Difference between revisions of "Ischemia of the glans penis"
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| − | + | '''Ischemia of the glans penis''' is a not-so-rare [[iatrogenic]] [[complication]] of [[circumcision]].<ref name="pepe2015">{{REFjournal | |
| − | '''Ischemia of the glans penis''' is a complication of circumcision.<ref>{{REFjournal | ||
|last=Pepe | |last=Pepe | ||
|first=Pietro | |first=Pietro | ||
| − | |init= | + | |init=P |
|author-link= | |author-link= | ||
|last2=Pietropaolo | |last2=Pietropaolo | ||
|first2=Francesco | |first2=Francesco | ||
| − | |init2= | + | |init2=F |
|author2-link= | |author2-link= | ||
|last3=Candiano | |last3=Candiano | ||
|first3=Guiseppe | |first3=Guiseppe | ||
| − | |init3= | + | |init3=G |
|author3-link= | |author3-link= | ||
|last4=Pennisi | |last4=Pennisi | ||
|first4=Michele | |first4=Michele | ||
| − | |init4= | + | |init4=M |
|author4-link= | |author4-link= | ||
|etal=no | |etal=no | ||
|title=Ischemia of the glans penis following circumcision: case report and revision of the literature | |title=Ischemia of the glans penis following circumcision: case report and revision of the literature | ||
| − | |||
| − | |||
|journal=Arch Ital Urol Androl | |journal=Arch Ital Urol Androl | ||
|location= | |location= | ||
| Line 39: | Line 36: | ||
==Disruption of blood circulation== | ==Disruption of blood circulation== | ||
| − | Male circumcision frequently includes excision of the [[frenulum]], which carries the frenular artery.<ref>{{REFjournal | + | Male [[circumcision]] frequently includes excision of the [[frenulum]], which carries the frenular artery.<ref>{{REFjournal |
|last=Shenoy | |last=Shenoy | ||
|first= | |first= | ||
|init=SP | |init=SP | ||
|author-link= | |author-link= | ||
| − | |last2=Marla | + | |last2=Marla |
|first2= | |first2= | ||
|init2=PK | |init2=PK | ||
| Line 54: | Line 51: | ||
|etal=yes | |etal=yes | ||
|title=Frenulum Sparing Circumcision: Step-By-Step Approach of a Novel Technique | |title=Frenulum Sparing Circumcision: Step-By-Step Approach of a Novel Technique | ||
| − | + | |journal=J Clin Diagn Res | |
| − | |||
| − | |journal=J Clin Diagn Res | ||
|location= | |location= | ||
|date=2015-12 | |date=2015-12 | ||
| Line 71: | Line 66: | ||
|DOI=10.7860/JCDR/2015/14972.6860 | |DOI=10.7860/JCDR/2015/14972.6860 | ||
|accessdate=2022-02-20 | |accessdate=2022-02-20 | ||
| − | }}</ref> The frenular artery supplies arterial blood | + | }}</ref> The frenular artery supplies arterial blood to the [[glans penis]], so the excision of the [[frenulum]] reduces the supply of arterial blood to the glans penis. |
| − | Circumcision also disrupts the return flow of blood to the heart. Veins in the prepuce provide "at least part of the drainage of the glans surface."<ref name="mcgrath2001">{{REFbook | + | [[Circumcision]] also disrupts the return flow of blood to the heart. Veins in the [[prepuce]] provide "at least part of the drainage of the [[glans]] surface."<ref name="mcgrath2001">{{REFbook |
|last=McGrath | |last=McGrath | ||
|first=Ken | |first=Ken | ||
| − | |init= | + | |init=K |
| − | |author-link= | + | |author-link=Ken McGrath |
|year=2001 | |year=2001 | ||
|title=The Frenular Delta: A New Preputial Stucture | |title=The Frenular Delta: A New Preputial Stucture | ||
|url=http://www.cirp.org/library/anatomy/mcgrath1/ | |url=http://www.cirp.org/library/anatomy/mcgrath1/ | ||
|work=Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem | |work=Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem | ||
| − | | | + | |editors=Denniston GC, Hodges FM, Milos MF |
|edition= | |edition= | ||
|volume= | |volume= | ||
| Line 88: | Line 83: | ||
|pages= | |pages= | ||
|location=New York | |location=New York | ||
