Circumcision, while simple, is less so with age and thus growth in size of the penis. ‘Complications’, although low, are generally about 10-fold higher than in infancy.
In the Kenyan RCT 1.7% of the men had an adverse event. Of these, the most common were postoperative bleeding (0.4%) or infection (0.4%), followed by wound disruptions (0.3%), delayed healing (0.2%), and swelling at the incision site (0.1%) [56, 311]. One man had an adverse reaction to an excess of the local anesthetic. In this trial, 96% of the men had returned to normal activities, including work, by day 3 following circumcision. At 3 days 48% reported no pain, 52% mild pain, none having severe pain. By the 8 day visit 89% reported no pain and 11% mild pain. By 30 days the wound had healed completely in 99% and by 3 months 100%. By one month all had returned to normal activities.
In the South African RCT 3.8% had an adverse event as follows: pain (0.8%), excessive bleeding (0.6%), infection (0.2%), swelling or hematoma (0.6%), problems with appearance (0.6%), damage to the penis (0.3%), insufficient skin removed (0.3%), delayed wound healing (0.1%), anesthesia-related event (0.06%) [43]. At 21 months follow-up the following were seen in 1.0%: problem with urinating (0.3%), dissatisfaction with the appearance of the penis (0.4%), mild or moderate erectile dysfunction (0.4%).
In the Ugandan RCT the rate of moderate adverse events was 3% and severe 0.2% [216], ie, 0.2 events per 100 surgeries. The severe events included 1 wound infection, 2 hematomas that required re-exploration and ligation of bleeding vessels, one wound disruption due to an external cause, and one postoperative herpetic ulceration [216]. All were successfully managed and they all resolved.
An average of 3.8% adverse events has been seen for the first 1-100 circumcisions a clinician does [311]. For the next 100 this drops to 2.1% and by the time they have done 200-400 this drops to less than 1%. Beyond 400 it is 0.7%.
In boys up to age 15 in the UK, 1.5% experienced a complication [104]. These included hemorrhage (0.8%), infection (0.3%) and requirement to return to theatre (0.5%).
Wiswell and co-workers examined records of boys circumcised in US Army Hospitals after the neonatal period (mean age 2.9 years), in whom 93% was by ‘sleeve’ or ‘freehand’ resection under general anesthesia in 91% [637]. Eight of 476 experienced a complication, namely excessive bleeding (3; 0.6%), malignant hyperthermia (2; 0.4%), aspiration pneumonia (1; 0.2%), large hematoma (1; 0.2%) and postoperative fever (1; 0.2%).
In Turkey, circumcision of boys aged 1.5-14 (mean 7 years) by unlicensed traditional circumcisers led to a far greater number of complications (85%) compared with those performed by surgeons in a sterile hospital setting (2.6%); the boys were aged 2-13 (mean 6) [34]. For example, excessive bleeding (23% vs. 1.2%), infection (14% vs. 0.5%), hematoma (6% vs. 0.2%).
The rate of complications for boys in Iran mostly operated on by traditional circumcisers was 7.4%, including excessive residual foreskin (3.6%), excessive skin removed (1.3%), meatal stenosis (0.9%), granaloma (0.7%), penile rotation (0.5%), secondary cordee (0.2%) [655].
Circumcision of Muslim boys by medical personnel during circumcision festivities in the Comoros Islands was associated with a low (2.3%) complication rate, mostly infections (1.5%) [9].
Thus circumcision is quite a safe procedure, with a low rate of complications, most of which are immediately and easily treated. However, the rate of complications is 10 times higher in men and older children than in infants, making infancy the best time to circumcise for this and other reasons.
One should be aware that many men are incorrectly advised to ‘put up’ with a problem caused by their foreskin rather than have a circumcision. Early elective surgery eliminates or greatly reduces the risk of getting such problems in the first place, and later circumcision will ensure they or other problems are avoided or reduced substantially.
