Figure 1. Click on image to
obtain a full size image. 
Figure 2. Click on image to
obtain a full size image. A 6 day old male was circumcised uneventfully using the Plastibell technique in the pediatrician's office. Two days later the patient developed penile shaft swelling and blistering accompanied by a temperature of 38.3 degree celsius. Intravenous Ampicillin and Gentamicin was started by the pediatrician. Gram stain of the blister aspirate revealed no inflammatory cell or organism. The patient improved the next day and antibiotics were changed to intramuscular ceftriaxone.
On post-circumcision day 4, urologic consultation was obtained as the penile swelling had extended into the scrotum and the penis started to blister. The Plastibell ring was removed without difficulty and the blisters drained. An ultrasound was obtained which revealed scrotal edema with normal testicles bilaterally. Provisional diagnosis of necrotizing fasciitis was made and the patient was transferred to Children’s Hospital Medical Center by helicopter.
On arrival, examination revealed a swollen scrotum with induration and
erythema extending to the lower abdominal wall (See figure 1 and 2
below). A coin-sized patch of purplish discoloration was also evident on
the right hemi-scrotum. The circumcision wound was covered with yellowish
granulation tissue. His temperature was 37.6 deg Celsius, heart rate
160-170/min and blood pressure 80/60 mmHg. WBC was 27,000/cmm with 12744/cmm
polys and 1296/cmm bands. Figure 1. Click on image to
obtain a full size image. Figure 2. Click on image to
obtain a full size image.
Fluid resuscitation with adminstration of broad spectrum antibiotics using vancomycin, gentamicin and clindamycin. The child was brought into the operating room for debridement of necrotizing fasciitis. The infective process had involved the upper thighs, the lower abdominal wall and posteriorly to the perineal body. Wide excision of scrotum, penile skin, and lower abdominal wall was carried out. Deep tissue layers including the penile shaft, testicles, and abdominal musculature appeared normal. (See figure 3)
Figure 3. Click on image to obtain a full size
image.
Post-operatively, the child underwent second-look surgery and further debridement to the level of the mid-abdomen and the superior thigh on post-operative day 2. (See figure 4)
Figure 4. Click on image to obtain a full size
image.
In addition, 7 hyperbaric oxygen treatments were given. On post-operative 15, split-thickness skin autografts were applied to the lower abdomen, penile shaft, thighs and testicles.
Neonatal circmucisions are commonly performed by obstetricians and pediatricians in the first week of life in their offices in Washington. In general, either the plastibell or the Gomco clamp techniques are used. While both techniques should give reasonable cosmetic results, the plastibell alows better visualization of the circumcision. With the plastibell, a ring is left to assist coaptation of the wound edges after the circumcision. Upon healing, the ring will be released from the wound. The Gomco clamp leaves no foreign body on the wound but has the risk of wound edge separation. Moreover, the Gomco clamp does not allow an accurate estimation of skin to be excised and can remove excess skin when the location of the penoscrotal junction is misjudged. It is important that electro-coagulation (in place of the scalple) is not used on the Gomco clamp during circumcision. The Moyal clamp performs the circumcision on the same principle as the Gomco clamp. There is no device to hold the wound edges together. Most pediatric urologists prefer using the free-hand technique.
Whether the type of techniques used is related to a higher incidence of infection is not entirely clear. Gee and Ansell compared the use of Plastibell and Gomco in 5521 children between 1963 and 1972. In the Plastibell group, 19/2625 (0.72%) infections encountered. In the Gomco group, 4/2896 (0.14%) circumcisions infected. The incidence of infection following Plastibell circumcision was significantly more frequent than that following Gomco circumcision (p<.005). Moreover, 4/19 Plastibell infections developed irritability and required antibiotic treatment while all Gomco infections were successfully treated with topical agents. The other patient with Fourniew's gangrene developed after circumcision reported in teh literature also had a Plastibell circumcision (Woodside JR, 1990). Of all the serious infections that are known at this center, the plastibell has been used.
The wound more often than not will look edematous and even red. However, the erythema should not spread to penile shaft skin. Erythema in the shaft skin should raise the concern for spreading wound infection and impending faciitis if not treated promptly. Though WBC in the neonates can be as high as 30,000/mm3, neonates with faciitis in general will demonstrate leukocytosis with bandemia and WBC higher than 20,000/mm3. Normal neonates do not show bandemia. Admission for observation and broad spectrum antibiotics is warranted. However, there is no consensus on whether the plastibell should be removed at this point. The plastibell is an external device and it is not unreasonable to leave it on if the circumcision is only recently performed. Surgical intervention is indicated when faciitis is suspected.
High index of suspicion, prompt diagnosis, immediate fluid resuscitation and institution of broad spectrum antibiotics followed by debridement is the key successful treatment of Fournier's gangrene. The disease is extremely lethal. In adults, the recent mortality has improved to 18% (Clayton et al, 1990). In children, the overall mortality rate is 9% and can be as high as 30% in infants younger than 3 month (Adams JR et al, 1990), the time when neonatal circumcision is performed. Faciitis caused by streptococcal infection and Chicken pox on the face has been successfully treated by raising skin flaps for subcutaneous drainage without excision. In this way, skin can be preserved and cosmesis preserved. At present this technique should not be extrapolate to use in Fournier’s gangrene which is polymicrobial in nature. Wide excision should be the rule followed by frequent re-examination.
It is important that the testes should be preserved as necrotising faciitis almost never involves the testes. The tunica vaginalis should remain intact during dissection so theat the testes will not dessicate. Retraction of testes occur secondary to wound contraction. Tagging the testes in their orthotopic position after debridement may decrease the extent of proximal migration.
This conference was conducted on February 15, 1996 at 7.00 am by the Department of Surgery at the Children’s Hospital and Medical Center, University of Washington, Seattle, Washington. Attendance: D. Tapper, M.D. R. Sawin M.D., E. Hatch M.D., J Waldhausen M.D., D. Bliss M.D. (pediatric surgery fellow), P Healey M.D.(pediatric surgery fellow), R. Woods M.D. Ph.D. (R3), B. Plaskon M.D.(R3), L. Kawamura M.D.(R1), M. Burns M.D.(Urology), M. Carr M.D. (Urology), C. Close M.D.(pediatric urology fellow), J. Ngan M.D.(pediatric urology fellow), R Santucci M.D.(R5-urology), S. Manning M.D.(ENT), D. Cara M.D. (ENT fellow).
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