1411Vol. 11 | No. 02 | March- April 2014 |U R O LO G Y J O U R N A L 1 Department of Pediatric Sur- gery, Faculty of Medicine, Izmir University, Izmir, Turkey. 2 Denizli State Hospital, Clinics of Pediatric Surgery, 20.100, Denizli, Turkey. Erdal Turk,1 Fahri Karaca,2 Yesim Edirne2 Determining External Genital Abnormali- ties with a Pre-Circumcision Examination in Previously Undiagnosed Male School Children Corresponding Author: Erdal Turk, MD Yeni Girne Bulvarı 1825 Sok., No:12 Karsiyaka , Izmir, Turkey. Tel: +90 232 399 5050 Fax: +90 232 367 0559 E-mail: eturk19@yahoo.de Received March 2013 Accepted January 2014 Purpose:‎We‎investigated‎whether‎children‎getting‎ready‎for‎circumcision‎under‎local‎anesthe- sia‎had‎any‎additional‎genital‎region‎abnormalities‎not‎detected‎before‎the‎circumcision.‎‎ Materials and Methods:‎We‎performed‎circumcision‎under‎local‎anesthesia‎for‎children‎with‎ normal‎physical‎examination‎findings,‎and‎together‎with‎corrective‎surgery‎for‎those‎with‎other‎ genital‎anomalies‎among‎the‎children‎aged‎6‎years‎old‎and‎over‎presenting‎at‎the‎pediatric‎sur- gery‎department‎of‎our‎hospital‎during‎the‎school‎break.‎‎‎ Results:‎Circumcision‎was‎planned‎under‎local‎anesthesia‎in‎a‎total‎of‎1,695‎cases‎aged‎be- tween‎6‎and‎17‎years‎during‎the‎June‎to‎September‎2010‎and‎2011‎periods.‎We‎found‎an‎exter- nal‎genital‎anomaly‎in‎the‎pre-circumcision‎physical‎examination‎in‎58‎patients‎(3.4%),‎with‎a‎ mean‎age‎of‎7.87‎±‎1.49‎years.‎These‎patients‎were‎operated‎on‎with‎corrective‎surgery‎while‎ 1,637‎children‎underwent‎circumcision‎under‎local‎anesthesia.‎The‎most‎common‎anomaly‎ was‎inguinal‎hernia‎seen‎in‎14‎(24.1%),‎followed‎by‎hypospadias‎in‎11‎(18.9%),‎hydrocele‎in‎9‎ (15.9%)‎and‎undescended‎testis‎in‎8‎(13.8%).‎ Conclusion:‎In‎countries‎where‎circumcision‎is‎traditional,‎an‎intervention‎room‎within‎the‎ hospital‎to‎perform‎circumcision‎under‎local‎anesthesia‎can‎enable‎many‎children‎to‎be‎circum- cised‎under‎hospital‎conditions‎and‎previously‎undetected‎genital‎abnormalities‎to‎be‎found‎ with‎a‎pre-circumcision‎genital‎region‎examination.‎ Keywords:‎circumcision;‎disorders‎of‎sex‎development;‎male;‎genital‎diseases‎genitalia;‎child,‎ preschool. PEDIATRIC UROLOGY 1412 | Pediatric Urology INTRODUCTION In‎Turkey,‎as‎in‎other‎Muslim‎countries,‎circumcision‎is‎a‎routine‎surgical‎procedure‎mainly‎performed‎for‎reli-gious‎reasons.‎So,‎most‎Turkish‎boys‎are‎circumcised‎ at‎some‎time‎from‎the‎eighth‎day‎after‎birth‎to‎the‎age‎of‎ puberty.‎Circumcision‎should‎be‎considered‎as‎a‎surgical‎ operation‎which‎requires‎maximum‎care‎and‎should‎be‎per- formed‎by‎licensed‎surgeons‎in‎sterile‎hospital‎conditions.‎ Unfortunately,‎of‎100‎circumcision‎cases‎performed‎in‎our‎ country,‎approximately‎85%‎are‎performed‎by‎traditional‎ circumcisers,‎10%‎by‎health‎technicians‎and‎only‎5%‎by‎ licensed surgeons.(1,2)‎The‎ratio‎of‎circumcisions‎performed‎ by‎surgeons‎is‎5-10%‎in‎Pakistan‎56.5%‎in‎Iran,‎and‎85%‎in‎ The‎United‎Arabic‎Emirates‎and‎Saudi‎Arabia.(3,4) Most‎parents‎are‎not‎aware‎of‎the‎normal‎anatomy‎of‎the‎ genital‎region,‎leading‎to‎delays‎in‎the‎diagnosis‎of‎genital‎ abnormalities.