FASCIITIS OF GENITALS. COMPLICATIONS OF CIRCUMSCISIONS. AUTHOR: Dr. C. LOPEZ ST. LUIS 2nd.DEGREE SPECIALIST IN PLASTIC SURGERY M Sc. Medical Emergency Assistant Professor COLABORATORS:SURGEONS FROM SURGICAL DEPARTMENT. RUNDU HOSPITAL. STAFF MEMBERS FROM SURGICAL W Namibia 29 October 2016 INTRODUCTION In the United States, circumcision is a commonly performed procedure. It is a relatively safe procedure with a low overall complication rate. Most complications are minor and can be managed easily. Though uncommon, complications of circumcision do represent a significant percentage of cases seen by pediatric urologists. Often they require surgical correction that results in a significant cost to the health care system. Severe complications are quite rare, but death has been reported as a result in some cases. A thorough and complete preoperative evaluation, focusing on bleeding history and birth history, is imperative. Proper selection of patients based on age and anatomic considerations as well .as proper sterile surgical technique are critical to prevent future circumcision-related adverse events. Keywords: Penis, circumcision, complications, child, micropenis, inconspicuous. OBJECTIVES

1. To explain general elements about circumcision. 2. To demostrate the complications can exist after a circumcision operation. 3. To understand the need of circumcision by the medical community and by the society. BACKGROUND

Circumcision is one of the oldest surgical procedures and one of the most commonly performed surgical procedures in practice today. Descriptions of ritual circumcision across cultures, and have been described in ancient Egyptian texts as well as the Old Testament. Approximately, 1.1 million neonatal circumcisions were performed in the USA in 2008 alone and the incidence of this procedure appears to be rising. In a large retrospective review of the Nationwide Inpatient Sample, estimated rates of newborn circumcision have risen from 48.3% nationwide in the years 1988–91 to 61.1% of male newborns from 1997–2001. This represents an increase in incidence of approximately 6.8% per year. Penis Human Anatomy The penis is the male sex organ, reaching its full size during puberty. In addition to its sexual function, the penis acts as a conduit for urine to leave the body. What is the foreskin? The foreskin is a continuation of the skin of the penis shaft which forms a fold over the glans of the penis. Shown to the right are three views labelling the various parts of the foreskin and shaft skin. Since it is a fold, the inner foreskin (in green) and the outer foreskin (in turquoise) are continuous with each other, and also freely mobile with respect to each other. Anatomy Male Foreskin CIRCUMCISION Circumcision is a common procedure in which the skin covering the tip of the penis is surgically removed. Boys are born with a hood of skin, called the foreskin, covering the head (glans) of the penis. In circumcision, the foreskin is removed to expose the head of the penis. It's a quick procedure that causes very little bleeding and stitches aren't needed. Older boys can be circumcised, but the procedure is a bit more involved. After the circumcision, a protective bandage may be placed over the wound, which generally heals on its own within a week to 10 days. TYPES OF CIRCUMCISION Can be divided into two main categories : 1. Traditional Limitations .Glans penis may accidently cut .Has been practiced world wide before the and injured. introduction of modern style surgery of suturing and .Pain during the procedure and stitch. These type of circumcision found practiced in few days to weeks after that. Africa and Asia. .Foreskin did not cut optimally. It .The foreskin is gripped by either fingers or may be cut too little or too much. specially made object (eg. wooden pincers). .Bleeding, unless rapidly .By using sharp knife, a cut is made through the controlled, it may cause a skin between the pincers and head of penis. When profound significant blood lost. the remain skin retracted, it produced a raw .Healing time prolonged circumferential cut area around the shaft of penis. especially those of older .The active bleeding area is then rapidly covered by children or adult. powdered or herbs before applying clean cloth .Immobility, patient was unable wrapping around the cut area to prevent further to freely moved as movements or activities may caused bleeding. bleeding and pain. .Almost all of the traditional method did not use any .Cannot taking bath for some anaesthetic agents. time until wound closure or partial healing occurred. TYPES OF CIRCUMCISION Can be divided into two main categories : Benefits 2. Clinical .reduced rate of injury to glans penis and infections. .Has been practiced world wide before the .minimized and controlled bleeding introduction of modern style surgery of suturing and better. stitch. These type of circumcision found practiced in .less pain or no pain at all with Africa and Asia. introduction of anaesthesia. .The foreskin is gripped by either fingers or . shortened the healing period. .a decreased risk of urinary tract specially made object (eg. wooden pincers). infections. .By using sharp knife, a cut is made through the .A reduced risk of some sexually skin between the pincers and head of penis. When transmitted diseases in men. the remain skin retracted, it produced a raw .Protection against penile circumferential cut area around the shaft of penis. cancer and a reduced risk .The active bleeding area is then rapidly covered by of cervical cancer in powdered or herbs before applying clean cloth female sexpartners. wrapping around the cut area to prevent further .Prevention of balanitis (inflammation of the bleeding. glans) and balanoposthitis .Almost all of the traditional method did not use any (inflammationof the glans and anaesthetic agents. foreskin). .Prevention of phimosis ). METHODS OF CIRCUMCISION

