While not as common as skin infection or penile adhesion formation, cicatrix formation – excessive scar tissue which can cause a “trapped penis” – remains a challenging complication after neonatal circumcision. Surgical correction under general anesthesia is the most aggressive treatment option, but there are many reasons to avoid it when possible. The most widely-used non-operative treatments are stretching the scar tissue with a hemostatic clamp or an outpatient course of topical steroids, but the risk of cicatrix reoccurrence persists with either.
For the last few years, members of the Section of Urology at Nationwide Children’s Hospital actually have been combining the two non-operative treatments in order to try to prevent cicatrix recurrence. They have demonstrated in a recent publication that the combination produces excellent results and a low risk of reintervention.
“This is a challenging situation, because these are very young infants, and the parents understandably want an effective treatment that reduces the chance that the child would need more invasive surgical procedure,” says Seth Alpert, MD, a urologist at Nationwide Children’s and lead author of the study, published in the Journal of Pediatric Urology. “Our method can be completed entirely on an outpatient basis and often completely resolves the issue.”
The study considered a case-series of 33 patients who underwent neonatal circumcision and who subsequently presented with cicatrix at a mean age of 2.7 months. In each case, a surgeon used topical lidocaine cream and/or an injected lidocaine local penile block, then stretched the cicatrix tissue with a hemostat to tear the scar and release the trapped penis. Caregivers then applied a betamethasone steroid cream to the scar site twice per day for a mean time of almost four weeks.
A total of 27 patients, or 82 percent, healed with no further intervention needed. One patient underwent a repeat of the combination procedure; three patients needed further lysis of adhesions in the office; and two needed circumcision revision to remove excess foreskin.
The study both illustrates the process and the good cosmetic outcomes that often occur.
“With this combination protocol, we largely avoid the need for additional procedures and general anesthesia in the operating room, and our experience leads us to believe that we are reducing the recurrence rate,” says Dr. Alpert. “Based on this experience, we think other pediatric urologists should consider the combination treatment option as well.”
Alpert SA, Ching CB, DaJusta DG, McLeod DJ, Fuchs ME, Jayanthi VR. Combination treatment for cicatrix after neonatal circumcision: An office-based solution to a challenging problem. Journal of Pediatric Urology. 2018 Oct; 14(5):471-475.