Aim: This study aimed at describing the various aspects of complications of circumcision and their management in patients referred to N’Djamena Mother & Child Hospital (Chad). Material and Methods: All patients referred for complications of circumcision reported on a 3-year period (July 2011-May 2014) were included. Demographic data, circumstances of the circumcision, clinical presentation and management were computed. Results: Thirty-one cases of complications from traditionally performed circumcisions (n = 19) or circumcisions were performed by paramedics (n = 12). The average age was 7.5 ± 2 years. More than 60% of the patients were between 6 and 10 years old. The complications reported included: urethral fistula in the balano preputial sulcus in 10 cases (32%), entire amputation of the glans in 2 cases (6.5%), amputation of the penis in one case (3.5%), stenosis of the urethral meatus in 8 cases (26%), bleeding in 5 cases (16%) and infections in 5 cases (16%). A surgical treatment was performed according to clinical cases. Conclusion: Circumcision is safe when performed in hospitals. Unfortunately, serious complications may occur if it is performed by non-experts. Hence there is a necessity to raise people’s awareness on the importance of the medicalization of circumcision.
Circumcision is a surgical operation consisting on partially or completely removing the foreskin. It is assumed that 25% of men (male) worldwide are circumcised [1] . Bearing this in mind, it is clear that circumcision is the most performed surgical operation worldwide [2] . Most circumcisions are due to religious reasons and some to medical ones [3] . In Africa, circumcision is mostly performed by traditional practitioners, sometimes by qualified or non-qualified paramedics with limited or no knowledge about anatomy, surgery and asepsy [4] . In Chad, circumcisions are commonly performed at home and in the villages, during collective circumcisions rites; this often leads to major complications; few cases of circumcisions are performed in health facilities. Complications related to circumcision are benign or severe, sometimes sexual, urinary and life threatening for patients. In developed countries, the rate of circumcision related complications ranges from 2% to 5% [5] . In developing countries, circumcision related complications rate is rather higher; up to 85% when performed by traditional practitioners [6] . This study aimed at identifying and describing the complications of circumcision in patients referred to the Paediatric Surgery Department of the Mother & Child Hospital and the clinical management.
2. Patients and Methods
All patients admitted in the pediatric surgery unit for a complication following circumcision were included. 19 cases of circumcision have been performed by traditional practitioners versus 12 cases by paramedics. For these patients medical record abstraction was used to collect data. The variable of interest were patient age, area of circumcision performance, cirumcision method, healthcare provider, time to referral to the hospital for complication management, reason for referral and clinical presentation. Laboratory work included blood cell count and hemoglobin. Type of complication, medical and surgical treatment and outcomes were the remaining variables. Complications were further grouped as penile urethral fistula; urethral meatus stenosis; bleeding; infections and amputation. We performed descriptive analysis of the variable, statistical significance was considered for p ˂ 0.05.
3. Results
The distribution of patients by age is reported in (Figure 1). The average age of the patients was 7.5 ± 2 years, ranging from 1 to 12 years. There was a predominance of the 6 - 10 years age group (61.9%). In 69.6% of cases the circumcisions were performed by traditional practitioners versus 39.4% by paramedics. The various complications are reported in (Figure 2). Two cases of glans amputation and one case of complete amputation of the
Distribution of the patients according to age group
penis were recorded. A meatoplasty with a placement of a trans-urethral catheter was carried out for 8 cases of urethral meatus stenosis, for 1 case of glans amputation admitted too late, as well as for 1 case of failure of replantation of the penis after amputation (Table 1).
One (1) case of amputation of the glans was performed by a paramedic and then admitted to the department within 30 minutes. The amputated penis was put in fresh saline. It was immediately brought to the operating room (Figure 3) and the glans was successfully replanted (Figure 4).
Overall, the result of the treatment was satisfactory in 78% of cases.
4. Discussion
Although circumcision-related accidents occur in developed countries, they are much commonest in developing countries. In Africa, circumcision is usually performed by people without any medical competency (hairdresser, traditional healer, paramedics...) [7] . However, many parents, often illiterate, unaware of the seriousness of potential accidents, and wishing to avoid lengthy hospital administrative procedures and general anaesthesia, considered too risky for such a simple operation, choose providers without any medical skills [8] .
In our study over 3 years we report 31 accidents. The frequency of these complications is comparable to those
Distribution of complications
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