Untrained circumcision providers create high risk for infectious complications when performing male circumcision. Well-trained surgical providers ensure safe surgical techniques . Circumcision procedures performed by qualified surgeons are under sterile conditions that do not pose a threat for postsurgical infection. Hence, infection is rare and uncommon after the procedure. Although most circumcision-related infections are mild, self-limiting and easily treatable conservatively with antibiotics, infectious complications of circumcision can become significant clinical problems.
Circumcision related infection can be either local, systemic or toxin-related. Occasionally, circumcision site wound infection might cause local complications including staphylococcal and streptococcal infections, cellulitis, impetigo, pyoderma, necrotizing fasciitis, scalded skin syndrome (staphylococcal), Fournier gangrene, granular necrosis, scrotal abscess and peritonitis. Complications due to systemic infections include bacteraemia, wound sepsis and meningitis. There has been rare incidence of neonatal and adult tetanus associated with nonmedical circumcision.
Symptoms of infection to be noticed after circumcision can avoid infectious complications. Symptoms may vary depending on the age of the male undergoing the procedure. While the procedure by itself can give faster and better results during younger years of age, symptoms of infection post circumcision can be difficult to know in children.
Symptoms of infection in children
Wound infection is the complication that occurs in less than 1 out of 200 circumcised boys. Due to the rich dual blood supply of the penis, wound infection occurs infrequently. The plastibell technique is reported to have more chances of infections. Common sites of infection are the open wounds of the circumcision leading either to an ascending urinary tract infection or directly to bacteraemia. Respiratory distress is also seen in infants with Staphylococci bacterial infection revealed from the urine and blood.
Spreading redness/erythema – Redness of the penis that may worsen over time after circumcision could be a sign of local infection. The redness may gradually extend up the shaft of the penis.
Fever – If the child has a low-grade fever ranging from 99 or 100 degrees Fahrenheit after surgery, it is generally considered normal. Fever that may shoot up to greater than 101.5 degrees a day after surgery could be a sign of concern. Post-surgical respiratory infections including ear infections, colds or pneumonia could be a reason for high fever. High fever soon after surgery should be checked with a doctor to ensure that it is not an ear, sinus or lung infection.
Pus – In circumcision, the foreskin is pulled back and the head of the penis gets exposed. The yellowish white film that develops on the raw head of the penis in the first few days after surgery is often mistaken for pus. This is not pus or a symptom of infection and usually disappears within one week. Foul smelling, cloudy discharge that may come from the tip of the penis can be a symptom of infection.
Irritability/Lethargy – when the child presents with persisting irritability, lethargy or poor feeding, it could be a sign of pain from systemic infection. The child may need admission, intravenous antibiotics and wound debridement to clear the infection.
Infections after circumcision in children emphasize the basic rule that any surgical procedure however minor, traditional or less interventional, should be considered free from danger. Children are relatively immunocompromised, so infections in this age group can become serious problems. Skin flora is the usual causative organism of infection but it develops due to the uniquely dirty environment of the diaper. The penis being in a wet environment of the diaper and the proximity to stool contamination, makes it a more susceptible for infection. Proper patient preparation, sterile handling and good local wound care that includes regular cleaning of the penis and application of antibiotic ointment with frequent diaper change can prevent infection.
Symptoms of infection in adults
In adult men, circumcision is considered a possible treatment option for penile infections such as recurrent balanitis or for acquired infections such as HIV from infected partner. Foreskin has been a covering on the penis for a life time in adult men and it is likely that some discomfort and swelling around the head of penis may be experienced after circumcision. It is a common apprehension among men, that any breach of the skin surface may lead to infection. Though post-surgical circumcision infections are rare, symptoms to look for such infections may include:
- Feeling ill
- Pus from the wound
- Unhealing wound
- Pain of sudden onset or worsening in to throbbing pain that was relatively mild
- Swelling or tenderness on or around the wound
- Continued bleeding
- Skin discoloration
- Foul smelling from the dressing or wound
- Difficulty passing urine
- Swelling or tenderness in the groin (painful inguinal glands)
- Hardness or stiffness of the abdomen
- Stiffness of the jaw
- Fits or convulsion
Erections which are common as nocturnal sexual arousal in adolescent and adult men do not usually harm the wound and may aid in healing. Men are advised to avoid sexual stimulation and sexual activity during the circumcision wound healing time which is usually about six weeks. This is in view that masturbation and sexual intercourse can cause damage to the healing wound or exposed skin leading to infection. In addition to injury expected to the wound or skin, sexual intercourse immediately during the six weeks of circumcision healing can increases the risk of acquiring HIV. There are high possibilities that the virus may get into the body through parts of the wound that are still fresh, raw and not healed. Engaging in sexual intercourse before completing six weeks will require the man to wear a condom to protect the wound and skin and thereby prevent acquiring HIV and other sexually transmitted infections. Consistent and correct use of condoms even after the six-week period is advised as male circumcision does not give complete protection against HIV and other STDs. Having sex with someone new or when engaging in any risky sexual situation after being circumcised will require the usage of condoms to avoid acquiring infections.
Male circumcision should be insisted on being performed by trained, competent practitioners using sterile techniques and effective post-surgical infection control to reduce and avoid post-circumcision Infectious complications.