Abstract

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Circumcision is one of the commonest surgical procedures performed by Urologist. Complication rates varies worldwide. Urinary retention after circumcision is an uncommon complication. We report a case that happened after an open circumcision to highlight its existence.

Introduction

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Circumcision is one of the commonest surgical procedures performed by any Urologist. The main medical indications include Balanitis xerotica obliterans (BXO), Paraphimosis, Phimosis, and Balanoposthitis. A number of techniques are used with the open method being the preferred option by the Urologist. The common complications include infection, bleeding,altered sensation, poor comestic outcome and scar tenderness.These are highlighted in the information leaflet and consent form recommended by the British Association of Urological Surgeons (BAUS). Urinary retention is a very uncommon complication. The few reported cases in literature have occurred mainly in neonates and infants who were circumcised (for religious or social reasons) using plastibell.1-3

We report a case of urinary retention that occurred after a routine open circumcision to highlight this rare complication.

Case Report

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An eleven year boy was referred to his local Urologist by his GP on account of a phimosis. He had had a single episode of balanitis. After review in the outpatient he was consented for a circumcision. He was electively  admitted for surgery, had a general anaesthetic with gas induction and was given a penile block using 10mls of 0.25% bupivacaine with good effect. He then had a routine open circumcision utilizing the dorsal slit method. He had vaseline gauze dressing applied loosely and had unremarkable post operative period in recovery. He was discharged 6-8 hours post operatively without having passed urine. He presented 30 hours post operatively with a history of not having passed urine since the operation. On examination, he had a tender palpable bladder. An assessment of acute urinary retention was made. He was managed conservatively by being put into a bath filled with warm water and he voided to completion.

Discussion

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The incidence of complications of circumcision varies from 0.2-10% depending on which series is taken.4-6 It is dependent on the type of circumcision, the experience of the practitioner and the age of the patient.4 Urinary retention as a complication has been reported in cases using a Plastibell.1,2 To our knowledge no cases of urinary retention have been reported following the open methods of either dorsal slit or sleeve.

Our patient had a penile block, which is now a standard measure for post operative analgesia in penile surgery as it is associated with less likelihood of experiencing urinary retention or voiding difficulties.4

The likely pathophysiology of his urinary retention would be a combination of factors including, post operative swelling, the penile block, fear and pain. 5

Most cases like the index one will respond to simple measures such as sitting in a bathtub of warm water or taking a warm shower, very rarely will a child need catheterization to relief his retention. A review of the literature showed that in the few reported cases, simply removing of the plastibell or dressing was sufficient to allow return of voiding.1,2

Conclusion

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Although very rare, we think it is important to ensure that parents/patients are aware of the possibility of urinary retention and given instructions on what to do if it happens. We also recommend that protocols such as making sure patients void prior to discharge will help prevent similar cases.

References

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1. Mihssin N, Moorthy K, Houghton PW. Retention of urine: an unusual complication of the Plastibell device. BJU Int 1999;84(6):745
2. Jee LD, Millar AJ. Ruptured bladder following circumcision using the Plastibell device. Br J Urol 1990;65(2):216-7
3. Berman W. Urinary Retention Due to Ritual Circumcision. Pediatrics Vol. 56 No. 4 October 1, 1975:621
4. Weiss HA, Larke N, Halperin D, Schenker I. Complications of circumcision in male neonates, infants and children: a  systematic review BMC Urology 2010, 10:2
5. Ozdemir E. Significantly increased complication risks with mass circumcisions. Br J Urol, 1997,80(1):136–139.
6. Cathcart P, Nuttall M, van der Meulen J, et al. Trends in paediatric circumcision and its complications in England between 1997 and 2003. Br J Surg 2006;93:885-890
7. Cyna AM, Middleton P. Caudal epidural block versus other methods of postoperative pain relief for circumcision in boys. Cochrane Database Syst Rev 2008; 8:CD003005.  
8. Metzelder ML, Kuebler JF, Glueer S, Suempelmann R, Ure BM, Petersen C. Penile block is associated with less urinary retention than caudal anaesthesia in distal hypospadias repair in children. World J Urol 2010;28:87-91.

Source(s) of Funding

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None

Competing Interests

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None

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