study of 200 circumcisions, 19 were recircumcisions.41 There is danger of painful erections if too much skin is removed.

More serious surgical mishaps include excision of part of the penis42-45 or glans penis,46-48 necrosis of the glans penis,48 necrosis of the penis caused by electrocautery devices,49-51 and total ablation or amputation of the penis.52


Death may be the result of either bleeding7-9 or infection.11,12,15,21 There is no central registry of circumcision deaths, so the incidence of death from circumcision is controversial. Williams & Kapila (1993) characterize death as “rare.”3 Gairdner (1949), however, reported 16 deaths annually in Britain in the 1940s.53 Circumcision deaths may be attributed to bleeding or infection rather than the underlying circumcision. Few doctors are willing to acknowledge death from an elective, unnecessary, non-therapeutic, allegedly “minor,” surgical procedure. Gellis (1978) estimated there are more deaths from circumcision than from cancer of the penis (which would mean more than 200 deaths per year).54 (Prevention of penile cancer is not a valid excuse for circumcising. See Chapter 3.) Baker (1979) argued that there are at least 229 deaths per year in the United States from circumcision.55 Bollinger (2010) estimates 114 deaths in the United States annually from circumcision-related causes.56


Miscellaneous immediate complications of circumcision include life-threatening pulmonary embolism,57 apnea and projectile vomiting,58,59tachycardia and heart failure,60 pneumothorax,61 and gastric rupture.62


