Circumcision-related tragedies seen in children at the Komfo Anokye Teaching Hospital, Kumasi, Ghana
- Kwaku Addai Arhin Appiah1Email authorView ORCID ID profile,
- 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
© The Author(s). 2016
Received: 7 January 2016
Accepted: 27 October 2016
Published: 8 November 2016
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.
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.
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 %).
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.
KeywordsCircumcision Penile amputation Circumcision injury Urethrocutaneous fistula Ghana
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 injury-related morbidity and mortality in children . 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  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 . Various degrees of circumcision-related injuries occur. However, severe ones seldom occur in developed countries  where circumcision is practised by well-trained personnel . 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 cross-sectional observational study was designed to describe the scope of circumcision-related injuries seen at the Komfo Anokye Teaching Hospital in Kumasi, Ghana.
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.
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 %).
Age at circumcision for circumcision-related injuries recorded in Kumasi
Age at Circumcision
Categories of complications among children with circumcision-related injuries recorded in Kumasi
Type of Complication
Complete Penile Amputation
Epidermal Inclusion cyst
Partial Penile Amputation
Circumcision remains one of the oldest and commonest surgical procedures performed on young boys worldwide [9, 10]. It is widely practiced in the United States  and especially in Israel where virtually every male child is circumcised . However in Europe it is rarely performed . The notable advantages of circumcision include: reduction in early childhood urinary tract infections, which is also noted in adult men [13–17], reduction of HIV transmission by almost 60 % [18–21], and reduction in the incidence of penile cancer [22–24]. Ghana’s circumcision rate is estimated to be on the high side as the majority of ethnic groups and religions identify circumcision as an appropriate religious or cultural practice for males to undergo .
The timing of circumcision among children in this study suggests an early age of circumcision in Ghana as over 87 % of cases had circumcision done in the neonatal period (Table 1). This is similar to findings by Osifo and Oraifo  and Chaim et al. . However, in Eastern and Southern Africa and some parts of the pacific, circumcision is performed far beyond the neonatal period [6, 25, 26]. For some, it is a rite of passage into adulthood [6, 25]. Only 5.6 % of our cases were circumcised beyond the neonatal period. While our study population may not be representative of the population of Ghana, it provides an indication that most circumcisions are being performed during the neonatal period. This may have implications for interventions in the areas of circumcision such as persons to target for training, timing of educational messages on circumcision and the location of circumcision services.
In this study, over 65 % of children with the complications recorded had their circumcisions done in a hospital. The proportion is even higher (75 %) when lower level health facilities (health centres and clinics) are included. Similarly in Nigeria, more circumcisions were done in orthodox medical centres (66.9 %) than traditional settings (33.1 %) . Our findings however, contrast sharply with studies from Southern and Eastern Africa where virtually all circumcisions are performed outside hospitals as part of traditional rites of passage into manhood with high complication rates [6, 25]. In Israel, however, although a significant proportion of circumcisions are undertaken outside health facilities by the ritual circumciser, a lower proportion of complications have been recorded because they are well trained and the practice is regulated .
In this study, nurses accounted for the majority of circumcision-related injuries - 77.8 % of cases. Doctors and traditional circumcisers (locally referred to as Wanzams) accounted for 8.3 and 20.8 % of the circumcision-related complications respectively. Likewise in Nigeria, nurses were found to account for the majority of complications (55.9 %) with doctors and traditional circumcisers accounting for 35.1 and 9 % respectively . In a comparative study by Atikeler et al., it was found that circumcisions done by unlicensed circumcisers resulted in more early phase complications as well as late lifelong complications compared with licensed surgeons . Even among physicians performing circumcisions, there is evidence that there a is lack of formal training amongst them as to how to perform circumcision correctly and providers also lack the requisite skills to manage the complications of circumcisions [4, 7]. Our findings indicate gaps either in knowledge and/or practice among persons providing circumcision services in health facilities in Ghana and it is therefore imperative that training workshops are organised for all providers especially nurses to reduce the incidence of circumcision-related injuries in the future.
