Abstract

Background: Circumcision is one of the most common surgical procedures globally, yet complications remain prevalent in traditional practice where untrained practitioners often operate under unsafe conditions. This remains a preventable cause of penile-scrotal morbidity in children. This review uses three index cases to illustrate the wound-healing and scarring consequences of traditional circumcision in Ghana, while contextualizing them within the broader literature. Methods: Three pediatric cases from South-Eastern Ghana were reviewed: a 4‑month-old male with penoscrotal denudation, and two boys aged two and four years with post-circumcision phimosis, meatal stenosis, and buried penis. A narrative review of 120 screened records with 24 included relevant articles was conducted (PubMed, Scopus, Cochrane, Google Scholar) to synthesize evidence on circumcision complications, reconstructive strategies, and scar-related outcomes. We then illustrated key injury patterns with the three paediatric cases managed in the study area. Results: Case 1 (penoscrotal denudation) was reconstructed with dartos-fasciocutaneous flaps; complete epithelial coverage by postoperative day 7. Case 2 (post-circumcision phimosis + meatal stenosis, buried penis) underwent release + meatotomy/meatoplasty; meatal calibre improved from 2 French to 8 French at 2 weeks. Case 3 (phimosis + meatal stenosis) had release + meatotomy/meatoplasty; peak urinary stream increased from “pin-hole” to a continuous stream with post-void residual 0 mL at 2 weeks. Across the literature, common complications included infection, haemorrhage, penile skin loss, urethral fistula, phimosis, and meatal stenosis; timely salvage using local flaps and meatotomy/meatoplasty yielded favourable outcomes. Conclusions: Training and oversight for traditional circumcisers, aseptic technique, and early referral reduce morbidity. Reconstruction using dartos-fasciocutaneous flaps and meatotomy/meatoplasty are effective salvage options in resource-limited settings.

Keywords

Circumcision, Traditional Circumcision, Penile Complications, Scrotal Injuries, Scar Outcomes, Pediatric Urology, Reconstructive Surgery

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1. Introduction

Circumcision is a widespread surgical procedure performed for cultural, religious, and medical reasons, with an estimated one-third of males globally undergoing circumcision [1] [2]. While medical circumcision is generally safe, complications arise when performed by untrained traditional circumcisers who often lack the necessary anatomical knowledge, sterilization practices, and access to proper medical facilities [1] [2].

In sub-Saharan Africa, traditional circumcision remains prevalent due to deep-rooted cultural and religious practices. However, this approach is associated with significant risks, including infections, hemorrhage, urethral fistulae, penile and scrotal tissue loss, and even mortality. Studies in Nigeria and Kenya by Magoha (1999) and Peltzer & Kanta (2009) have documented higher rates of complications in traditional circumcision compared to those conducted in formal medical settings [1] [2].

This narrative review examines penile and scrotal complications related to circumcision. Drawing insights from three cases: (an index case of penoscrotal denudation [3] and two other cases of post-circumcision phimosis and buried penile shaft) and existing literature, it underscores the critical need for bridging the gap between traditional and medical practices to improve patient outcomes.

The index cases that provide the context for this narrative review illustrate the devastating consequences of such practices. A 4-month-old male presented with extensive penile and scrotal tissue loss following circumcision by a traditional herbalist [3]. The two other cases had post-circumcision phimosis and buried penile shaft. This narrative review builds on the experience of the index cases to explore the broader implications of traditional circumcision practices, their associated risks, and effective management strategies.

The gap between traditional and medical practices highlights the need for regulated training and supervision to reduce complications. Additionally, while medical circumcision techniques such as the dorsal slit and sleeve resection have proven effective in minimizing adverse outcomes [4]-[6], the lack of accessible medical facilities in rural and resource-constrained settings continues to push communities toward traditional methods.

2. Methods

A search in peer reviewed databases (Google Scholar, PubMed, Cochrane Library and Scopus) was done using the keywords, Traditional Circumcision, Penile and Scrotal Injuries, Trapped Penis, Meatotomy-meatoplasty, Dartos Flaps, Circumcision Complications, Herbal Circumcisers. Pertinent literature on the subject matter was reviewed within the delimited context of Penile and Scrotal Complications of Male Circumcision, and the index cases in this narrative review.