  1. Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83 Suppl. 1:34–44. [Full Text]
  2. Persad R, Sharma S, McTavish J, et al. Clinical presentation and pathophysiology of meatal stenosis following circumcision. Br J Urol 1995;75(1):91–3. [Full Text]
  3. Williams N, Kapila L. Complications of circumcision. Brit J Surg 1993;80:1231–6. [Full Text]
  4. Feigal DW, Jr. Potential for Injury from Circumcision Clamps. Rockville: U.S. Food and Drug Administration, 2000. [Full Text]
  5. Corbett HJ, Humphrey GME. Early complications of circumcisions performed in the community. Br J Gen Pract 2003;53(496):887–8. [Full Text]
  6. Smart J, Nolan T. (Editors). Paediatric Handbook, Sixth Edition. Victoria, Australia: Blackwell Science Asia, 2000: p. 82
  7. Wetli CV. Case 93–1711. Autopsy of Demetrius Manker. Miami: Dade County Medical Examiner Department, June 23, 1993. [Full Text]
  8. Hiss J, Horowitz A, Kahana T. Fatal haemorrhage following male ritual circumcision. J Clin Forensic Med 2000;7:32–4. [Full Text]
  9. Newell TEC. Judgement of inquiry into the death of McWillis, Ryleigh Roman Bryan. Burnaby, B.C.: B.C. Coroner’s Service, Monday, 19 January 2004. [Full Text]
  10. Kirkpatrick BV, Eitzman DV. Neonatal septicemia after circumcision. Clin Pediatr 1971;13(9):767–8. [Full Text]
  11. Scurlock JM, Pemberton PJ. Neonatal meningitis and circumcision. Med J Aust 1977;1(10):332–4. [Full Text]
  12. Reuben MS. Tuberculosis following ritual circumcision. Arch Pediatr 1917;XXXIV:186–90. [Full Text]
  13. Mahlberg FA, Rodermund OE, Muller RW. Ein Fall von Zirkumzision-stuberkulose. [A case of circumcision tuberculosis] Hautarzt 1977; 28: 424–5. [Abstract]
  14. Rosenstein JL. Wound diphtheria in the newborn infant following circumcision: report of a case. J Pediatr 1941;18:657–8. [Full Text]
  15. Sauer LW. Fatal staphylococcus bronchopneumonia following ritual circumcision. Am J Obstetr Gynecol 1943;46:583. [Full Text]
  16. Nelson JD, Dillon HC Jr, Howard JB. A prolonged nursery epidemic associated with a newly recognized type of group A streptococcus. J Pediatr 1976;89:792–6. [Abstract]
  17. Enzenauer RW, Dotson, C. Leonard T, et al. Increased incidence of neonatal staphylococcal pyoderma in males. Mil Med 1984;149(7):408.
  18. Stranko J, Ryan ME, Bowman AM. Impetigo in newborn infants associated with a plastic bell clamp circumcision. Pediatr Infect Dis J 1986;5:597–9. [Full Text]
  19. Enzenauer RW, Dotson CR, Leonard T, et al. Male predominance in persistent staphylococcal colonization and infection of the newborn. Hawaii Med J1985;44(10):389–90, 392, 394–6.
  20. Uwyyed K, Korman SH, Bar Oz B, Vromen A. Scrotal abscess with bacteremia caused by Salmonella group D after ritual circumcision. Pediatr Infect Dis J1990;9:65–6.
  21. Paediatric Death Review Committee: Office of the Chief Coroner of Ontario. Circumcision: a minor procedure? Paediatr Child Health 2007;12(4):311–2. [Full Text]
  22. Cohen HA, Drucker MM, Vainer S, et al. Postcircumcision urinary tract infection. Clin Pediatr 1992;31(6):322–4. [Abstract]
  23. Eason JD, McDonnell M, Clark G. Male ritual circumcision resulting in acute renal failure. BMJ 1994;309(6955):660–1. [Full Text]
  24. Goldman M, Barr J, Bistritzer T, and Aladjem M. Urinary tract infection following ritual Jewish circumcision Isr J Med Sci 1996;32:1098–102. [Full Text]
  25. Woodside, Jeffrey R. Necrotizing fasciitis after neonatal circumcision. Am J Dis Child (Chicago) 1980:134(3):301–2. [Abstract]
  26. Woodside JR. Circumcision disasters. Pediatrics 1980; 65:1053–4. [Full Text]
  27. Bliss DP, Healey PJ, Waldhausen JHT. Necrotizing fasciitis after Plastibell circumcision. J Pediatr 1997;31:459–62. [Full Text]
  28. Sussman SJ, Schiller RP, Shashikumar VL. Fournier’s syndrome. Report of three cases and review of the literature. Am J Dis Child 1978 Dec;132(12):1189–91. [Abstract]
  29. Zafar AB, Butler RC, Reese DJ, et al. Use of 0.3% triclosan (Bacti-Stat) to eradicate an outbreak of methicillin-resistant Staphylococcus aureus in a neonatal nursery. Am J Infect Control 1995;23(3):200–8. [Abstract]
  30. Hoffman KK, Weber DJ, Bost R, Rutala WA. Neonatal Staphyloccus aureus pustulous rash outbreak linked by molecular typing to colonized healthcare workers. Infect Control Hosp Epideminol 2000;21(2):136. [Abstract]
