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J Ped Surg Case Reports 1 (2013) 186e188

Journal of Pediatric Surgery CASE REPORTS

journal homepage: www.jpscasereports.com

Management of Plastibell circumcision ring migration and glans penisincarceration

A.W. Smith*, A. Hebra, J.M. Mansfield, C.J. StreckDepartment of Surgery, Division of Pediatric Surgery, Medical University of South Carolina, 96 Jonathan Lucas St., Charleston, SC 29425, USA

a r t i c l e i n f o

Article history:Received 9 May 2013Accepted 14 May 2013

Key words:CircumcisionNeonateComplication

* Corresponding author. 96 Jonathan Lucas St., CSBUSA. Tel.: þ1 843 792 3851; fax: þ1 843 792 3858.

E-mail addresses: smithamena@gmail.com, smitha

2213-5766� 2013 Published by Elsevier Inc.http://dx.doi.org/10.1016/j.epsc.2013.05.007

Open acce

a b s t r a c t

Circumcision is one of the most common elective surgical procedures performed. Common complicationsof Plastibell circumcision, a popular method of neonatal circumcision performed in surgery outpatientclinics, include bleeding, wound infection, and technical issues related to the Plastibell ring. Delayed orincomplete separation of the ring occurs in some cases, and can result in proximal slippage of the ringwith penile shaft or glans herniation. Despite the risk of adverse outcomes, a universal method for thesafe, expedient management of retained Plastibell rings has not been described. We report three cases ofdelayed separation of the Plastibell ring with a novel approach for ring removal. Each case presentedwithin several weeks post-circumcision. The presentations ranged from normal appearance of thephallus to mild dysuria, to glans erythema and disfigurement. An orthopedic ring cutter was successfullyused to remove the ring in clinic, with no sequelae. This technique is simple and the instrumental designvirtually eliminates the risk of further trauma to the penis. We propose use of the ring cutter as a safe,reliable approach to remove a retained Plastibell ring. Expectant management may include prophylacticring removal if the ring has not separated within a reasonable post-operative time period.

� 2013 Published by Elsevier Inc. Open access under CC BY-NC-ND license.

Circumcision is one of the most common surgical proceduresperformed worldwide with approximately one in three malescircumcised globally [1]. The incidence of neonatal male circumci-sion in the United States is currently 54.7% [2]. In the past,circumcision was considered a purely elective, cosmetic procedure,but recent evidence suggests a higher rate of urinary tract infections[3] and in adulthood, sexually transmitted disease acquisition andtransmission [4,5] among uncircumcised males.

The most popular methods of neonatal circumcision include thePlastibell device, the Gomco clamp, and the Mogen clamp. TheGomco and Mogen clamps protect the glans while producing crushinjury to the prepuce, which is then surgically excised. The Plasti-bell device leaves the prepuce intact following crush, allowing it tonecrose and slough off along with the plastic shield within a week[6]. With this technique, a ring of appropriate size is selected andapplied to the glans after freeing the adhesions between the glansand prepuce. The Plastibell ring is then covered by the prepuce, anda ligature is tied firmly around the prepuce, crushing the skinagainst the groove in the Plastibell. The excess skin protrudingbeyond the ring is trimmed off, and the compression against the

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me@musc.edu (A.W. Smith).

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underlying ring causes the prepuce tissue to necrose. The ringis expected to fall off in 5e7 days, completing the process ofcircumcision. Plastibell circumcision is themost common techniqueused for neonatal circumcision in outpatient clinics. The rate ofreported Plastibell complications ranges from (3e11%), and iscomparable to the rate reported for infants circumcised by theGomco and Mogen techniques [7e11]. Common complicationsinclude peri- or post-operative bleeding, wound infection, redun-dant prepuce, and technical issues with the Plastibell ring [9,10,12].In a recent study of 1129 neonates, 2.9% of infants experienceddelayed or incomplete separation of the ring, and 0.7% had proximalslippage of the ring resulting in penile shaft or glans herniation [9].Although some patients with this complaint present with normalappearance of the phallus and good outcomes, others present withpenile injuries, disfigurement, and functional sequelae [10,13].Despite the risk of adverse outcomes, a universal method for thequick and safemanagement of retained Plastibell rings has not beendescribed. We report three cases of removal of a retained ring withan orthopedic ring cutter. This technique is simple, effective andvirtually eliminates the risk of further trauma to the penis.

1. Case report

Here we describe three cases of proximal migration of thePlastibell ring within 1e4 weeks following infant circumcision

Table 1Infants presenting with retained Plastibell ring. The age of the patient in months atcircumcision, the day post-circumcision on which the ring was removed with a ringcutter, and the clinical presentation is described.