Ethics and consent: This work conformed to the Declaration of Helsinki and local policy. The submission reports anonymized case descriptions and non-identifiable images. Written parental/guardian consent for publication—including clinical photographs—was prospectively obtained for all three children, with consent forms on file. No patient received experimental therapy; management followed standard of care.

3. Case Context and Literature Review

3.1. Case Reports

Case 1 (4-month-old, penoscrotal denudation): Traumatic skin loss after traditional circumcision [3]. Emergency wound toileting/debridement and dartos-fasciocutaneous flap coverage achieved complete epithelialisation by post-op day 7; normal voiding and penile tumescence at 6-week review (Figure 1 shows pre-operative appearance and Figure 2 shows post-operative outcome).

Source: Image taken personally by authors in Theatre in June 2024.

Figure 1. This pictograph shows a deep scrotal laceration involving both hemi-scrota with both testicles and coverings exposed (Penoscrotal denudation).

Source: Image taken personally by authors in Theatre in June 2024.

Figure 2. Preliminary results; 5 days after the primary closure in theatre, epithelialization was excellent at this time, and was optimal by 7 days post-operative.

3.2. Case 2 and Case 3

Case 2 (2-year-old circumcised by a traditional circumciser at a home setting without anesthesia or aseptic technique): Patient presented with post-circumcision phimosis, meatal stenosis, buried/inconspicuous penis; ultrasound showed no hydronephrosis. Surgical release, plus meatotomy/meatoplasty restored voiding; meatal calibre improving from 2 to 8 French at 2 weeks. Parents reported normal nocturnal penile tumescence by six weeks post-operative period. (Figure 3: pre-operative appearance; Figure 4: post-operative result).

Source: Image taken personally by authors in september 2024.

Figure 3. Post circumcision phimosis and meatal stenosis with a buried penis/penile entrapment in a two-year-old Boy after circumcision by a traditional circumciser. Some wetness from a urine spurt can be observed over the skin of the perineum on the patient’s right side. This came from a forced urine jet that spurted as the patient strained to urinate (through the pin-hole meatus) during gentle physical examination. The bladder was not distended on physical examination. There was no bladder distention or hydronephrosis on ultrasound.

Case 3 (4-year-old, also circumcised by a traditional circumciser at a home setting without anesthesia or aseptic technique): He had post-circumcision phimosis with meatal stenosis also managed by surgical release, plus meatotomy/meatoplasty. The initial pin hole meatus with pencil shaped urine spurts on straining (at presentation) improved to a continuous urinary stream and a post-void residual urine of zero mL at 2 weeks post-operatively (Figure 5).

Source: Image taken personally by authors in September 2024.

Figure 4. Post circumcision phimosis and meatal stenosis in a four-year old boy after circumcision by a traditional circumciser.

Source: Image taken personally by authors in September 2024.

Figure 5. Post-operative appearance for both cases after salvage surgeries involving a release of phimosis and buried penis, followed by meatotomy and meatoplasty.

4. Literature Review, Circumcision Practices

4.1. Traditional Circumcision Practices

Traditional circumcision is deeply rooted in cultural and religious practices but is often conducted without medical supervision. Studies by Magoha (1999) and Peltzer and Kanta (2009) demonstrated higher complication rates in traditional settings due to the absence of sterilized tools, insufficient anatomical knowledge, and limited capacity to manage emergencies [1] [2].

4.2. Medical Circumcision Techniques

Table 1. Literature review [1] [2] [4]-[10].

Medical circumcision techniques have been shown to significantly reduce complications. Vakalopoulos et al. (2015) highlighted, that techniques such as the dorsal slit and sleeve resection allow for better control, visibility, and reduced risk of tissue damage [4]. Barone et al. (2012) further emphasized that device-assisted methods, such as the Gomco clamp and Plastibell device, provide consistent outcomes with minimal complications when used appropriately [5].

As summarized in Table 1, Medical methods of circumcision include a dorsal slit, sleeve resection, guillotine, Gomco clamp, Plastibell, Mogen clamp, Shang Ring, and PrePex device, each with specific benefits and risks [1] [2] [4] [7]-[10].

