Parental Assessment of Pain Control Following Pediatric Circumcision: Do Opioids Make a Difference?

OBJECTIVE: To determine whether a postoperative prescription for opioids affects parental assessment of pain control following pediatric circumcision. METHODS: This postoperative survey assessed the parental assessment of pain control in 199 patients, ages<18 years undergoing circumcision. This study was conducted at a quaternary care children's hospital in Houston, Texas from December 2018 to January 2020. Postoperative pain regimens included acetaminophen and ibuprofen or combination hydrocodone/acetaminophen in addition to ibuprofen for postoperative analgesia based on the surgical preference. The primary study outcome was identification of the proportion of parents rating their child's analgesia following pediatric circumcision as poor or inadequate based on the postoperative analgesic regimen. RESULTS: Of the 502 surveys sent, the response rate was 40% (199/502) of those who received the survey email, and 64% (199/308) for those who opened the email. Between the opioid and nonopioid groups, there was no difference in, race/ethnicity (Caucasian; 28% vs 37%; P = .43) or insurance status (insured; 51% vs 45%; P = .44). The proportion of parents who rated their child's pain as poor or inadequately controlled following circumcision was relatively rare:5.5% and 1.1% in the nonopioid and opioid groups, respectively. Parents rating their child's pain as excellent with regards to pain control following circumcision were 61% and 53% in the nonopioids and opioid groups, respectively. CONCLUSION: The results of this study indicate that nonopioid analgesic regimens following pediatric circumcision were not associated with decreased parental satisfaction or an increasing assessment of poor or inadequately controlled pain. Limiting opioid exposure following pediatric circumcision is feasible and does not result in worse parental satisfaction with the analgesic plan.

Cost-effectiveness analysis of two-way texting for post-operative follow-up in Zimbabwe's voluntary medical male circumcision program.

OBJECTIVE: Although adverse events (AEs) following voluntary medical male circumcision (VMMC) are rare, their prompt ascertainment and management is a marker of quality care. The use of two-way text messaging (2wT) for client follow-up after VMMC reduces the need for clinic visits (standard of care (SoC)) without compromising safety. We compared the cost-effectiveness of 2wT to SoC for post-VMMC follow-up in two, high-volume, public VMMC sites in Zimbabwe. MATERIALS AND METHODS: We developed a decision-analytic (decision tree) model of post-VMMC client follow-up at two high-volume sites. We parameterized the model using data from both a randomized controlled study of 2wT vs. SoC and from the routine VMMC program. The perspective of analysis was the Zimbabwe government (payer). The time horizon covered the time from VMMC to wound healing. Costs included text messaging; both in-person and outreach follow-up; and AE management. Costs were estimated in 2018 U.S. dollars. The outcome of analysis was AE yield relative to the globally accepted safety standard of a 2% AE rate. We estimated the incremental cost per percentage increase in AE ascertainment and the incremental cost per additional AE identified. We conducted univariate and probabilistic sensitivity analyses. RESULTS: 2wT increased the costs due to text messaging by $4.42 but reduced clinic visit costs by $2.92 and outreach costs by $3.61 -a net savings of $2.10. 2wT also increased AE ascertainment by 50% (92% AE yield in 2wT compared to 42% AE yield in SoC). Therefore, 2wT dominated SoC in the incremental analysis: 2wT was less costly and more effective. Results were generally robust to univariate and probabilistic sensitivity analysis. CONCLUSIONS: 2wT is cost-effective for post-VMMC follow-up in Zimbabwe. Countries in which VMMC is a high-priority HIV prevention intervention should consider this mHealth intervention to reduce overall cost per VMMC, increasing the likelihood of current and future VMMC program sustainability.

Need for improved detection of voluntary medical male circumcision adverse events in Mozambique: a mixed-methods assessment.

