Meatal Stricture Following Neonatal Circumcision

Introduction  Circumcision is the most widely practised surgical procedure in the world. One sixth of the male popuiation have a ritual circumcision. The procedure was formerly exclusively per­formed by lay practitioners, jewish rabbis and barbers with physicians playing no role in the performance and it was a purely religious rite up to the late 19th Century.  Abraham apparently first advocated its performance, although jewish regard Moses as the originator. Jews circumcise their boys on the 7th day of life and it is obligatory that it should be performed by their religious officials.  Moslems, except Iranians, also circumcise within the neonatal period. However, amongst the Iranians the circumcision is usually per­formed at the age of 4 years with a ceremony called circumcision party or "Kha tnah Sooran".  Other faiths and nationalities have accepted circumcision for medical reasons. There are various medical indications, but the firmly-held beliefs of parents, grandparents, nurses, mid­wives and many doctors are the commonest reasons for an early operation.  Mat.erials and Methods  A follow-up of 100 children who had been circumcised within their neonatal period has proved a high incidence of this disabling serious complication and during 1961 to 1969 out of more than 1500 early circumcised children, 300 cases of meatal stricture were recorded at Nemazee Hospital, Shiraz.  Figure 1-2 demonstrates an example of well established stricture.  Out of the 100 circumcised babies, 53 ulcers and strictures were demonstrated, but in another 100 children who underwent circumcision at the ages of 3 or 4, no such complication occurred.  Discussion  The prepuce has a protective role for an infant in napkins. If the operation were post­poned until the babies are out of napkins, then fewer complications would occur. Normally, the prepuce is nonretractile for the first 9 - 15 months of life. It is men-retractile in 4 out of 5 males babies at the age of 6 months, in 50% at the age of 1 year and in 10% at the age of two years.  The prepuce also protects the glans from meatal ulceration. At birth there is a layer of squamous cells between the glans and the pre­puce and these cells usually begin to degenerate sometimes between 6 and 18 months and then the prepuce becomes fully retractile.  During the neonatal period the glans is very sen·sitive and exposure of the unprotected glane to the urine-soaked diapers leads to amo­niacal. dermatitis and meatal ulcers. Amoniacal dermatitis is extremely common and is caused by urea-splitting organisms in the infants feces acting on the urea in the urine and decomposing it into amonia. Meatal ulcers due to diaper sores and amoniacal dermatitis are common in those neonates which have undergone circum­c1s10n. The sensitive glans become ulcerated and scarring of the meatal orifice forms stric­ture. Meatal stricture itself can again again cause more severe complications such as urinary infections, urinary calculi, rectal prolapse and inguinal hernia. Irritability of circumcised babies is also related to these ulcers.  The type of diapering seems also to play a significant role. When wearing waterproof pants 18 out of 25 babies had ulcers and :stric­tures. The reasons that the frequency of meatal ulcerations and strictures is not well appreciated is due to the fact that obstetricians perform the neonatal circumision, the pediatri­cians then must take care of the early complica­tions and then the surgeons are handed cases of late complications.  Conclusion There is no doubt that there are many genuine indications for circumcision and that many parents are happier when the procedure has been completed. But because of the high incidence of meatal ulcers and ·strictures follow­ing early circumcision, a plea is made to post­pone the procedure until the diaper-stage has been passed.