A 30-year-old man is in the recovery room following elective circumcision. There is no family history of bleeding disorders. The procedure was performed under sedation and local anesthesia without intraoperative complications. However, shortly after arrival at the recovery room, bleeding was noted at the surgical site, and a compressive elastic dressing was applied to the glans and distal shaft of the penis. Temperature is 36.7 C (98.1 F), blood pressure is 136/82 mm Hg, pulse is 92/min, and respirations are 14/min. The patient is alert and appears comfortable. The penile dressing is intact, with no evidence of residual bleeding. Which of the following is the best next step in management of this patient?
Although more commonly performed in neonates, circumcision is performed in adult males for a variety of indications, including penile foreskin pathology (eg, constriction preventing retraction [phimosis]), dyspareunia, aesthetic preference, and HIV prevention in endemic areas. A variety of surgical techniques (eg, direct excision, circumcising devices) can be used, but all can typically be performed under local anesthetic (eg, penile ring block) as an outpatient procedure.
Postprocedural bleeding is one of the most common complications of circumcision. Due to the superficial nature of the surgical site and small caliber of the bleeding vessels, direct pressure (eg, compressive elastic dressing) for a short amount of time typically stops the bleeding. As for any appendage (eg, penis, fingers, ears), the elastic dressing should not be wrapped too tightly or left on too long because distal necrosis may occur. Therefore, in this patient whose surgical site has stopped bleeding and who is otherwise ready for discharge (eg, stable vital signs, alert and comfortable), the compressive dressing should be removed.
(Choices A and B) A small amount of postprocedural bleeding is common in circumcision and other superficial (eg, skin and soft tissue) procedures. The typically small amount of blood loss, which can be directly visualized and monitored, does not warrant obtaining a complete blood count or coagulation studies, especially in the setting of normal vital signs.
(Choice C) Retrograde urethrography can be used to evaluate for urethral injury. Aggressive suturing or clamping on the ventral surface of the penis, where the urethra is closer to the surface, may cause urethral injury. However, in the immediate postoperative period, this more commonly presents with dysuria or hematuria.
(Choice D) Infection is rare (<1%) following circumcision, and prophylactic antibiotics are not typically used. Even in the case of wound dehiscence, which is not present in this patient, topical antibiotic ointment is usually sufficient to prevent infection until the circumcision site heals by secondary intention.
Educational objective:
Postprocedural bleeding is a common complication of circumcision and typically resolves with direct pressure (eg, compressive elastic dressing). A compressive dressing should be used for only a short time and must be removed prior to discharge to prevent necrosis.