Objectives: We aimed to evaluate the circumcision status and complications, and the value of penile visibility index in predicting circumcision complications among elementary school children. Patients and Methods: Elementary school students were evaluated with physical exam in terms of circumcision complications. Visible penile length/stretched penile length ratio was calculated for each subject and recorded as penile visibility index (PVI). Data were assessed with SPSS 15.0 software. Results: Average age was 9.04 (5 - 14) years. Circumcision complications were detected in 84 of 361 circumcised subjects (23.2%). There was no relationship between age at circumcision and complications (p > 0.05). Concealed penis was detected in 3.6% of all subjects. Mean PVI was significantly different between cases with and without glanular adhesion, and between cases with and without residual prepuce. On the overall, mean PVI in complication and no complication groups were 0.52 and 0.59 respectively, and the difference was statistically significant (p < 0.001). Conclusion: PVI calculation before circumcision, might help predict the cosmetic outcome of circumcision beforehand.
Circumcision has been one of the most frequently performed surgeries since ancient times. It is estimated that one third of the males in the world are circumcised [
The indications and benefits of circumcision have been well-defined [
We evaluated the circumcision properties and complications among a group of elementary school students aged 6 - 12 years, and assessed the utility of penile visibility index (PVI) in predicting the complications in a retrospective analysis.
Males at elementary schools from three different socioeconomic regions of Istanbul were included in the study after parental informed consents were obtained. Age at circumcision (AaC) and operator who performed the circumcision as the parents recalled were recorded. Age groups were categorized as <2, 2 - 6 and >6 years. Complications related with circumcision were assessed with physical exam. Penile length (PL) from glans edge to radix penis was measured by one Urologist both when penis was relaxed and stretched. A stretched PL below 2.5SD of average PL according to age was referred to as micropenis, while a penis with a normal stretched length but which was not noticeable on the body surface from the lateral view was defined as concealed penis. The ratio of visible PL to stretched PL was calculated for each subject and recorded as PVI, which was used to describe the intermediate group of penises between wholly visible ones and concealed ones (
Calculation of penile visibility index
Informed consents from the parents of 415 students could be obtained out of 1200 (34.6%) who were invited to participate in the study. Average age was 9.04 (5 - 14) years. 361 of 415 children examined (86.9%) were circumcised. The distribution of 361 subjects who were circumcised according to AaC were as follows: <2 years: 27.9%; 2 - 6 years: 45.9%; >6 years: 26.2%. The professions doing circumcision and corresponding number of subjects were Urologist: 36 (9.97%), Pediatric Surgeon: 73 (20.22%), General Surgeon: 43 (11.9%), General Practitioner: 25 (6.92%), Surgical Technician: 23 (6.37%), other and unknown: 161 (44.59%).
Circumcision-related complications were detected in 84 subjects (23.2%) such that bad cosmesis in 24, glanular adhesion in 8, residual prepuce in 52 subjects. No secondary phimosis and glans amputation were found. There was no significant relationship between AaC and complication rate (p > 0.05) (
Circumcised subjects were grouped according to whether glanular adhesion, residual prepuce, or bad cosmesis were present or not, and mean PVI was also calculated for each group. Mean PVI was significantly different between cases with and without glanular adhesion, and between cases with and without residual prepuce. On the contrary, mean PVI of the cases with and without bad cosmesis were statistically similar (
Circumcision rate approaches to 100% in Turkey [
. Complication rates according to age groups
Age groups (years) | Bad cosmesis (n) | Glanular adhesion (n) | Residual prepuce (n) |
---|---|---|---|
<2 | 3 | 1 | 15 |
2 - 6 | 12 | 3 | 18 |
>6 | 9 | 4 | 19 |
p > 0.05.
. Comparison of PVI values between cases with and without complications
Glanular adhesion | Residual prepuce | Bad cosmesis | ||||
---|---|---|---|---|---|---|
Present | Absent | Present | Absent | Present | Absent | |
n | 8 | 353 | 54 | 307 | 18 | 343 |
Minimum PVI | 0.25 | 0.29 | 0.27 | 0.17 | 0.33 | 0.17 |
Maximum PVI | 0.67 | 0.82 | 0.82 | 0.89 | 0.68 | 0.89 |
Mean PVI | 0.49 | 0.59 | 0.52 | 0.59 | 0.57 | 0.59 |
P value | 0.026 | 0.001 | 0.324 |
apparent that we report a high incidence of complications. This might be because a large number of parents did not know the profession of the operator doing the circumcision, or a considerable percentage of circumcisions were performed by people who were not even doctors in our study cohort. This indicates that circumcision is considered as a traditional act rather than being a surgical procedure, and medical aspect of the outcome is underestimated.
Most frequent circumcision complications reported in Turkey are glanular adhesions and insufficient circumcision (residual prepuce) [
CP refers to an anomaly such that penis appears to be short though its length is normal. CP may be divided into 3 groups according to the Maizels classification which is based on the etiologic mechanism: Buried penis, webbed penis, trapped penis [
Complete CP is a contraindication to circumcision. However, there are intermediate forms with differing degrees of concealment, and the outcome of circumcision in cases with partial CP remains to be described. If a relationship between the degree of concealment and circumcision complications could be established, surgical technique for circumcision could be adjusted, and parents could be informed accordingly prior to the circumcision. By recognizing the intermediate forms preoperatively, dissatisfaction due to bad cosmetic outcome might be prevented. For this reason, in an effort to obtain a measurable parameter defining the degree of concealment, we used an index, i.e., the ratio of the visible penile length over the body surface to the stretched penile length (
We were unaware of the precircumcision appearance of the penises, and circumcision itself might have contributed to the concealment in some subjects, or the PVI may have changed after the circumcision, and this decreases the power of our analysis. However, ours is a descriptive pilot study, results of which indicate that prospective studies investigating the ability of PVI in predicting the outcome of circumcision are worthwhile.
Circumcision is a frequently performed surgery around the world. Some circumcision complications appear to be more frequent among cases with complete or partial CP. Especially the partial CP often remains unrecognized before circumcision, and this leads to increased rates of cosmetic complications, such as glanular adhesions or secondary phimosis. Estimating the preoperative PVI may help predict the cosmetic outcome after circumcision, which in turn might alter the management. For example, if a circumcision is being performed for non-health-related reasons, the procedure could be delayed until the penis grows out of partial concealment. If the circumcision seems inevitable in a case with partially concealed penis, a more careful followup by the parents and surgeon could be planned, such that, penile skin is frequently slid back by the parents after circumcision to prevent adhesions, and the patient is called to the office more frequently to make sure that parents did their part effectively.
Penile visibility index calculation before circumcision, might help predict some cosmetic complications beforehand, and provide better information for the parents. Prospective studies are needed to corroborate our analysis.
None of the authors has any direct or indirect commercial financial incentive associated with publishing the article. There is no source of extra-institutional funding, particularly that provided by commercial sources.
None declared.
None declared.