The method of circumcision was unknown in 37 (51.4 %) of the cases. A significant proportion (91.4 %) of the cases for which the method of circumcision was known underwent surgical circumcision with a scalpel and this is still consistent with other studies that have examined circumcision-related injuries and complications in the West African sub-region [3, 7]. Due to the high proportion (51.4 %) of cases for which the method of circumcision was unknown in this study, we are unable to associate the method of circumcision with the complications observed. However, there is evidence that the Plastibel device poses a higher risk of complication compared with conventional dissection .
The iatrogenic hypospadias seen in this study may not necessarily be as a result of complications of circumcision but may have been missed mega meatus with intact prepuce variants before circumcision and only found thereafter. This study is unable to determine whether the iatrogenic hypospadias observed had megameatus with intact prepuce before circumcision. Clinically, these are difficult to distinguish after circumcision .
Our study did not record any case of haemorrhage which was among the leading complications recorded by Gee and Ansell . Haemorrhage, most likely, will occur in the first few hours of circumcision. We surmise that late reporting may account for the non-recording of haemorrhage as a complication in our study. It may also be due to clients accessing acute care in lower level health facilities and only reporting severe complications to the Urology Unit. This may also imply that the complete spectrum of circumcision-related injuries may not have been fully covered in our study, thus a bigger burden may exist.
Circumcision has social, cultural and religious implications and this may account for the high uptake of the procedure despite the associated complications [1, 6, 8]. It is imperative that the procedure is made safe in order to ensure that children undergoing the procedure in the future do not develop complications. Persons who have not been circumcised have been ostracised in some parts of Africa; this can take the form of denial of marriage since uncircumcised men were frowned upon [6, 35, 36] in the past and such stereotypes may still exist.
Neonatal circumcision, a common practice in Ghana is associated with several and sometimes tragic complications such as penile amputations. The high proportion of urethrocutaneous fistulae recorded in this study requires further investigation to determine the underlying causes and allow for the institution of appropriate preventive measures. There is the need for further studies focusing on the immediate or early complications following circumcision including injuries related to specific methods of circumcision. The training of providers in order to reduce the incidence of injuries is also recommended.
Human Immunodeficiency virus
Komfo Anokye Teaching Hospital
Statistical Software Package for Social Sciences
We would like to acknowledge the immense contributions of Prof Francis Abantanga and Prof Peter Donkor both of KATH for critically reviewing this manuscript before final submission. We are grateful to them for their words of wisdom and encouragement. We will also like to thank Ms Portia Adutwumwaa, our research assistant who typed and administered the questionnaires and helped enter them into SPSS.
Location of Work: Komfo Anokye Teaching Hospital.
The study received no funding.
Availability of data and materials
The datasets during the current study is available from the corresponding author on reasonable request.
KAAA: Conceived and designed the study and was involved in all stages of the manuscript writing. RA: drafting of manuscript, literature search and critical revision of manuscript for important intellectual content. CKG-S: Literature search, drafting of manuscript and helped in the analysis and interpretation of data. KA: Literature search, manuscript drafting and final approval for submission of manuscript. PM: Helped in data acquisition and was involved in drafting the manuscript at all stages. DOL: Helped in designing the manuscript, was involved in the drafting as well as the critical revision for important intellectual content and approved the final submission of the manuscript. KNB: Was involved in data collection and helped with data analysis and interpretation and approved the final submission of manuscript. KO-B: Data acquisition and interpretation of data. Approved the final submission of manuscript. BF-T: Data acquisition and interpretation, drawing of figures and approval of final submission of manuscript. DA: Data acquisition and analysis, drafting of manuscript and approval for final submission of manuscript. IOA: Data acquisition and analysis, drafting of manuscript and approval for final submission of manuscript. EMY: Data acquisition and interpretation, helped generate the tables and figures. He approved the final submission of manuscript. GA: Was involved in designing the study, helped with data acquisition and interpretation, was involved in drafting of the manuscript and revised it critically for important intellectual content. He also gave approval for the final submission of manuscript. SKT: Data acquisition and interpretation, helped generate the tables and figures. He approved the final submission of manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Written informed consent was obtained from the parents/guardians of all children enrolled for participation in the study and for publication of the accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Ethics approval and consent to participate
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.
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