‎Families‎can‎feel‎ashamed‎of‎the‎condition‎ and delay going to a physician. Inguinal and scrotal hernias and‎hydroceles‎are‎common‎pediatric‎congenital‎disorders. (5,6) Avoiding‎such‎problems‎requires‎early‎diagnosis‎and‎ treatment.‎Unfortunately,‎regular‎screening‎for‎these‎pro- grams‎in‎babies‎and‎children‎is‎not‎available‎in‎Turkey.‎ The‎aim‎of‎this‎study‎is‎to‎emphasize‎how‎important‎it‎is‎ to‎have‎an‎‎intervention‎room‎within‎the‎hospital‎to‎per- form‎circumcision‎under‎local‎anesthesia‎that‎can‎enable‎ many‎children‎to‎be‎circumcised‎under‎hospital‎conditions‎ and‎any‎previously‎undetected‎genital‎abnormalities‎can‎‎be‎ found‎with‎a‎pre-circumcision‎genital‎region‎examination‎ by specialists. MATERIALS AND METHODS This‎study‎was‎conducted‎on‎a‎total‎of‎1,695‎children‎who‎ were‎scheduled‎to‎undergo‎circumcision‎during‎the‎break‎in‎ the‎school‎year‎in‎the‎years‎2010-2011‎at‎the‎Denizli‎State‎ Hospital,‎Pediatric‎Surgery‎Outpatient‎Department.‎Chil- dren‎aged‎6‎years‎and‎over‎who‎presented‎at‎the‎hospital‎to‎ undergo‎circumcision‎were‎scheduled‎at‎a‎rate‎of‎5-15‎cir- cumcisions‎a‎day.‎The‎cases‎that‎came‎for‎the‎appointments‎ underwent‎a‎detailed‎physical‎examination‎by‎3‎separate‎ Pediatric‎Surgery‎specialists.‎Patients‎who‎had‎hypospadi- as, inguinal hernia, hydrocele, undescended testis or other genital‎region‎pathologies‎during‎the‎physical‎examination‎ underwent‎ the‎circumcision‎ together‎with‎corrective‎sur- gery‎after‎their‎familıes‎were‎informed.‎ RESULTS A‎ total‎ of‎ 2,489‎ cases‎ aged‎ 0-17‎ years‎ presented‎ at‎ the‎ Pediatric‎Surgery‎Outpatient‎Department‎of‎our‎hospital‎for‎ circumcision‎between‎June‎1st‎and‎September‎30th‎2010- 2011.‎The‎ 326‎ cases‎ (13%)‎ that‎ did‎ not‎ attend‎ their‎ ap- pointment‎were‎not‎included‎in‎the‎study.‎Among‎the‎2,163‎ remaining‎cases‎we‎planned‎to‎operate‎on‎the‎1,695‎cases‎ aged‎6-17‎years‎(78.3%)‎under‎local‎anesthesia‎and‎the‎468‎ cases‎aged‎0-6‎years‎(21.6%)‎under‎general‎anesthesia.‎ ‎Further‎58‎children‎who‎were‎older‎than‎6‎years‎but‎were‎ found‎ to‎ have‎ additional‎ abnormalities‎ during‎ the‎ pre- circumcision‎routine‎physical‎examination‎underwent‎cir- cumcision‎together‎with‎corrective‎surgery‎under‎general‎ anesthesia‎ after‎ the‎ family‎ was‎ informed,‎ although‎ local‎ anesthesia‎was‎planned‎at‎first.‎ We‎found‎a‎genital‎region‎abnormality‎during‎the‎pre-cir- cumcision‎physical‎examination‎in‎58‎patients‎aged‎6-13‎ years‎with‎a‎mean‎age‎of‎7.87‎±‎1.49‎years.‎Table‎1‎presents‎ the‎mean‎age‎in‎which‎these‎abnormalities‎were‎detected‎ and‎the‎corrective‎surgery‎performed.‎The‎most‎common‎ abnormality‎ was‎ inguinal‎ hernia‎ at‎ 24.1%,‎ followed‎ by ‎hypospadias‎at‎18.9%‎(11‎patients).‎ Minor‎complications‎developed‎in‎11‎(0.6%)‎of‎the‎chil- dren‎undergoing‎circumcision.‎These‎consisted‎of‎bleeding‎ in‎6‎patients‎and‎this‎was‎stopped‎by‎local‎compress‎in‎4‎ patients‎and‎suturing‎at‎the‎operating‎room‎in‎2‎patients.‎ The‎hematoma‎developed‎in‎3‎patients‎and‎infection‎devel- oped‎in‎2‎patients‎after‎the‎circumcision‎which‎recovered‎ with‎conservative‎treatment.