• the Gomco clamp. The most commonly utilized techniques used in the newborn • the Mogen clamp. • the Plastibell clamp. • the “free-hand circumcision” using either the sleeve technique or the dorsal-ventral slit technique is most commonly used. The Gomco Clamp method

Consists of 4 pieces: the bell, platform, hooking arm, and screw. These are assembled after placing the bell completely over the glans and the skin drawn through the hole in the platform. The Mogen Clamp method

The Mogen clamp is used by drawing the skin to be removed into the V and then providing hemostasis followed by amputation. The Plastibell Clamp method

The Plastibell is placed over the glans and a suture is secured over the skin. After several days, the skin will slough and the Plastibell falls off. The “sleeve” method

The “free-hand circumcision” is accomplished in the operating room and involves excising the skin as marked, hemostasis using electrocautery and then reapproximation of the skin edges using absorbable sutures. The dorsal-ventral slit method

The dorsal-ventral slit technique of circumcision involves making these incisions and then removal of the skin between them. Sutures are most commonly used to approximate the skin edges. TIMING OF CIRCUMCISION

• Complications occur more frequently with increasing age of the patient. Bleeding becomes more common during the “minipuberty” of infancy that begins at 4 weeks of age and extends to 3 months of age. This is thought to be due to hormonally mediated increase in penile and prepuce size and vascularity • Based on use of the Neonatal Infant Pain Scale the ideal timeframe for a “pain free” circumcision is during the first week of life. Complications during circumscision

• injury to the glans or amputation. • excessive skin removal. • Bleeding and Hemorrhage • Buried, Concealed, and Hidden Penis • insufficient drawing up of the skin will lead to an incomplete circumcision. • insufficient tightening of the screw results in inadequate compression of the skin and subsequent bleeding. Early circumscision complications • bleeding • pain • inadequate skin removal • surgical site infection tend to be minor and quite treatable. • However, postcircumcision bleeding in patients with coagulation disorders can be significant and sometimes even fatal • Chordee • iatrogenic hypospadias • glanular necrosis • glanular amputation The latter, of course, requires prompt surgical intervention. Late circumscision complications • Epidermal inclusion cysts • Suture sinus tracts • Inadequate skin removal resulting in redundant foreskin • Penile adhesions • Phimosis • Buried penis • Urethrocutaneous fistulae • Meatitis • Meatal stenosis • Infections The fearmost complication: INFECTION Severe infections following circumcision, including necrotizing fasciitis. Presenting signs and symptoms as erythema, induration, pain out of proportion to physical findings, coupled with tachycardia, leucocytosis, or bandemia. Is usually a polymicrobial infection. Empiric broad spectrum antibiotics to cover Gram-negative, Gram- positive, and anaerobic organisms are essential. A suggested regimen is an aminoglycoside, nafcillin, or vancomycin and clindamycin and aggressive debridement of necrotic tissue is required. NECROTIZING FASCIITIS • Commonly called a "flesh-eating bacteria" rare disease can be caused by more than one type of bacteria. These include group AStreptococcus (group A strep), Klebsiella, Clostridium, Escherichia coli,Staphylococcus aureus, and Aeromonas hydrophila, among others. Group A strep is considered the most common cause of necrotizing fasciitis. • Usually, infections from group A strep bacteria are generally mild and are easily treated. But in cases of necrotizing fasciitis, bacteria spread rapidly once they enter the body. They infect flat layers of a membrane known as the fascia, which are connective bands of tissue that surround muscles, nerves, fat, and blood vessels. The infection also damages the tissues next to the fascia. Sometimes toxins (poisons) made by these bacteria destroy the tissue they infect, causing it to die. When this happens, the infection is very serious and can result in loss of limbs or death. FOURNIERS GANGRENE or FASCIITIS OF GENITALS

Fournier gangrene was first identified in 1883, when the French venereologist Jean Alfred Fournier described a series in which 5 previously healthy young men suffered from a rapidly progressive gangrene of the penis and scrotum without apparent cause. This condition, which came to be known as Fournier gangrene, is defined as a polymicrobial necrotizing fasciitis of the perineal, perianal, or genital areas. Male Circumcision and HIV With the publication of several promising studies on the protective effect of Male Circumcision (MC), an additional tool was added to the HIV prevention toolkit. In three ground-breaking studies, in South Africa, Kenya, and Uganda, MC, was shown to reduce the risk of HIV infection in men by up to 60%. Although this protection is not total – and offers no protection against HIV to women – the World Health Organization (WHO) and the Joint United Nations Programme on HIV and AIDS (UNAIDS) have both recommended MC for countries, like Namibia, where the population prevalence of HIV is high and few men are circumcised. Following this recommendation, the potential impact of a national MC campaign on future HIV incidence rates in Namibia was modeled. According to these estimates, scaling up MC to reach 80 percent of adult and newborn males in Namibia by 2015 would avert almost 35,000 adult HIV infections between 2009 and 2025. With only 21% of Namibian men currently circumcised, reaching 80% coverage nationally will be a challenge. Does circumcision of the penis reduce the risk of HIV transmission? • For men who have sex with women: Penile circumcision does provide protection for HIV- negative men who are at risk of HIV infection through vaginal sex with women. Research studies in East and South Africa found that circumcised heterosexual men were approximately 50% to 60% less likely to become infected with HIV than uncircumcised men. The circumcised men were also at reduced risk of herpes, syphilis and human papillomavirus (HPV). • For women who have sex with men: Penile circumcision does not provide protection for HIV-negative women who are at risk of infection through vaginal sex with men. Although an HIV-negative circumcised man is less likely to become infected with HIV through vaginal sex, an HIV-positive circumcised man is not less likely to pass HIV to others. • For men who have sex with men (MSM): Penile circumcision does not provide protection for HIV-negative men who are at risk of HIV infection through insertive and receptive anal sex (topping and bottoming) with other men. However, some studies suggest that circumcision of the penis may protect HIV-negative men from HIV if they engage only in insertive anal sex (topping). Epidemiology