| − | |publisher=Kluwer/Plenum | + | |publisher=Kluwer/Plenum |
|ISBN= | |ISBN= | ||
|quote= | |quote= | ||
|accessdate=2022-02-20 | |accessdate=2022-02-20 | ||
|note= | |note= | ||
| − | }}</ref> Moreover, the dorsal veins from the [[acroposthion]] are severed and excised by circumcision. This frequently results in post-circumcision [[lymphoedema]] due to the reduction in blood circulation. Ferhatoglu et al. (2019) reported edema in 108 of 198 patients or 54.5 percent, indicating substantial impairment of circulation.<ref>{{REFjournal | + | }}</ref> Moreover, the dorsal veins from the [[acroposthion]] are severed and excised by [[circumcision]]. This frequently results in post-circumcision [[lymphoedema]] due to the reduction in blood circulation. Ferhatoglu et al. (2019) reported edema in 108 of 198 patients or 54.5 percent, indicating substantial impairment of circulation.<ref>{{REFjournal |
|last=Ferhatoglu | |last=Ferhatoglu | ||
|first= | |first= | ||
| − | |init= | + | |init=MF |
|author-link= | |author-link= | ||
|last2=Kartal | |last2=Kartal | ||
| Line 108: | Line 103: | ||
|etal=no | |etal=no | ||
|title=Evaluation of Male Circumcision: Retrospective Analysis of One Hundred and Ninety-eight Patients | |title=Evaluation of Male Circumcision: Retrospective Analysis of One Hundred and Ninety-eight Patients | ||
| − | |||
| − | |||
|journal=Cureus | |journal=Cureus | ||
|location= | |location= | ||
| Line 128: | Line 121: | ||
==Case reports== | ==Case reports== | ||
| − | Tzeng et al. (2004) reported the case of a 33-year-old man who experienceed ischemia of the glans penis within 24 hours after | + | Tzeng et al. (2004) reported the case of a 33-year-old man who experienceed ischemia of the [[glans penis]] within 24 hours after an [[adult circumcision]]. He was treated with intravenous pentoxifyllin and hyperbaric oxygenation.<ref name="tzeng2004">{{REFjournal |
|last=Tzeng | |last=Tzeng | ||
|first=Yuan-Sheng | |first=Yuan-Sheng | ||
| − | |init= | + | |init=YS |
|author-link= | |author-link= | ||
|last2=Tang | |last2=Tang | ||
|first2=Shou-Hung | |first2=Shou-Hung | ||
| − | |init2= | + | |init2=SH |
|author2-link= | |author2-link= | ||
|last3=Meng | |last3=Meng | ||
|first3=En | |first3=En | ||
| − | |init3= | + | |init3=E |
|author3-link= | |author3-link= | ||
|etal=yes | |etal=yes | ||
|title=Ischemic glans penis after circumcision | |title=Ischemic glans penis after circumcision | ||
| − | |||
| − | |||
|journal=Asian J Androl | |journal=Asian J Androl | ||
|location= | |location= | ||
| Line 151: | Line 142: | ||
|issue=2 | |issue=2 | ||
|article= | |article= | ||
| − | |||
|pages=161-3 | |pages=161-3 | ||
|url=http://www.asiaandro.com/archive/1008-682X/6/161.htm | |url=http://www.asiaandro.com/archive/1008-682X/6/161.htm | ||
| Line 162: | Line 152: | ||
}}</ref> | }}</ref> | ||
| − | Aslan et al. (2005) reported the case of an eleven-year-old boy who experienced ischemia of the glans penis within 24 hours of a circumcision. The boy was successfully treated with pentoxifylline injection for 5 days.<ref name="aslan2005">{{REFjournal | + | Aslan et al. (2005) reported the case of an eleven-year-old boy who experienced ischemia of the [[glans penis]] within 24 hours of a [[circumcision]]. The boy was successfully treated with pentoxifylline injection for 5 days.<ref name="aslan2005">{{REFjournal |
|last=Aslan | |last=Aslan | ||
| − | |first= | + | |first=Adnan |
| − | |init= | + | |init=A |
|author-link= | |author-link= | ||
|last2=Karagüzel | |last2=Karagüzel | ||
| Line 177: | Line 167: | ||
|etal=no | |etal=no | ||
|title=Severe ischemia of the glans penis following circumcision: a successful treatment via pentoxifylline | |title=Severe ischemia of the glans penis following circumcision: a successful treatment via pentoxifylline | ||