5. Discussion

5.1. Overview of Complications

Circumcision, while considered a simple and routine procedure, is not without risks, especially when performed by untrained traditional practitioners. Complications associated with male circumcision are diverse and range from minor issues, such as mild bleeding and infections, to severe outcomes, including penile and scrotal tissue loss, urethral fistulae, and glans amputations, post circumcision phimosis, buried penis, meatal stenosis [1] [2]. The severity of these complications is often amplified in non-medical settings due to inadequate sterilization techniques, lack of anatomical knowledge, and absence of emergency preparedness [1] [2].

Table 2. Overview of complications of circumcision [1] [2] [4] [6].

Table 3. Scrotal skin complications [5] [7]-[10].

Table 4. Penile skin complications [11]-[21].

Table 5. Dual complications of scrotal and penile skin.

5.2. Penile Injuries

Penile injuries are among the most severe complications of circumcision [1]-[21]. These injuries include skin degloving, glans necrosis, and urethral damage [13]. According to Gao et al. (2019), penile resurfacing using flaps pedicled on the scrotal artery has been shown to be an effective reconstructive approach for managing severe skin loss [14]. Additionally, Qaid et al. (2022) reported successful outcomes with scrotal flap advancements for repairing extensive penile skin defects caused by ritual circumcision [13]. These techniques underscore the critical role of surgical innovation in managing post-circumcision penile injuries (Tables 2-5).

5.3. Scrotal Injuries

Scrotal injuries during circumcision, though less common, can lead to significant functional and cosmetic challenges. Bar-Yosef et al. (2019) highlighted the rarity of scrotal injuries during neonatal circumcision, reporting that most cases were superficial and could be managed with suture closure [12]. However, complex injuries involving multiple layers, as seen in the index case 1, require more advanced reconstructive techniques (Tables 3-5).

5.4. Index Case 1: Dual Complications

The first index case involved a 4-month-old male who presented with extensive penile skin degloving and scrotal lacerations. The complications, including the exposure of the tunica vaginalis and loss of multiple tissue layers, underscore the risks associated with untrained practitioners performing circumcisions. Immediate surgical intervention using dartos and scrotal flaps restored functionality and aesthetics, aligning with findings from Qaid et al. (2022), who reported similar success in reconstructive surgery for penile defects [13].

The combination of penile and scrotal injuries, as observed in this index case, represents a rare and challenging scenario. This dual presentation complicates management, as both anatomical and functional considerations must be addressed simultaneously. Surgical reconstruction using local tissue flaps, such as dartos and scrotal flaps, has proven effective in restoring form and function. This approach aligns with findings by Ignjatović et al. (2010), who reported successful outcomes using full-thickness skin grafts for extensive penile and scrotal defects [15].

5.5. Index Cases 2 and 3

These two other cases exemplify delayed but salvageable complications from traditional circumcision practices commonly performed without anesthesia or sterile technique in sub-Saharan Africa [1]-[3]. The presentation of post-circumcision phimosis, meatal stenosis, and buried/trapped penis—absent systemic infection or renal compromise—underscores the anatomical but non-systemic nature of such injuries [11] [20]. Surgical management with phimosis release, meatotomy, and meatoplasty yielded good outcomes, aligning with pediatric urologic reconstruction standards [6] [8] [13]. These cases reiterate the documented burden of complications linked to unskilled circumcision and support calls for policy reforms and community education to integrate safety and standardization into cultural practices [2] [3] [21] [22].

5.6. Management of Penile and Scrotal Injuries

Scrotal flaps and full-thickness skin grafts are among the most effective techniques for managing extensive genital injuries. Gao et al. (2019) demonstrated the efficacy of scrotal artery pedicled-flaps in resurfacing penile defects, achieving favorable cosmetic and functional outcomes [14]. Bar-Yosef et al. (2019) also highlighted the adaptability of scrotal tissue in neonatal circumcision-related injuries, noting successful outcomes with tissue flaps and suture closures [12]. See Tables 2-5.

5.7. Factors Contributing to Complications

Several factors contribute to the high complication rates observed in traditional circumcision settings.