Case Age at circumcision(months)

Post-circumcisionday

Clinical presentation

1 3 28 Glans disfigured2 8 29 Dysuria3 4 16 Normal

A.W. Smith et al. / J Ped Surg Case Reports 1 (2013) 186e188 187

(Table 1). The circumcision in each of our cases was performedusing standard Plastibell technique. The size of the Plastibell ringwas determined based on the size of the individual glans. Thesmallest possible size was chosen in each case according to thesurgeon’s judgment at the time of the procedure.

In each case, there was delayed ring separation post-circumcision. An orthopedic ring cutter (Fig. 1) was used toremove the ring in clinic, as illustrated in Fig. 2, with no compli-cations. The first case presented 28 days after Plastibell circum-cision with incarceration of the glans (ring migration) by aretained ring (Fig. 2). The ring was removed without difficultyusing the ring cutter. Initially there was glans disfigurement wherethe ring was adhered and mild erythema, but no other signs orsymptoms of infection. The patient was treated with topicalantibiotic ointment and the appearance of the external genitaliareturned to normal within two weeks. The second case presented29 days after circumcision with the Plastibell still in place andevidence of migration. The patient’s parents reported pain totouch. There were no signs of infection other than edema and

Fig. 1. Orthopedic ring cutter. The ring cutter was used in each case to break thePlastibell ring and remove the pieces while protecting the underlying phallus andglans.

redness. Ring removal was achieved with the cutter withoutcomplications. The external genitalia appeared normal threeweeks after the procedure. The third case presented 16 days aftercircumcision with a retained Plastibell ring (ring migration) andglans swelling. There was no evidence of infection. The ring wasremoved without difficulty using the ring cutter. The externalgenitalia appeared normal two weeks after removal.

2. Discussion

As detailed in this report and others, proximal migration ofthe Plastibell ring after neonatal circumcision can injure thephallus, with cosmetic and functional consequences. In thelargest case series to date, only three patients of 2000 (0.015%)experienced problems with device slippage [14]. However, arecent prospective study identified 23 neonates with significantpenile injuries secondary to ring migration. All infants experi-enced apparent dysuria, 73.9% had extensive denudation ofpenis or glans, 39.1% developed urethrocutaneous fistulae, 26%presented with sepsis, and 17.4% had partial necrosis of theglans [11].

Migration may occur secondary to selection of a plastic bell thatis too large [13]. The proper bell size is chosen based on thecircumference of the glans, which is difficult to judge preopera-tively due to varying thicknesses of the prepuce. Accurate assess-ment of glans size is made after the dorsal slit is created, the glans isexposed, and complete mobilization of the inner preputial adhe-sions to the glans penis has been performed. Incomplete mobili-zation of adhesions particularly increases the risk of selecting awrong size bell. In practice, however, it is not uncommon for thesurgeon to select the Plastibell size preoperatively. In this case,appropriate fit can be confirmed by placing the bell over the glansbefore completing the operation. If inappropriate, a more properlysized device must be opened and tested. In addition to the possi-bility of operator error, an intrinsic device flawmay call for redesignof the Plastibell to incorporate an anti-migration or quick-releasecomponent.

One other group has reported using a ring cutter for Plastibellremoval [9,15]. We describe three additional cases of safe ringremoval using a ring cutter with no further sequelae. Promptattention to this complication is key, and expectant managementincludes asking parents to inspect the circumcision wound dailyand call the physician immediately if the ring migrates proximally.Furthermore, the infant should be reexamined in 7e14 days if thering has not fallen off. As a more conservative approach, ringremoval in the clinic may be scheduled early as 2e3 days post-operatively, as some complications occur within this time frame[11,16].

3. Conclusion

In conclusion, an orthopedic ring cutter is both safe and effectiveto release a Plastibell ring that has slipped proximally resulting inglans or distal shaft herniation. By design, this instrument protectsthe tissue from further damage. It can also be used prophylacticallyif the ring has not fallen off within a reasonable post-operative timeperiod.

Conflict of interestThere is no conflict of interest to be disclosed by the authors.

Sources of fundingThe authors received no financial support for the research,

authorship, and/or publication of this article.

Fig. 2. Sequential removal of a Plastibell ring that migrated proximally resulting in glans herniation. Removal of the ring 28 days after Plastibell circumcision is shown (Case 1).

A.W. Smith et al. / J Ped Surg Case Reports 1 (2013) 186e188188

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