| − | |||
| − | |||
|journal=Int J Urol | |journal=Int J Urol | ||
|location= | |location= | ||
| Line 196: | Line 184: | ||
}}</ref> | }}</ref> | ||
| − | Devarakonda & Aghavendra (2010) reported a case of ischemia of the glans penis.<ref name="devarakonda2010">{{REFjournal | + | Devarakonda & Aghavendra (2010) reported a case of ischemia of the [[glans penis]].<ref name="devarakonda2010">{{REFjournal |
|last=Devarakonda | |last=Devarakonda | ||
|first= | |first= | ||
| Line 207: | Line 195: | ||
|etal=no | |etal=no | ||
|title=A case of ischemia of the glans penis | |title=A case of ischemia of the glans penis | ||
| − | |||
| − | |||
|journal= Paediatr Anaesth | |journal= Paediatr Anaesth | ||
|location= | |location= | ||
| Line 226: | Line 212: | ||
}}</ref> | }}</ref> | ||
| − | Karaguzel et al. (2013) reported a case of ischemia of the glans penis after circumcision in a four-year-old boy. The boy was successfully treated with pentoxifylline.<ref>{{REFjournal | + | Karaguzel et al. (2013) reported a case of ischemia of the [[glans penis]] after [[circumcision]] in a four-year-old boy. The boy was successfully treated with pentoxifylline.<ref>{{REFjournal |
|last=Karaguzel | |last=Karaguzel | ||
|first= | |first= | ||
| Line 241: | Line 227: | ||
|etal=yes | |etal=yes | ||
|title=Postcircumcisional ischemia of the glans penis treated with pentoxifylline | |title=Postcircumcisional ischemia of the glans penis treated with pentoxifylline | ||
| − | |||
| − | |||
|journal=Case Rep Urol | |journal=Case Rep Urol | ||
|location= | |location= | ||
| Line 249: | Line 233: | ||
|issue= | |issue= | ||
|article= | |article= | ||
| − | |page=278523 | + | |page=278523 |
| − | |||
|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3575659/ | |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3575659/ | ||
|archived= | |archived= | ||
| Line 260: | Line 243: | ||
}}</ref> | }}</ref> | ||
| + | Pepe et al. (2015) reported the case of a young man who had ischemia of the [[glans]] five days after [[circumcision]]. He was treated with hyperbaric therapy.<ref name="pepe2015"/> | ||
| + | Cárdenas Elías et al. (2016) reported a case of ischemia of the [[glans penis]] in a ten-year-old patient with symptoms appearing two hours after circumcision. The boy was treated with pentoxifylline (PTX) that is maintained for 6 days, topical testosterone and a caudal blocking (for 48 hours).<ref>{{REFjournal | ||
| + | |last=Cárdenas Elías | ||
| + | |first= | ||
| + | |init=MÁ | ||
| + | |author-link= | ||
| + | |last2=Rueda | ||
| + | |first2= | ||
| + | |init2=FV | ||
| + | |author2-link= | ||
| + | |last3=Crespo | ||
| + | |first3= | ||
| + | |init3=VJ | ||
| + | |author3-link= | ||
| + | |etal=yes | ||
| + | |title=Isquemia postcircuncisión: una complicación inesperada. Revisión de la literatura | ||
| + | |trans-title=An unexpected complication: glans ischemia after circumcision. Review of the literature | ||
| + | |language=Spanish | ||
| + | |journal=Cir Pediatr | ||
| + | |location= | ||
| + | |date=2016-07 | ||
| + | |volume=29 | ||
| + | |issue=3 | ||
| + | |article= | ||
| + | |page= | ||
| + | |pages=127-30 | ||
| + | |url=https://pubmed.ncbi.nlm.nih.gov/28393509/ | ||
| + | |archived= | ||
| + | |quote= | ||
| + | |pubmedID=28393509 | ||
| + | |pubmedCID= | ||
| + | |DOI= | ||
| + | |accessdate=2022-02-20 | ||
| + | }}</ref> | ||
| + | Migliorini et al. (2018) reported a case of ischemia of the [[glans penis]] after [[circumcision]] in a 24-year-old male. The patient was successfully treated with hyperbaric oxygen therapy in combination with pentoxifylline.<ref>{{REFjournal | ||
| + | |last=Migliorini | ||
| + | |first=Fillipo | ||
| + | |init=F | ||
| + | |author-link= | ||