‎One‎patient‎was‎operated‎on‎ under‎general‎anesthesia‎for‎penile‎chordee‎and‎presented‎3‎ days‎later‎with‎marked‎bruising‎and‎swelling‎of‎the‎penis.‎ The‎preoperative‎tests‎were‎normal‎but‎the‎complete‎blood‎ count‎check‎revealed‎a‎thrombocyte‎count‎of‎6,000/mm3. The‎child‎was‎therefore‎evaluated‎by‎the‎pediatric‎hematol- ogy‎specialist‎and‎treatment‎was‎started‎with‎a‎diagnosis‎of‎ acute‎idiopathic‎thrombocytopenic‎purpura. DISCUSSION Circumcision‎is‎unavoidable‎due‎to‎many‎religious‎and‎so- cial‎reasons‎in‎Turkey‎and‎the‎incidence‎reaches‎99%‎in‎the‎ male‎population.(1,7)‎The‎ideal‎time‎and‎anesthesia‎are‎the‎ 0-2 years age group and general anesthesia, but the rituals 1413Vol. 11 | No. 02 | March- April 2014 |U R O LO G Y J O U R N A L Male External Genital Abnormalities | Turk et al of‎Muslim‎countries‎in‎the‎rural‎areas‎usually‎mean‎that‎ it‎is‎performed‎after‎the‎age‎of‎5‎years.(3,4,8)‎Approximate- ly‎600,000‎male‎children‎are‎circumcised‎in‎our‎country‎ every‎year‎and‎approximately‎85%‎of‎these‎are‎performed‎ by‎traditional‎circumcisers.(1,2,8)‎These‎figures‎are‎similar‎ in‎other‎Muslim‎countries.(3,4)‎It‎seems‎unlikely‎that‎such‎ a‎high‎demand‎for‎circumcision‎can‎be‎met‎with‎general‎ anesthesia.‎We‎therefore‎circumcise‎children‎who‎present‎ during‎school‎break‎when‎the‎demand‎increases‎under‎lo- cal‎anesthesia‎as‎most‎of‎these‎children‎are‎older‎than‎6‎ years.‎Our‎hospital‎provides‎secondary‎health‎care‎services‎ and‎the‎establishment‎of‎units‎where‎circumcision‎can‎be‎ performed‎under‎healthy‎conditions‎with‎local‎anesthesia‎ and‎also‎extending‎this‎to‎tertiary‎health‎care‎facilities‎may‎ enable‎many‎patients‎to‎be‎circumcised‎under‎hospital‎con- ditions in countries where the procedure is traditionally per- formed‎at‎older‎ages. Children‎ need‎ to‎ be‎ observed‎ carefully‎ in‎ the‎ newborn,‎ preschool‎and‎school‎ages‎to‎prevent‎the‎development‎of‎ late‎complications.(9,10)‎Screening‎tests‎to‎determine‎genital‎ region‎abnormalities‎in‎children‎are‎therefore‎performed‎at‎ the school age in such countries.(6,10-13)‎We‎have‎1200-1500‎ children‎a‎year‎who‎present‎at‎the‎hospital‎themselves‎with- out‎any‎symptoms‎and‎we‎select‎those‎with‎an‎abnormality‎ through‎a‎physical‎examination.‎Our‎3.4%‎(n‎=‎58‎patients)‎ rate‎in‎this‎study‎may‎seem‎to‎be‎low‎compared‎to‎the‎rates‎ of‎6.18-18.31%‎found‎in‎epidemiological‎studies‎of‎school‎ age‎children‎previously.(6,10,11,13)‎However,‎the‎reasons‎are‎ that‎our‎group‎had‎a‎limited‎age‎range‎of‎6-13‎years,‎female‎ children were not included in the study and our study was limited‎to‎the‎external‎genital‎region.‎ The‎complication‎rates‎are‎1-5%‎in‎children‎circumcised‎by‎ physicians,‎10%‎in‎those‎circumcised‎by‎health‎care‎techni- cians‎and‎up‎to‎85%‎in‎children‎circumcised‎by‎traditional‎ circumcisers.(1,2,14)‎Most‎of‎these‎complications‎are‎bleeding‎ and‎hematoma‎that‎can‎be‎stopped‎by‎a‎simple‎intervention‎ but‎serious‎complications‎such‎as‎amputation‎or‎death‎can‎ also be encountered.