Lack of Training: Traditional practitioners often lack formal medical training, leading to improper surgical techniques and increased risk of complications [2] [5].

Inadequate Sterilization: The absence of sterilized instruments in traditional settings significantly increases the risk of infections [1].

Delayed Presentation: In many cases, patients seek medical attention only after complications have become severe, further complicating management [8]. This situation was observed in the index cases 2 and 3.

5.8. Surgical Innovations and Advances

Advancements in surgical techniques have improved outcomes for circumcision-related injuries. Scrotal flaps, as highlighted by Gao et al. (2019), provide a reliable and versatile option for reconstructing penile and scrotal defects [14]. Similarly, Ignjatović et al. (2010) demonstrated the efficacy of full-thickness skin grafts for complex cases involving extensive tissue loss [15]. These innovations emphasize the importance of skilled surgical intervention in mitigating complications.

5.9. Need for Regulatory Oversight

The World Health Organization (WHO) and other health bodies advocate for increased regulation of traditional circumcision practices. A WHO-affiliated systematic review of surgical voluntary medical male circumcision (VMMC) safety (40 studies) estimated moderate/severe adverse events at ~0.30 per 100 clients, with higher infection-related adverse events in boys aged 10 - 14 years. Rare but serious events (e.g., tetanus, glans injury) were also reported; the authors call for robust safety surveillance as programs mature [23]. In 2023, WHO issued a landscape report on sustaining safe VMMC services, re-affirming VMMC’s role in combination HIV prevention while emphasizing quality, age-appropriate services, and prevention of urethrocutaneous fistulae through surgical best-practice and supervision [24]. These updates support our conclusion that training, oversight and early referral are central to harm-reduction in settings where traditional circumcision persists.

5.10. Regulatory and Educational Interventions

The World Health Organization (WHO) advocates formal training programs for traditional practitioners to enhance their understanding of aseptic techniques and anatomy [9]. Collaborative efforts between traditional and medical practitioners can help bridge the gap in knowledge and improve outcomes [3]. Public awareness campaigns are also essential to educate communities about the risks of unregulated circumcision and encourage safer practices [1] [15]-[19].

6. Limitations

This is a narrative review anchored by a small, single-centre case series, which limits generalizability and precludes incidence estimates. Selection and publication bias are likely (severe or unusual cases are more often reported). The literature base varies in quality, with heterogeneous definitions of complications and follow-up intervals. Finally, timelines and outcomes in our three cases reflect specialist availability in a referral setting and may not be reproducible in all resource-limited contexts.

7. Conclusions

This narrative review highlights the significant risks associated with traditional circumcision practices and the effective management of penile and scrotal complications through principled salvage-surgical techniques. Recommendations targeted at the national health authorities are suggested here. The lessons and experience from the index cases, underscore the need for urgent corrective measures.

Key recommendations to the national healthcare authorities, include Providing formal training in aseptic techniques and anatomical knowledge [9]. Establishing collaborative frameworks between traditional and medical practitioners to bridge gaps in practice [3]. Conducting community awareness campaigns to educate the public about the risks associated with unregulated circumcision [1]. Through these measures, complications arising from circumcision can be minimized, ensuring better outcomes for patients.

Funding

This research received no external funding. It was entirely self-funded by the authors with in-kind institutional support from the University of Health and Allied Sciences, Ho, Ghana.

Ethics Statement

This work conformed to the Declaration of Helsinki and local policy. The submission reports anonymized case descriptions and non-identifiable images. Written parental/guardian consent for publication—including clinical photographs—was prospectively obtained for all three children, with consent forms on file. No patient received experimental therapy; management followed standard of care.

Author Contributions

Frank Obeng (FO): Conceptualization, observation, field intervention, literature review, manuscript drafting, supervision, and final approval.

Mahamadu Ayamba Ali (MAA), Aishah Fadila Adamu (AFA), Karen Michelle Anyebanying Whittal (KMAW): Literature search, digital illustration and reconstruction, data synthesis, manuscript drafting, supervision and critical revisions.

Both authors meet the ICMJE authorship criteria, take full responsibility for the integrity of the work, and have approved the final version of the manuscript.

Conflicts of Interest

The authors declare that they have no competing interests.

References