| + | |last2=Bianconi | ||
| + | |first2=Francesco | ||
| + | |init2=F | ||
| + | |author2-link= | ||
| + | |last3=Bizzotto | ||
| + | |first3=Leonardo | ||
| + | |init3=L | ||
| + | |author3-link= | ||
| + | |etal=yes | ||
| + | |title=Acute Ischemia of the Glans Penis after Circumcision Treated with Hyperbaric Therapy and Pentoxifylline: Case Report and Revision of the Literature | ||
| + | |journal=Urol Int | ||
| + | |location= | ||
| + | |date=2018-02-13 | ||
| + | |volume=100 | ||
| + | |issue=3 | ||
| + | |article= | ||
| + | |page= | ||
| + | |pages=361-3 | ||
| + | |url=https://www.karger.com/Article/Abstract/444399 | ||
| + | |archived= | ||
| + | |quote= | ||
| + | |pubmedID=26871688 | ||
| + | |pubmedCID= | ||
| + | |DOI=10.1159/000444399 | ||
| + | |accessdate=2022-02-20 | ||
| + | }}</ref> | ||
| + | |||
| + | Polak et al. (2021) present two cases of ischemia of the [[glans penis]] after medically-unnecessary, non-therapeutic [[circumcision]] in which hyperbaric oxygen was used as salvage therapy to save the penises of the newborn boys.<ref name="polak2021">{{REFjournal | ||
| + | |last=Polak | ||
| + | |first=Nir | ||
| + | |init=N | ||
| + | |author-link= | ||
| + | |last2=Fisheley | ||
| + | |first2=Gregory | ||
| + | |init2=G | ||
| + | |author2-link= | ||
| + | |last3=Lang | ||
| + | |first3=Erez | ||
| + | |init3=E | ||
| + | |author3-link= | ||
| + | |etal=yes | ||
| + | |title=Hyperbaric Oxygen as Salvage Therapy for Neonates Suffering From Critical Ischemia of the Glans Penis After Circumcision | ||
| + | |journal=Urology | ||
| + | |location= | ||
| + | |date=2021-03 | ||
| + | |volume=149 | ||
| + | |issue= | ||
| + | |article= | ||
| + | |page= | ||
| + | |pages=e48-e51 | ||
| + | |url=https://www.goldjournal.net/article/S0090-4295(20)31134-1/fulltext | ||
| + | |archived= | ||
| + | |quote= | ||
| + | |pubmedID=32956687 | ||
| + | |pubmedCID= | ||
| + | |DOI=10.1016/j.urology.2020.09.006 | ||
| + | |accessdate=2022-02-20 | ||
| + | }}</ref> | ||
| + | |||
| + | ==Conclusion== | ||
| + | The medical literature has a number of reports of successful treatment of ischemia of the [[glans penis]]. But what of the cases in which treatment was not timely instituted and the case progressed to [[necrosis]] and gangrene of the [[glans penis]]? | ||
| + | |||
| + | Ischemia of the glans penis after [[circumcision]] is not an act of God. It is an [[iatrogenic]] occurrence that happens when medical personnel intentionally sever blood vessels in the [[penis]] and reduce the blood circulation into and through the [[glans penis]]. | ||
| + | |||
| + | A surgical operation which severs blood vessels and impedes circulation cannot be viewed as other than harmful. The first rule of medical ethics is ''premum non nocere''. First do no harm. The typical infant [[circumcision]] is a non-therapeutic amputation that harms without providing a benefit such as prevention or treatment of disease. | ||
| + | |||
| + | Tasci et al. (2020) report that the Turkish Institution of Forensic Medicine has undertaken the consideration of 24 cases of necrosis of the penis after circumcision with regard to malpractice.<ref name="tasci2020">{{REFjournal | ||
| + | |last=Tasci | ||
| + | |first= | ||
| + | |init=AI | ||
| + | |author-link= | ||
| + | |last2=Danacioglu | ||
| + | |first2= | ||
| + | |init2=YO | ||
| + | |author2-link= | ||
| + | |last3=Arikan | ||
| + | |first3= | ||
| + | |init3=Y | ||
| + | |author3-link= | ||
| + | |etal=yes | ||
| + | |title=Management of post-circumcision necrosis of the penis: the medicolegal aspect | ||
| + | |journal=Pediatr Surg Int | ||
| + | |location= | ||
| + | |date=2020-02-22 | ||
| + | |volume=36 | ||
| + | |issue=4 | ||
| + | |article= | ||
| + | |pages=523-8 | ||
| + | |url= | ||
