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 Table of Contents  
ORIGINAL RESEARCH REPORT
Year : 2018  |  Volume : 15  |  Issue : 3  |  Page : 123-125

Choosing an appropriate Plastibell size for infant circumcision


Department of Surgery, Division of Paediatric Surgery, University of Ilorin, University of Ilorin Teaching Hospital, Ilorin, Nigeria

Date of Web Publication1-Nov-2018

Correspondence Address:
Dr. Abdulrasheed A Nasir
Department of Surgery, Division of Paediatric Surgery and Urology, University of Ilorin Teaching Hospital, PMB 1459, Ilorin
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcls.jcls_90_17

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  Abstract 


Background: The Plastibell technique is the most frequently used device due to its perceived “ease of use” by all categories of practitioners including nonqualified people like barbers and technicians. Nonetheless, Plastibell technique for circumcision is not without its problems. We aim to describe a simple and objective technique of choosing an appropriate Plastibell size for Plastibell circumcision. Technique and Methods: The circumference of the glans penis (C) is measured at the level of the glanular ridge. The diameter of the glans corresponding to the Plastibell size is determined using the formula πD = C. The glans diameter (D) equals 0.32C. This technique was used to choose Plastibell size for 25 consecutive infants in a pilot study. Results: The median age of the infants was 21 days. The median circumference of the glans was 4.1 cm, and the median size of the Plastibell used was 1.3. The median time taken by the device to fall off spontaneously after circumcision was 4 days. There was no complication recorded. Conclusions: This objective method of choosing the appropriate Plastibell size is easy and safe. It has the potential to reduce the complications of Plastibell circumcision.

Keywords: Circumcision, complications, penile injury, Plastibell, technique


How to cite this article:
Nasir AA, Bamigbola KT, Abdur-Rahman LO, Adeniran JO. Choosing an appropriate Plastibell size for infant circumcision. J Clin Sci 2018;15:123-5

How to cite this URL:
Nasir AA, Bamigbola KT, Abdur-Rahman LO, Adeniran JO. Choosing an appropriate Plastibell size for infant circumcision. J Clin Sci [serial online] 2018 [cited 2018 Nov 19];15:123-5. Available from: http://www.jcsjournal.org/text.asp?2018/15/3/123/244748




  Introduction Top


The practice of circumcision is thought to be at least 15,000 years old.[1] The medical benefit of circumcision includes reduction in the risk of urinary tract infection, phimosis, paraphimosis, balanoposthitis, penile cancer, HIV, and human papillomavirus.[2]

In the newborn, various devices such as the Gomco clamp, Mogen clamp, and Plastibell device (PD) are used for circumcision.[2] Plastibell™ (Hollister Incorporated, Illinois, USA) [Figure 1] is the most widely used device for neonatal circumcision because of its versatility and reduced complication rate.[2],[3],[4] It is used by all categories of practitioners including nonqualified people like barbers and technicians because of its perceived “ease of use.” Nonetheless, Plastibell technique for circumcision is not without its problems.[4],[5],[6],[7] Significant complications such as ischemic necrosis of the glans and urethrocutaneous fistula have been documented.[3] These injuries usually arise from impaction and device migration which have been ascribed to incorrect selection of the size of the Plastibell.[3],[7] However, there is no literature describing an objective method of selecting Plastibell size. Most practitioners use experience to choose Plastibell size.[2],[3] The aim of this study is to describe a simple and objective technique of determining an appropriate Plastibell size for infant circumcision.
Figure 1: Plastibell device

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  Technique and Methods Top


The circumference of the glans penis is measured using a paper tape that is snugly wound round the ridge of the glans penis [Figure 2]a,[Figure 2]b,[Figure 2]c. The measurement is done preoperatively at the outpatient clinic and may be confirmed also intraoperatively after retracting the prepuce using suture. Measurement is taken when the child is well relaxed and the penis is in detumescence state. Paper tape is preferred because it sticks to the penis and ensures accuracy of measurement. The diameter of the glans is determined using the formula πD = circumference (C) of glans where π is 22/7 and D is the diameter of glans. The glans diameter (D) is, therefore, C/π or 0.32C. The diameter is approximated to one decimal place. The widest diameter (D) of the glans in centimeter corresponds to the size of the Plastibell. The Plastibell™ (Hollister Incorporated, Illinois, USA) ring device is available in sizes ranging from 1.1 to 1.7 cm and is correlated to the size (diameter) of the glans penis. An appropriate bell size which snugly fits the glans is thereby correlated to the circumference of glans as shown in [Table 1]. For instance, the diameter of glans of a circumference of 3.5 cm will be 1.12 approximated to one decimal point corresponding to 1.1 Plastibell size, and the diameter of a glans with circumference of 4.1 cm will be 1.31 corresponding to Plastibell of size 1.3; glans circumference of 4.0 cm corresponds to 1.28 diameter is assigned Plastibell size of 1.3, and glans diameter of 3.7 cm is assigned Plastibell size of 1.18≈ 1.2. We have successfully adopted this technique in a pilot study of 25 consecutive children presenting to the corresponding author for circumcision. All patients were followed up for complications either in person or by telephone till Plastibell fell off. Informed consent was obtained for the procedure and this study. The data were entered and analyzed using the SPSS software version 21.0 (SPSS, Inc., Chicago, IL, USA). Descriptive statistics, such as median and interquartile range (IQR), were used to describe age of patient, size of Plastibell, and days taken by the Plastibell to fall off after circumcision.
Figure 2: (a-c) Measuring the diameter of glans penile at the ridge

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Table 1: Correlating glans circumference and diameter to Plastibell size

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  Results Top


Twenty-five patients were enrolled into the study at the median age of 21 days, IQR: 14–49 days. The median glans circumference was 4.1 cm, IQR: 4.0–4.4 cm. The median size of the Plastibell used was 1.3, IQR: 1.2–1.4. The median time taken by the device to fall off spontaneously after circumcision was 4 days, IQR 4–5 days. There was delayed separation in one patient otherwise no postoperative complication was recorded.


