Ischemia of the glans penis

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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 a 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.

References

  1. a b REFjournal 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.
  2. REFjournal 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.
  3. REFbook 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.
  4. REFjournal 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.
  5. REFjournal 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.
  6. REFjournal 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.
  7. REFjournal 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.
  8. REFjournal 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.
  9. REFjournal 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.
  10. REFjournal 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.
  11. REFjournal 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.
  12. REFjournal 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.