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Sunday, February 22, 2015

Maggot infestation of the penis after circumcision


Maggots make for cool, cringe-inducing posts. There's something about these wriggly creatures that really makes our flesh creep (well, figuratively speaking). As of today, thousands of people have seen my post about an unfortunate Brazilian man's maggot-infested oral cancer wound. Another post, about a poor bedridden boy with cerebral palsy, whose tracheostomy wound became a haven for squirming white nasties, has also garnered a lot of interest. Today, I'm back with yet another little maggot horror story, this time from Narayangonj, Bangladesh.

A 10-year-old boy was circumcised by an itinerant circumciser who used unsterilized equipment and dressing material. A tight bandage was also applied over the wound, causing severe pain. A few days later, when the bandage was removed, the boy's parents noticed maggots coming out from the wound site. 7 days after circumcision, he was taken to hospital, since the wound was obviously festering and infected.

On examination, the penis was grossly swollen and reddened. There was a gap in the skin exposing the shaft. The base was covered with unhealthy-looking granulation tissue. After a little manipulation, maggots started to come out from underneath the skin of the shaft. The skin could not be pulled back. On palpation, it was observed that there were more maggots under the skin extending to the root of the penis. The picture on the right speaks louder than a thousand words.

Obviously, an immediate surgical intervention was the only reasonable decision. Under a penile block, a dorsal slit was made on the penile skin and maggots started to come out in large numbers. There was some necrotic skin and multiple pockets containing maggots, some even extending to the mons pubis which made exploration difficult. Some of these insects were removed using forceps and some were treated with hydrogen peroxide to completely eradicate these pockets. Almost 30 maggots were removed and the wound was covered with an antibiotic dressing. The pain subsided immediately following debridement. A day later, reexploration of the wound was performed and the remaining maggots came out spontaneously. The picture on the right shows the maggots after removal.

The patient was treated with antibiotic dressing and oral antibiotics for 30 days following the operation, until doctors were certain the wound had healed properly. On final exploration of the site, the penile shaft including all three corpora and the glans were found to be healthy. Later, reconstruction (a partial thickness skin graft) was carried out at the plastic surgery department.

While circumcision is common in Bangladesh, infestation of the wound by fly larvae is, thankfully, a rare complication. However, educating circumcisers on the importance of using sterile gloves and sterilized equipment would help make it rarer still. (Interestingly, less complications and other adverse effects occur after circumcision among neonates and infants as compared to older boys, even in similar settings, probably because the procedure is simpler in the younger age group). 


Source:

Hossain MR, Islam KM, Nabi J. (2012) Myiasis as a Rare Complication of Male Circumcision: A Case Report and Review of Literature. Case Rep Surg. 2012: 483431.



1 comment:

  1. The easiest way to avoid circumcision complications is to avoid circumcsion. Penile prepuce is healthy, functional, normal, natural, and HIGHLY erogenous tissue. Amputation of the prepuce always reduces sensation, always involves surgical risk, always degrades sexual function, and never confers immunity to anything the way a vaccine would. When performed on a healthy patient who has not freely given fully informed consent, circumcision is a violation of that patient's human right to bodily integrity and autonomy. When prepuce problems are indeed present, however, as with any other part of the body, amputation of the part is a last resort, and more conservative measures are available and indicated. Many future problems can be prevented by observing proper care of the neonate and small child. In almost all baby boys, the prepuce is attached to the glans by the balanopreputial lamina, and the boy's prepuce is not retractable. Many problems occur when caregivers incorrectly and prematurely forcibly retract the prepuce. The boy should be the one to retract his foreskin for the first time when this attachment has of its own timing released. This timing is different for different boys and it may happen in infancy, or the synechia may persist all the way past puberty. If a boy wishes to hurry the process along, gentle manipulation and prescription creams can hasten retractibility. A foreskin is a terrible thing to waste!

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