Foreskin necrosis – Complication following self-circumcision

Abstract

Male circumcision (MC) seems to be practiced since ancient times by Muslims and Jewish, and it is considered as commandment. Attempts at self-circumcision for any reason are very rare in our country. This article aims to highlight another case of self-circumcision in a 30 year-old male, using a sharp vegetable knife. The reasons behind this act are various and the most common complications, especially in the use of sharp tools, in addition to bleeding or laceration of the penis, are infection, penile curvature, urethral injury or necrosis of the foreskin and penile tissues. To our knowledge, this is the first case report with necrotic foreskin as complication.

Introduction

Male circumcision (MC) seems to be practiced since ancient times by Muslims and Jewish, and it is considered as commandment.¹ Nowadays, MC is performed for social, cultural, and religious as well as medical reasons. In our cultural environment, in Morocco and in all Muslims country, circumcision is performed for all our children at a young age and often in a clinical setting. In the other countries, MC is essentially performed in patients with phimosis, but also for other foreskin pathologies, including aesthetic reasons, which is generally the main motivation for adult patients to undergo surgical circumcision.² Attempts at self-circumcision for any reason are very rare in our country. Few cases have been reported and most of them used devices marketed on the internet.³ Circumcision carried out in a non-hospital setting lead to more complications than those in the clinical setting, and in particular, self-circumcision is associated with a high rate of complications.³ This article aims to highlight another case of self-circumcision, involving a young male who was seen at Ibn Rochd University Hospital in Casablanca. It points out the related complications, and how they were managed, and further explore the reasons behind this behaviour. This case specifically contributes to the record of device-free self-circumcisions.

Case report

A 30 year-old man presented with an interval of one month to the emergency department with complaint of necrosis foreskin after a trial of self-circumcision with a sharp vegetable knife (Fig. 1). The procedure was carried out without local anesthetic. He was referred to the department of urology for further management. On presentation, the patient had a phimosis, the foreskin was necrotic and he had a circumferential wound on his penis. There was no bleeding or infection sign. Review of the patient's medical history ruled out psychological and organic problems. Phimosis made it difficult for him to establish intimate contact, so he decided to solve the problem. However, due to feelings of shame and financial problem, he did not seek medical help, but instead decided to perform the surgery by himself. The patient said he had never seen the procedure or had access to literature, images or videos of the surgery.

Fig. 1.

Initial appearance after the attempt at self-circumcision.

He was admitted to the operation room urgently. An informed consent for the operation was given to the patient. Under spinal anesthesia, we removed initially the necrotic tissues (Fig. 2) and then the circumcision was performed satisfactorily. A peripenile bandage was applied at the end of the surgery, which was removed on postoperative first day. No complication was observed.

Fig. 2.

Appearance after removing necrosis on the foreskin.

He was discharged two days after surgery on oral antibiotic therapy, tetanus antitoxin and tetanus vaccine. Twenty five days after the intervention, his follow up examination revealed a normal appearance of the penis (Fig. 3). Skin sensation and erectile function were normal, and the patient had no symptoms of the lower urinary tract.

Fig. 3.

Aspect after 25 days of follow up.

Discussion

MC is one of the commonest surgical procedure performed all over the world for ritual, traditional or medical reasons. Although it must be done by experienced surgeons, but there are some countries, like morocco, where circumcision is carried out by untrained persons outside the medical environment. Recent data from clinical trials showed that circumcision can protect against HIV and other sexually transmitted diseases.⁴

The reasons behind self-circumcision are various. The inability to afford the operation has been reported as reason for self-circumcision. Some patients may be driven by feelings of shame, if they are rejected by their society or partner. Fear of medical environment and of anesthesia, based on ignorance, are also documented as possible cause.⁵ Depression after bereavement had been considerate as a precipitating cause for self-circumcision. In this case, we have to make difference between self-circumcision and self-mutilation. Self-circumcision is considerate by the patient like a self-treatment and its rarely or never involved major surgical manipulations, it's usually organised and commonly stops at simple measures.

The most common complications, especially in the use of sharp tools, in addition to bleeding or laceration of the penis, are infection, penile curvature, urethral injury or necrosis of the foreskin and penile tissues.³ To our knowledge, this is the first case report of self-circumcision presenting a necrotic foreskin as complication.

Conclusion

Cases of self-circumcision continue to emerge, presenting a cause of increase sexual complications. This case report emphasizes the need to raise awareness of our community about the fact that circumcision must always be performed by urologist. In our country, attempts at self-circumcision for any reason are very rare. With the growing list of self-circumcision in the literature, we believe that in the future studies will focus on social and medical aspect.

Declaration of competing interest

The authors state that they do not have competing interests.