  Discussion Top


Male circumcision is of public health interest because of recent evidence that indicates that the health benefits of newborn male circumcision outweigh the risks.[8] This has resulted in increased popularity of neonatal circumcision across countries.[4],[6] The Plastibell technique is the most frequently used device due to its perceived “ease of use” by all categories of practitioners including nonqualified people like barbers and technicians.

Although PD technique for circumcision has been studied extensively,[5],[6],[7] a number of studies shown that circumcision with PD is a safe and associated with minor complications including hemorrhage, local infection, sepsis, and meatal ulceration.[5],[6] On the other hand, tragic complications such as traumatic amputation of the glands and urethrocutaneous fistula in PD have been reported in other studies.[3],[7]

Plastibell impaction is considered to be a common complication,[3],[4],[5] probably related to incorrect selection of the size of the device. Personal interaction with many practitioners has shown that they either use experience to choose the size of Plastibell or do it by trial-and-error leading to waste of PDs before correct size is selected.

Choosing the correct size of Plastibell is, therefore, crucial as too small a size can cause impaction on glans penis, tissue strangulation, and necrosis, while too large a size may result in migration of the devise proximally onto the penile shaft leading to impaction causing denudation of the penile skin and urethrocutaneous fistula.[3]

In a prospective study of penile injury from Plastibell circumcision in Nigeria, Bode et al.[3] reported 23 children with penile injuries resulting from the ring retention and proximal migration. There were extensive skin loss in 17 (74%), urethrocutaneous fistulae in 9 (39%), and partial necrosis of the glans penis in 4 (17%). In another prospective study of 1223 babies (in Pakistan) who underwent Plastibell circumcision at mean age of 14.3 months over 7-year period, Samad et al.[7] reported 90 (7.4%) complication rate. Most of the complications (83%) were ring impaction.[7] Most of these complications resulted from the use of wrong-sized Plastibell ring. The need to document this objective method of determining appropriate Plastibell size becomes imperative, more so, in the era of evidence-based practice. In the current pilot study, all the children did well except a child with ring retention necessitating removal. Although choosing the appropriate size of ring is important for successful outcome of a Plastibell circumcision, it is not the only factor contributing to making the procedure safe and effective. Attention to other surgical details such as avoiding excessive prepuce tension and ensuring that the ligature is sufficiently tied is paramount. Necessitation removal without penile injury. Determining the correct size of Plastibell ring before use will eliminate the subjectivity associated with choosing Plastibell, thereby reduce Plastibell-related complications, and make circumcision safe. The measurement can be done by any literate individual with knowledge of metric. The technique we described enables the practitioner to choose the appropriate size of Plastibell even from outpatient clinic. It can also be adopted for community circumcision in area where circumcision is cultural. We have successfully adopted this approach in our practice. Paper tape is preferred for measuring the glans circumference because it can be snugly applied to the glans penis ensuring accuracy of measurement. Caliper can also be used to determine the glans diameter except that the child needs to be well relaxed. The normograph [Table 1] is depicting glans penis circumference and corresponding Plastibell size which can be displayed in the clinic and operating theater for trainees and practitioners. When using the normograph, it is worthy of note that measurement needs to be rounded up to the nearest size (in cm).

Limitations of study

This study is a pilot study of small number Plastibell circumcision. A large multicenter controlled trial will be needed to further validate the technique.


  Conclusions Top


This objective method of choosing the Plastibell size is easy, feasible, and safe and can be taught to trainees and general practitioner.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Darby R. “Where doctors differ”: The debate on circumcision as a protection against syphilis, 1855-1914. Soc Hist Med 2003;16:57-78.  Back to cited text no. 1
    
2.
Elder JS. Circumcision. BJU Int 2007;99:1553-64.  Back to cited text no. 2
    
3.
Bode CO, Ikhisemojie S, Ademuyiwa AO. Penile injuries from proximal migration of the plastibell circumcision ring. J Pediatr Urol 2010;6:23-7.  Back to cited text no. 3
    
4.
Lazarus J, Alexander A, Rode H. Circumcision complications associated with the plastibell device. S Afr Med J 2007;97:192-3.  Back to cited text no. 4
    
5.
Mousavi SA, Salehifar E. Circumcision complications associated with the plastibell device and conventional dissection surgery: A trial of 586 infants of ages up to 12 months. Adv Urol 2008;606123.  Back to cited text no. 5
    
6.
Moosa FA, Khan FW, Rao MH. Comparison of complications of circumcision by 'plastibell device technique' in male neonates and infants. J Pak Med Assoc 2010;60:664-7.  Back to cited text no. 6
    
7.
Samad A, Khanzada TW, Kumar B. Plastibell circumcision: A minor surgical procedure of major importance. J Pediatr Urol 2010;6:28-31.  Back to cited text no. 7
    
8.
American Academy of Pediatrics Task Force on Circumcision. Circumcision policy statement. Pediatrics 2012;130:585-6.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]



 

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Introduction
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