(1,4,15-17)‎Circumcising‎many‎children‎at‎ the‎same‎time‎means‎that‎children‎are‎circumcised‎rapidly,‎ usually‎under‎conditions‎that‎are‎not‎very‎healthy‎and‎usu- ally‎by‎traditional‎circumcisers‎or‎health‎care‎technicians. (1,2,7,8)‎Such‎procedures‎are‎legal‎in‎the‎England‎as‎long‎as‎ Table . The general characteristics and operations of anomalous cases. Genital Anomaly No. % Age, year (range) Operation Inguinal hernia 14 7.85 ± 1.40 (6-10) High Ligation Right 9 Left 5 24.1 Hypospadias 11 8.54 ± 2.01(6-13) Glanular 7 Meatoplasty Megameatus 4 18.9 Tubularized incised plate urethroplasty Hydrocele 9 8.11 ± 1.16 (6-10) High Ligation + fenestration Right 6 Left 3 15.6 Undescended testis 8 7.62 ± 1.40 (6-10) Orchiopexy Right 4 Left 4 13.8 Buried penis 5 8.6 7.4 ± 1.34 (6-9) Degloving and circumcision Penile Chordee 5 8.6 8 ± 1.58 (6-10) Chordee release and circumcision Penile torsion 4 6.9 6.75 ± 0.95 (6-8) Detorsion and circumcision Cord cyst 2 3.4 7.5 ± 0.70 (7-8) High Ligation Right 2 100.0 Left ----- Total 58 7.87 ± 1.49 (6-13) ----- 1414 | they are carried out by a physician.(18)‎It‎is‎known‎that‎the‎ circumcision‎of‎many‎children‎together‎by‎traditional‎cir- cumcisers‎in‎our‎country‎and‎other‎countries‎where‎circum- cision‎is‎traditional‎increases‎circumcision‎complications.‎ The‎most‎important‎reason‎for‎the‎very‎low‎percentage‎of‎ 0.6%‎and‎only‎minor‎complications‎being‎observed‎in‎the‎ 1,637‎patients‎we‎circumcised‎in‎our‎study‎is‎that‎they‎un- derwent‎the‎procedure‎in‎a‎period‎of‎three‎months‎and‎by‎ a‎specialist‎who‎operated‎on‎a‎limited‎number‎of‎patients‎ daily.‎Increasing‎such‎applications‎will‎decrease‎circumci- sion‎complications‎and‎will‎also‎decrease‎the‎interest‎of‎the‎ public‎in‎traditional‎circumcisers‎and‎mass‎circumcisions. The‎incidences‎of‎indirect‎inguinal‎hernias‎is‎approximate- ly‎1-5%,‎hypospadias‎between‎0.8‎and‎8.2‎per‎1000‎live‎ male‎births,‎hydrocele‎in‎children‎older‎than‎1‎year‎of‎age‎ probably‎less‎than‎1%‎and‎undescended‎testis‎in‎full-term‎ boys‎1-2%‎in‎the‎general‎population.(6,11)‎Our‎rates‎were‎ 0.82%‎for‎inguinal‎hernia,‎0.65%‎for‎hypospadias,‎0.53%‎ for‎hydrocele‎and‎0.47%‎for‎undescended‎testes.‎The‎rea- son‎for‎our‎lower‎prevalence‎than‎the‎general‎pediatric‎pop- ulation could be that our patient group was generally aged 6-13‎years‎and‎mostly‎6-8‎years.‎It‎is‎important‎to‎detect‎ and‎treat‎genital‎system‎abnormalities‎to‎prevent‎the‎seri- ous‎complications‎that‎can‎arise.‎All‎the‎problems‎we‎found‎ should‎have‎been‎operated‎on‎at‎the‎age‎of‎0-2‎years‎but‎ the‎mean‎age‎in‎our‎study‎was‎7.87‎±‎1.49‎years.‎However,‎ this‎does‎not‎decrease‎the‎value‎of‎our‎study‎and‎we‎could‎ say‎we‎were‎successful‎as‎we‎prevented‎the‎development‎ of‎complications‎in‎these‎children‎who‎had‎not‎yet‎experi- enced‎a‎complication‎until‎school‎age.‎ CONCLUSION Units‎such‎as‎circumcision‎outpatients‎so‎that‎a‎large‎num- ber‎of‎children‎can‎be‎circumcised‎under‎hospital‎conditions‎ in‎ communities‎ where‎ children‎ are‎ traditionally‎ circum- cised‎at‎school‎age‎will‎decrease‎complications‎by‎ensur- ing‎circumcision‎is‎performed‎under‎healthy‎conditions‎and‎ also‎enable‎the‎detection‎of‎external‎genital‎abnormalities‎ with‎a‎pre-circumcision‎physical‎examination‎of‎the‎poten- tial patient population. 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