Circumcision-related tragedies seen in children at the Komfo Anokye Teaching Hospital, Kumasi, Ghana

Appiah et al. BMC Urology (2016) 16:65 DOI 10.1186/s12894-016-0183-1 RESEARCH ARTICLE Open Access Circumcision-related tragedies seen in children at the Komfo Anokye Teaching Hospital, Kumasi, Ghana Kwaku Addai Arhin Appiah1* , Christian Kofi Gyasi-Sarpong2, Roland Azorliade1, Ken Aboah2, Dennis Odai Laryea3, Kwaku Otu-Boateng1, Kofi Baah-Nyamekye1, Patrick Opoku Manu Maison1, Douglas Arthur1, Isaac Opoku Antwi1, Benjamin Frimpong-Twumasi1, Edwin Mwintiereh Yenli4, Samuel Kodzo Togbe1 and George Amoah1 Abstract Background: Circumcision is a common minor surgical procedure and it is performed to a varying extent across countries and religions. Despite being a minor surgical procedure, major complications may result from it. In Ghana, although commonly practiced, circumcision-related injuries have not been well documented. This study is to describe the scope of circumcision-related injuries seen at the Komfo Anokye Teaching Hospital in Kumasi, Ghana. Methods: The study was conducted at the Urology Unit of the Komfo Anokye Teaching Hospital in Kumasi. Consecutive cases of circumcision-related injuries seen at the unit over an 18 month period were identified and included in the study. Data was collected using a structured questionnaire. Data was entered and analysed using SPSS version 16. Charts and tables were generated using Microsoft Excel. Results: A total of 72 cases of circumcision-related injuries were recorded during the 18 month period. Urethrocutaneous fistula was the commonest injury recorded, accounting for 77.8 % of cases. Other injuries recorded were glans amputations (6.9 %); iatrogenic hypospadias (5.6 %), and epidermal inclusion cysts (2.8 %). The majority of children were circumcised in health facilities (75 %) and nurses were the leading providers (77.8 %). The majority of circumcisions were conducted in the neonatal period (94.7 %). Conclusion: Circumcision-related injuries commonly occurred in the neonatal period. Most of the injuries happened in health facilities. The most common injury recorded was urethrocutaneous fistula but the most tragic was penile amputation. There is the need for education and training of providers to minimise circumcision-related injuries in Ghana. Keywords: Circumcision, Penile amputation, Circumcision injury, Urethrocutaneous fistula, Ghana Background Circumcision is routinely performed in most parts of Ghana as a tradition. While generally regarded as a minor surgical procedure, major complications may result from it [1–4]. Although circumcision injuries are unintended, the prominence of circumcision as a cause of major injury in children is not recognised, as the world report on injury in children did not identify circumcision-related injuries as significant causes of * Correspondence: 1 Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana Full list of author information is available at the end of the article injury-related morbidity and mortality in children [5]. This notwithstanding, some circumcision injuries may be associated with long term social and psychological challenges including the inability to have a fulfilling sexual life as the case may be in penile amputations [6] and even death in some cases of severe haemorrhage [6, 7]. In Nigeria, circumcision-related injuries have been on the ascendancy with an estimated 20 % circumcisions resulting in one form of complication or the other [3]. Various degrees of circumcision-related injuries occur. However, severe ones seldom occur in developed countries [2] where circumcision is practised by well- © The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Appiah et al. BMC Urology (2016) 16:65 Page 2 of 8 trained personnel [8]. Circumcision injuries have been associated with all the methods of circumcisions [1, 4] especially in untrained hands [3, 6–8]. In Ghana, data on circumcision-related injuries is scanty. This crosssectional observational study was designed to describe the scope of circumcision-related injuries seen at the Komfo Anokye Teaching Hospital in Kumasi, Ghana. Table 1 Age at circumcision for circumcision-related injuries recorded in Kumasi Methods The study was conducted at the Urology Unit of the Directorate of Surgery, Komfo Anokye Teaching Hospital (KATH). KATH is a major referral centre for the middle and northern zones of Ghana. All male children below 18 years of age referred to the Komfo Anokye Teaching Hospital’s Urology Unit for treatment of early and late complications of circumcision as determined by our eligibility criteria were included in the study. Urologists at the unit conducted penile examinations and assigned eligible patients specific injury categories as haemorrhage, urethrocutaneous fistula, penile amputation, iatrogenic hypospadias, skin bridges, excess foreskins, epidermal inclusion cysts, buried penis or any other injury that was deemed to be as a result of circumcision. Guardians/parents of eligible children were approached for inclusion in the study. The aim of the study was explained to them and informed consent obtained. Ethical approval was obtained from the Committee on Human Research, Publications and Ethics of the Kwame Nkrumah University of Science and Technology and the Komfo Anokye Teaching Hospital. Data collection involved a structured questionnaire administered by a trained research assistant. Data collected included demographic information, place of circumcision, person circumcising, age at circumcision and clinical examination findings. Data was collected over an 18 month period from September 2012 to February 2014. Data was entered into SPSS version 16 and the same was utilized for statistical analysis. Microsoft Excel was used to generate the tables and charts. Results A total of 72 cases of children with circumcision-related complications were seen during the 18 month period. The youngest case was recorded in a 2-day old neonate and the oldest case recorded was in an 11-year-old boy. The majority of the children were resident in urban communities (54.0 %). Over 87 % of children in this study were circumcised before they were 2 weeks old. Only 5.6 % were circumcised after 4 weeks of age (Table 1). The majority of children were circumcised in a hospital (65.3 %). The place of circumcision is as shown in Fig. 1. Nurses accounted for the majority of circumcision-related injuries recorded in this study, 77.8 %. Doctors and Age at Circumcisio (...truncated)