| + | |archived= | ||
| + | |quote= | ||
| + | |pubmedID=32088740 | ||
| + | |pubmedCID= | ||
| + | |DOI=10.1007/s00383-020-04630-2 | ||
| + | |accessdate=2022-02-20 | ||
| + | }}</ref> Medical doctors should be aware than such cases may be viewed by a future court as malpractice. | ||
| + | |||
| + | The public is reminded that the usual infant [[circumcision]] does not treat or cure disease, because disease is not present. It is classified as without medical indication, non-therapeutic, and medically-unnecessary, but puts the patient at risk. | ||
{{REF}} | {{REF}} | ||
| − | |||
[[Category:Circumcision complication]] | [[Category:Circumcision complication]] | ||
| + | [[Category:Circumcision risk]] | ||
| + | [[Category:Circumcision term]] | ||
Latest revision as of 17:35, 3 January 2024
Ischemia of the glans penis is a not-so-rare iatrogenic complication of circumcision.[1]
Disruption of blood circulation
Male circumcision frequently includes excision of the frenulum, which carries the frenular artery.[2] The frenular artery supplies arterial blood to the glans penis, so the excision of the frenulum reduces the supply of arterial blood to the glans penis.
Circumcision also disrupts the return flow of blood to the heart. Veins in the prepuce provide "at least part of the drainage of the glans surface."[3] Moreover, the dorsal veins from the acroposthion are severed and excised by circumcision. This frequently results in post-circumcision lymphoedema due to the reduction in blood circulation. Ferhatoglu et al. (2019) reported edema in 108 of 198 patients or 54.5 percent, indicating substantial impairment of circulation.[4]
Case reports
Tzeng et al. (2004) reported the case of a 33-year-old man who experienceed ischemia of the glans penis within 24 hours after an adult circumcision. He was treated with intravenous pentoxifyllin and hyperbaric oxygenation.[5]
Aslan et al. (2005) reported the case of an eleven-year-old boy who experienced ischemia of the glans penis within 24 hours of a circumcision. The boy was successfully treated with pentoxifylline injection for 5 days.[6]
Devarakonda & Aghavendra (2010) reported a case of ischemia of the glans penis.[7]
Karaguzel et al. (2013) reported a case of ischemia of the glans penis after circumcision in a four-year-old boy. The boy was successfully treated with pentoxifylline.[8]
Pepe et al. (2015) reported the case of a young man who had ischemia of the glans five days after circumcision. He was treated with hyperbaric therapy.[1]
Cárdenas Elías et al. (2016) reported a case of ischemia of the glans penis in a ten-year-old patient with symptoms appearing two hours after circumcision. The boy was treated with pentoxifylline (PTX) that is maintained for 6 days, topical testosterone and a caudal blocking (for 48 hours).[9]
Migliorini et al. (2018) reported a case of ischemia of the glans penis after circumcision in a 24-year-old male. The patient was successfully treated with hyperbaric oxygen therapy in combination with pentoxifylline.[10]
Polak et al. (2021) present two cases of ischemia of the glans penis after medically-unnecessary, non-therapeutic circumcision in which hyperbaric oxygen was used as salvage therapy to save the penises of the newborn boys.[11]
Conclusion
The medical literature has a number of reports of successful treatment of ischemia of the glans penis. But what of the cases in which treatment was not timely instituted and the case progressed to necrosis and gangrene of the glans penis?
Ischemia of the glans penis after circumcision is not an act of God. It is an iatrogenic occurrence that happens when medical personnel intentionally sever blood vessels in the penis and reduce the blood circulation into and through the glans penis.
