Introduction

Circumcision is one of the oldest recorded surgical procedures and is widely practiced with an average of 1 million newborn males circumcised yearly in the United States alone. Disposable plastic clamps have been developed to simplify adult circumcisions in developing countries with the aim to decrease human immunodeficiency virus (HIV) transmission. With the heightened interest in the simplification of the procedure has come increased accessibility to various circumcision clamps via Internet vendors. This provides those that would rather avoid visiting a trained professional, the opportunity for self-circumcision.

Case Presentation

Patient is a 31-year-old male, previously uncircumcised, with complaints of a deflected urine stream secondary to redundant foreskin. To obviate the need to retract his prepuce prior to voiding, he purchased a disposable plastic circumcising clamp from an Internet supplier to perform his self-circumcision (Figure 1). Five days after placement, the clamp was removed along with the redundant foreskin, and the patient noticed ventral separation of the skin edges. He then placed a single, midline, interrupted, 2-0 chromic stitch in the attempt to re-approximate the skin edges but was unable to place additional sutures due to discomfort (Figure 2). He then attempted to re-approximate the remaining dehiscence with skin glue but was unsuccessful. The patient presented to the emergency department approximately 36 hours following removal of the clamp at which point the urology service was consulted. No signs or symptoms of infection were noted and granulation tissue was present so conservative management with bacitracin ointment was decided upon. He was discharged home from the emergency department that day and returned to our clinic one month later. On follow-up, the wound was noted to have healed well with no significant sequelae.

Discussion

Circumcision is one of the oldest surgical procedures in history (1) and is widely practiced in the US, with an average of 1 million newborn males circumcised yearly (2). The benefits of circumcision are numerous, including prevention of phimosis, paraphimosis, balanoposthitis as well as a decreased risk of penile cancer and HIV (3). Despite this, up to 30% of adult males are uncircumcised in the US (2). Cultural practices of circumcision are common in regions such as sub-Saharan Africa, the Philippines, and Indonesia. The Abrahamic faiths exercise this ritual within the first week of birth with the belief that those who are circumcised are ‘purified’ in the eyes of God. The most popular belief of circumcision in these sub-Saharan African and Southeast Asian cultures is that it is a right of passage to manhood. Other reasons include proof of masculinity, self-identity, and spirituality. Circumcision is also practiced in these regions due to psychosocial dynamics. The idea here is that some ethnic groups, such as Dogon and Dowayo of West Africa, believe that the foreskin represents the female aspect of the penis and must be removed in order to transition to manhood (4). The indications for circumcision in the adult male include the preventable conditions listed above as well as excessive foreskin redundancy, frenular tears and patient preference due to social, religious or personal motivations as alluded to above (5). Recently, there has been increased interest in the procedure after three large randomized-controlled trials showed evidence that circumcision reduces transmission of HIV between 51% and 60% (6,7,8). Not surprisingly, these studies have lead to the advent of new technology aimed at simplifying the manner in which circumcisions can be performed, particularly in the form of clamps (9). The relative simplicity of clamp-assisted circumcisions has lead to an increase in accessibility to the devices, to the point that various clamps are now available for purchase via the Internet. It is important that patients be made aware that regardless of how easy these devices appear to use, they should only be utilized by those with the appropriate training. The dilemma lies in how to appropriately inform these specific patients on the potential complications of self-circumcision including: infection, bleeding, urethrocutaneous fistula, penile amputation, disfigurement, penile shortening, neurovascular injury, or even erectile dysfunction. With continued availability of these devices, however, urologists should be prepared to manage cases of poorly executed self-circumcision.

Conclusion

With the commercial availability of circumcising clamps, we may begin to see an increase in complications from patients that attempt to perform their own circumcisions at home. The dilemma lies in how to appropriately inform these specific patients on the potential complications of self-circumcision. With continued availability of these devices, however, urologists should be prepared to manage cases of poorly executed self-circumcision.

Ethics

Informed Consent: Informed consent was obtained.

Peer-review: Internal peer-reviewed.

Authorship Contributions

Surgical and Medical Practices: Tim Suttle, Concept: Timothy Rogers, Tim Suttle, Hesham Mostafa, Design:    Timothy Rogers, Tim Suttle, Hesham Mostafa, Data Collection or Processing: Timothy Rogers, Omar Mostafa, Analysis or Interpretation: Timothy Rogers, Omar Mostafa, Literature Research: Timothy Rogers, Omar Mostafa, Writing: Timothy Rogers, Omar Mostafa.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.