Acute venous stasis and swelling of the lower abdomen and extremities in an infant after circumcision.

© 2003 Canadian Medical Association or its licensors A an uneventful pregnancy and delivery, a healthy male infant was born at 39 weeks’ gestation and circumcised by his family physician on the sixth day of life. In the subsequent 36 hours, the boy continued to wet diapers, but had progressive irritability and lethargy, and was brought back to the family physician for reassessment at the age of 8 days. His lower abdomen and lower limbs were noted to be mottled, cyanosed and edematous, and the boy was referred to a local pediatrician who was concerned about a possible acute inferior vena cava thrombosis. A full abdominal examination of the unconsolable infant was impossible, however, a very slow but continuous dribble of urine was noted despite a Plastibell circumcision ring that may have been partly obstructing the urethral meatus. A urethral catheterization was attempted, but this could not be achieved because of meatal obstruction. The infant remained irritable, but his vital signs were stable. His abdominal distension and lower extremity venous congestion and cyanosis were confirmed. Portable abdominal radiographs showed a massive distended bladder with evidence of lumbar scoliosis (Figs. 1 and 2). (Arrowheads denote bladder outline on radiographs.) The boy was thought to have a Plastibell ring urethral meatus obstruction leading to enlargement of the bladder, which blocked the inferior vena cava, resulting in acute venous stasis of the lower abdomen and extremities. Using a 25-gauge butterfly needle, 200 mL of urine was aspirated suprapubically. Subsequently, the infant appeared calmer and the Plastibell ring was successfully removed by cutting the string that held it in place. When trying to cut the string, it was noted that the ring was embedded in the glans penis. The baby proceeded to pass spontaneously over 600 mL of urine in the following 12 hours. Over the next 36 hours he continued to urinate, and his venous engorgement and cyanosis disappeared. His penis appeared normal. The patient had no further problems or complications.