• A prevalence of 1 case in 7500 persons. A retrospective case review revealed 1726 cases documented in the literature from 1950-1999, with an average of 97 cases per year reported from 1989-1998. • In Rundu Intermediate hospital, since 2010 has been received 8, 1 died, representing 12.5% Case # 1

• Male. 31 years old • Referal from Nankudu. • Traumatic injury through the rectum • 7 days later: • Pain, swollen testis, fever 39dg. • DOA:01/02/14 • DOD:30/03/14 • Septic shock . H. C. Admision Case 1 Significant finding on examination of genitalia and perineum Case 1 Debridement under general anaesthesia Case 1 Necrotic tissue removed Case 1 Debridement under general anaesthesia Case 1 Abdominal wall incisions case1 Secondary closure of abdominal incisions not enough scrotal sac for closure Case 1 recovering Case 1 Recovering Case # 2 Male. 28 years old Referal from Katima. Circumcized 02/16 7 days later: Pain, swollen testis, fever 38dg. DOA:18/03/16 DOD:30/04/16 Swab: multibacterial On HAART Surgical+chemical debridment Case # 2 Case # 2 Male 28 years old File: 4656 DOA: 20-04-16 DOD: 13-0516

Case # 3 Male. 34 years old Referal from Katima. Circumcized 10 days later: Pain, swollen testis. DOA:02/12/15 DOD:24/12/15 Swab: multibacterial On HAART Surgical+chemical debridment Case # 3

Case # 4 Male. 28 years old Referal from Katima. Circumcized More a week later swollen penis. Swab: multibacterial No reactive Surgical+chemical debridment Case # 4

Case # 5 dehiscense. 3 days later.casualty at one week later

Male. 18 years old from Kavango. Circumcized More a week later swollen penis,septic wound. Swab: multibacterial No reactive Surgical+chemical debridment Case # 5

Case # 5 Case # 6

Male. Adult. Looks more than 40 years old from village near Katima. Not circumcized More than 15 days with pain and swollen testis Treated by a traditional healer. Swab: multibacterial reactive Surgical+chemical debridment

Case # 7 Male. Adult. 54 years old from rundu Not circumcized More than 7 days with pain and swollen testis, open septic wound Well known diabetic patient not reactive Swab: multibacterial Surgical+chemical debridment Passed away 1 week after debridment.

Caso # 8 Male. Adult. 38 years old from a village Not circumcized Many days with pain and swollen testis, nothing remarkable not reactive. Trauma pulling a cow. Swab: multibacterial Surgical+chemical debridment Passed away 1 week after debridment.

Case # 9 Male. Adult more than 30 years old. Not circumcized Many days with pain and swollen testis. On HAART. Swab: multibacterial Surgical+chemical debridment

CONCLUSIONS

• The general factors inducing genitals fasciitis in this presentation are the following: imunodepression, Diabetes, trauma, lack of hygiene. • Circumcision does not affect male sexual drive or functioning. • When a guy is not circumcised, moisture can get trapped between his penis and the foreskin, which creates an ideal environment for bacteria to grow. This means there’s a higher risk of infection and it’s easier to spread viruses to others. • Being circumcised reduces your female partner’s risk of cervical cancer. • By getting circumcised, you not only reduce your HIV , but your partner’s too. RECOMMENDATIONS • To increase the educative promotion using social media, about the need and importance of the circumcision in communities, homes, schools, jobs, neighborhoods, towns, HIV institutions, hospitals, clinics. • To increase the health promotion about the importance of a good personal hygiene. • To increase the circumcision programmes. • To promote exchange of experiences and knowledges about circumcision between differents hospitals in events and conferences. REFERENCES 1. Circumcision: A History of the World's Most Controversial Surgery. By Dr. David L. Gollaher. • 2. Male Circumcision Reduces Risk of HIV Acquisition for as Long as Seven Years. By Dr. Thomas, J. 3. Male Circumcision: A Gender Perspective. By Dr. Zoske, Joseph 4. Ministry of Health and Social Services. Policy on male circumcision for HIV prevention. 5. http://www.webmd.com/sexual- conditions/guide/circumcision.

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