  31. Rabin R. Mysterious Crop of Staph: Newborns, moms infected after stay at St. Catherine’s. Newsday, Long Island, New York, 9 October 2003. [Abstract]
  32. Bratu S, Eramo A, Kopec R, et al. Community-associated methicillin-resistant Staphylococcus aureus in hospital nursery and maternity units. Emerg Infect Dis2005,11(6): Available from [Full Text]
  33. Nguyen DM, Bancroft E, Mascola L, et al. Risk factors for neonatal methicillin-resistant Staphylococcus aureus infection in a well-infant nursery. Infect Control Hosp Epidemiol 2007;28(4):406–11. [Full Text]
  34. Wilson CL, Wilson MC. Plastic repair of the denuded penis. South Med J 1959;52:288–90. [Full Text]
  35. Smey P. Penile denudation injuries after circumcision. J Urol 1985;134:1220.
  36. Sotolongo JR Jr, Hoffman S, Gribetz ME. Penile denudation injuries after circumcision. J Urol 1985;133(1):102–3. [Full Text]
  37. Johnson S. Persistent urethral fistula following circumcision: report of a case. US Naval Med Bull 1949;49:120–2.
  38. Lackey JT, Mannion RA, Kerr JE. Urethral fistula following circumcision. JAMA 1968;206:2318.
  39. Baskin LS, Canning DA, Snyder III HM, Duckett JW Jr. Surgical repair of urethral circumcision injuries. J Urol 1997;158(6):2269–71. [Abstract]
  40. McGowan Jr AW. A complication of circumcision. JAMA 1969;207(11):2104. [Full Text]
  41. Leitch IOW. Circumcision – a continuing enigma. Aust Paediatr J 1970;6:59–65. [Full Text]
  42. Lerner BL. Amputation of the penis as a complication of circumcision. Med Rec Ann 1952;46:229–31.
  43. Yilmaz AF, Sarikaya S, Yildiz S, et al. Rare complication of circumcision: penile amputation and reattachment. Eur Urol (Basel) 1993; 23(3): 423–4.
  44. Audry G, Buis J, Vazquez MP, Gruner M. Amputation of penis after circumcision–-penoplasty using expandable prosthesis. Eur J Pediatr Surg 1994;4:44-5.
  45. Hanukoglu A, Danielli L, Katzir Z, Gorenstein A, Fried D. Serious complications of routine ritual circumcision in a neonate: hydro ureteronephrosis, amputation of glans penis, and hyponatraemia. Eur J Pediatr 1995;154:314–5.
  46. Gluckman GR, Stoller ML, Jacobs MM, Kogan BA. Newborn penile glans amputation during circumcision and successful reattachment. J Urol 1995;133(3) Part 1:778–9. [Full Text]
  47. Strimling BS. Partial amputation of glans penis during Mogen clamp circumcision. Pediatrics 1996;97(6):906–7. [Abstract]
  48. Rosefsky JB Jr. Glans necrosis as a complication of circumcision. Pediatrics 1967;39(5):774–6. [Abstract]
  49. Stefan H. Reconstruction of the penis after necrosis due to circumcision burn. Eur J Pediatr Surg 1994;4:40–3.
  50. Pearlman CK. Caution advised on electrocautery circumcisions. Urology 1982;19:453.
  51. Ahmed S, Shetty SD, Anandan N, Patil KP, Ibrahim AIA. Penile reconstruction following post-circumcision penile gangrene. Pediatr Surg Int 1994;9:295–6.
  52. Bradley SJ, Oliver GD, Chernick AB. Experiment of nurture: ablatio penis at 2 months, sex reassignment at 7 months, and a psychosexual follow-up in young adulthood. Pediatrics 1998;102(1):e9. [Full Text]
  53. Gairdner D. The fate of the foreskin. A study of circumcision. Br Med J 1949;2:1433–37. [Full Text]
  54. Gellis SS. Circumcision. Am J Dis Child 1978;132:1168. [Full Text]
  55. Baker RL. Newborn male circumcision: needless and dangerous. Sex Med Today 1979;3(11):35–6. [Full Text]
  56. Bollinger D. Lost boys: An estimate of U.S. circumcision-related deaths. Thymos: Journal of Boyhood Studies 2010; 4(1):78-90. DOI: 10.3149/thy.0401.78. [Full Text]
  57. Curtis JE. Circumcision complicated by pulmonary embolism. Nurs Mirror Midwives J 1971;132:28–30.
  58. Fleiss PM, Douglass J. The case against neonatal circumcision. Brit Med J 1979;2(6189):554. [Full Text]
  59. Lander J, Brady-Freyer B, Metcalfe JB, et al. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision. JAMA 1997; 278:2158–62. [Full Text]
  60. Mor A, Eshel G, Aladjem M, et al. Tachycardia and heart failure after circumcision. Arch Dis Child 1987;62:80–1. [Abstract]
  61. Auerbach MR, Scanlon JW. Recurrence of pneumothorax as a possible complication of circumision. J Pediatr 1978:132:583.
  62. Connelly KC, Shropshire LC, Salzberg A. Gastric rupture associated with prolonged crying in a newborn undergoing circumcision. Clin Pediatr 1992;31(9):560–1. [Full Text]

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