Infant male circumcision is commonly practiced in many parts of the world, by both formal health service providers such as doctors, medical assistants, midwives, general nurses and informal health service providers including traditional circumcision providers, traditional birth attendants, hospital workers with no formal medical training, e.g., orderlies and attendants, religious leaders and traditional medicine men or women [5]. As a surgical procedure, it is expected that male circumcision be performed to the required standard by all circumcision service providers with the requisite training. Yet, health service providers often do not receive any formal training and education to perform circumcision to required standards. Studies show that complications following circumcision are usually due to the lack of structured training on circumcision for medical circumcisers. Hence, these studies recommend structured and formal training to reduce complications associated with infant male circumcision [5, 6]. In this study, none of the 378 participants who performed circumcision had received any formal training on the procedure despite the fact that two-thirds of them had performed circumcision for more than 1 year. They had all learnt to perform circumcision by observing other colleagues who performed the procedure. At least each of them had encountered early complications such as excessive bleeding, insufficient skin coverage or redundant foreskin. Six (6) of them had seen patients who developed urethrocutaneous fistula post circumcision. It is possible that there are other late complications including urethrocutaneous fistulae, penile skin bridges, epidermal inclusion cysts and even glans or penile amputations that may not have reported to them. This is because most parents report late complications of circumcision to urologists and not to the circumciser as they do not attribute the complication to the circumcision procedure due to the long period it takes for the complications to manifest [3, 7]. In Uganda, it was shown that even trained doctors needed to complete 100 circumcisions to significantly reduce the incidence of adverse events of circumcision [8]. This therefore indicates that untrained medical personnel such as midwives, nurses, etc. are likely to have many adverse events from the procedure as was observed in this study.
The World Health Organization recommends anesthesia for neonatal circumcision [9, 10]. Local anesthesia using a surface cream like eutectic mixture of local anesthetics (EMLA), or using 1% lidocaine for targeted or ring block at the base of the penis helps reduce pain of circumcision for the patient and also makes him more cooperative for the procedure to be done, reducing risk of iatrogenic injuries and complications. In this study, only 27.0% of participants performed circumcision under anesthesia. This low rate of anesthesia for circumcision is despite the fact that local anesthetic agents like Lidocaine are readily available and affordable. This low rate may be due to poor comprehension of the principles of circumcision, which would have been acquired through formal training.
In infants and neonates, it is safest to use techniques such as the device methods with Plastibel or Gomco clamp which protect the glans penis or use surgical techniques like the dorsal slit or sleeve technique where excision of foreskin is done with the glans penis in view to reduce the risk of injury to it [11]. In the study by Appiah et al. on circumcision related tragedies in Ghana, almost 7% (5 out of 72) of the complications were penile amputations, mostly due to forceps guided/amputation technique [3]. In this study, the forceps guided technique/amputation technique was the most common technique used despite the fact that in neonates and infants, this technique risks injuring the glans or the phallus due to its relatively small size. This is consistent with the findings of Gyan et al. who observed that 88.9% of circumcisions performed in rural Ghana were done with the forceps guided technique [4]. The principles of circumcision recommend excision of foreskin while the glans penis is under direct vision as this helps to reduce risk of glans or penile injury [9]. Formal training may have exposed these participants to some of these guiding principles or recommendations and may have reduced the popularity of the forceps guided technique where foreskin is excised without the glans penis in view.