A surgical operation which severs blood vessels and impedes circulation cannot be viewed as other than harmful. The first rule of medical ethics is premum non nocere. First do no harm. The typical infant circumcision is a non-therapeutic amputation that harms without providing a benefit such as prevention or treatment of disease.
Tasci et al. (2020) report that the Turkish Institution of Forensic Medicine has undertaken the consideration of 24 cases of necrosis of the penis after circumcision with regard to malpractice.[12] Medical doctors should be aware than such cases may be viewed by a future court as malpractice.
The public is reminded that the usual infant circumcision does not treat or cure disease, because disease is not present. It is classified as without medical indication, non-therapeutic, and medically-unnecessary, but puts the patient at risk.
References
- ↑ a b
Pepe P, Pietropaolo F, Candiano G, Pennisi M. Ischemia of the glans penis following circumcision: case report and revision of the literature. Arch Ital Urol Androl. 31 March 2015; 87(1): 93-4. PMID. DOI. Retrieved 20 February 2022.
Quote:The patient had undergone circumcision 5 days before in a surgery department under local anesthesia.
- ↑ Shenoy SP, Marla PK, Sharma P, et al. Frenulum Sparing Circumcision: Step-By-Step Approach of a Novel Technique. J Clin Diagn Res. December 2015; 9(12): PC01-PC03. PMID. PMC. DOI. Retrieved 20 February 2022.
- ↑
McGrath K (2001): The Frenular Delta: A New Preputial Stucture. Work: Understanding Circumcision: A Multi-Disciplinary Approach to a Multi-Dimensional Problem. Denniston GC, Hodges FM, Milos MF (eds.). New York: Kluwer/Plenum. Retrieved 20 February 2022.
- ↑ Ferhatoglu MF, Kartal A, Gurkan A. Evaluation of Male Circumcision: Retrospective Analysis of One Hundred and Ninety-eight Patients. Cureus. 27 April 2019; 11(4): e4555. PMID. PMC. DOI. Retrieved 20 February 2022.
- ↑ Tzeng YS, Tang SH, Meng E, et al. Ischemic glans penis after circumcision. Asian J Androl. June 2004; 6(2): 161-3. PMID. Retrieved 20 February 2022.
- ↑ Aslan A, Karagüzel G, Melikoglu M. Severe ischemia of the glans penis following circumcision: a successful treatment via pentoxifylline. Int J Urol. July 2005; 12(7): 705-07. PMID. DOI. Retrieved 20 February 2022.
Quote:We suggest that pentoxifylline might be considered as a treatment of choice for severe ischemia of glans penis.
- ↑ Devarakonda K, Aghavendra TR. A case of ischemia of the glans penis. Paediatr Anaesth. June 2010; 20(6): 582-6. PMID. DOI. Retrieved 20 February 2022.
- ↑ Karaguzel E, Tok DS, Kazaz IO, et al. Postcircumcisional ischemia of the glans penis treated with pentoxifylline. Case Rep Urol. 4 February 2013; : 278523. PMID. PMC. DOI. Retrieved 20 February 2022.
- ↑ Cárdenas Elías MÁ, Rueda FV, Crespo VJ, et al. Isquemia postcircuncisión: una complicación inesperada. Revisión de la literatura [An unexpected complication: glans ischemia after circumcision. Review of the literature] (Spanish). Cir Pediatr. July 2016; 29(3): 127-30. PMID. Retrieved 20 February 2022.
- ↑ Migliorini F, Bianconi F, Bizzotto L, et al. Acute Ischemia of the Glans Penis after Circumcision Treated with Hyperbaric Therapy and Pentoxifylline: Case Report and Revision of the Literature. Urol Int. 13 February 2018; 100(3): 361-3. PMID. DOI. Retrieved 20 February 2022.
- ↑ Polak N, Fisheley G, Lang E, et al. Hyperbaric Oxygen as Salvage Therapy for Neonates Suffering From Critical Ischemia of the Glans Penis After Circumcision. Urology. March 2021; 149: e48-e51. PMID. DOI. Retrieved 20 February 2022.
- ↑ Tasci AI, Danacioglu YO, Arikan Y, et al. Management of post-circumcision necrosis of the penis: the medicolegal aspect. Pediatr Surg Int. 22 February 2020; 36(4): 523-8. PMID. DOI. Retrieved 20 February 2022.