BACKGROUND: Adverse events (AE) resulting from voluntary medical male circumcision (VMMC) are commonly used to measure program quality. Mozambique's VMMC program data reports a combined moderate and severe AE rate of 0.2% through passive surveillance. With active surveillance, similar programs report AE rates ranging from 1.0 to 17.0%. The objective of this activity was to assess potential underreporting of AEs via the passive surveillance system in Mozambique. METHODS: This mixed-methods assessment randomly selected one third (16) of all 46 VMMC clinics through stratified sampling, based on volume. A retrospective record review was conducted including patient clinical files, stock records of Amoxicillin/Clavulanic Acid (the choice antibiotic for VMMC-related infections), and clinic-level AE rates from the national database. Records from the month of April 21 to May 20, 2017 were analyzed to identify both reported and potentially unreported AEs. In addition, external, expert clinicians observed post-operative visits (n = 167). Descriptive statistics were calculated, including difference between reported and identified AEs, an adjusted retrospective AE rate, and an observed prospective AE rate in each clinic. RESULTS: A total of 5352 circumcisions were performed in the 16 clinics: 8 (0.15%) AEs were reported. Retrospective clinical record reviews identified 36 AEs (0.67%); AE severity or type was unknown. Using Amoxicillin/Clavulanic Acid dispensation as a proxy for VMMC-related infections, 39 additional AEs infections were identified, resulting in an adjusted AE rate of 1.4%, an 8.3 fold increase from the reported AE rate. Prospective, post-operative visit observations of 167 clients found 10 AEs (5.9%); infection was common and boys 10-14 years old represented 80% of AE clients. CONCLUSIONS: Evidence suggests underreporting of AEs in the Mozambican VMMC program. Quality improvement efforts should be implemented in all VMMC sites to improve AE identification, documentation and prevention efforts.

Incorporating Voluntary Medical Male Circumcision Into Traditional Circumcision Contexts: Experiences of a Local Consortium in Zimbabwe Collaborating With an Ethnic Group.

Employing voluntary medical male circumcision (VMMC) within traditional settings may increase patient safety and help scale up male circumcision efforts in sub-Saharan Africa. In Zimbabwe, the VaRemba are among the few ethnic groups that practice traditional male circumcision, often in suboptimal hygienic environments. ZAZIC, a local consortium, and the Zimbabwe Ministry of Health and Child Care (MoHCC) established a successful, culturally sensitive partnership with the VaRemba to provide safe, standardized male circumcision procedures and reduce adverse events (AEs) during traditional male circumcision initiation camps. The foundation for the VaRemba Camp Collaborative (VCC) was established over a 4-year period, between 2013 and 2017, with support from a wide group of stakeholders. Initially, ZAZIC supported VaRemba traditional male circumcisions by providing key commodities and transport to help ensure patient safety. Subsequently, 2 male VaRemba nurses were trained in VMMC according to national MoHCC guidelines to enable medical male circumcision within the camp. To increase awareness and uptake of VMMC at the upcoming August-September 2017 camp, ZAZIC then worked closely with a trained team of circumcised VaRemba men to create demand for VMMC. Non-VaRemba ZAZIC doctors were granted permission by VaRemba leaders to provide oversight of VMMC procedures and postoperative treatment for all moderate and severe AEs within the camp setting. Of 672 male camp residents ages 10 and older, 657 (98%) chose VMMC. Only 3 (0.5%) moderate infections occurred among VMMC clients; all were promptly treated and healed well. Although the successful collaboration required many years of investment to build trust with community leaders and members, it ultimately resulted in a successful model that paired traditional circumcision practices with modern VMMC, suggesting potential for replicability in other similar sub-Saharan African communities.

Adolescent Wound-Care Self-Efficacy and Practices After Voluntary Medical Male Circumcision-A Multicountry Assessment.

Background: Adolescent boys (aged 10-19 years) constitute the majority of voluntary medical male circumcision (VMMC) clients in sub-Saharan Africa. They are at higher risk of postoperative infections compared to adults. We explored adolescents' wound-care knowledge, self-efficacy, and practices after VMMC to inform strategies for reducing the risks of infectious complications postoperatively. Methods: Quantitative and qualitative data were collected in South Africa, Tanzania, and Zimbabwe between June 2015 to September 2016. A postprocedure survey was conducted approximately 7-10 days after VMMC among male adolescents (n = 1293) who had completed a preprocedure survey; the postprocedure survey assessed knowledge of proper wound care and wound-care self-efficacy. We also conducted in-depth interviews (n = 92) with male adolescents 6-10 weeks after the VMMC procedure to further explore comprehension of providers' wound-care instructions as well as wound-care practices, and we held 24 focus group discussions with randomly selected parents/guardians of the adolescents. Results: Adolescent VMMC clients face multiple challenges with postcircumcision wound care owing to factors such as forgetting, misinterpreting, and disregarding provider instructions. Although younger adolescents stated that parental intervention helped them overcome potential hindrances to wound care, parents and guardians lacked crucial information on wound care because most had not attended counseling sessions. Some older adolescents reported ignoring symptoms of infection and not returning to the clinic for review when an adverse event had occurred. Conclusions: Increased involvement of parents/guardians in wound-care counseling for younger adolescents and in wound-care supervision, alongside the development of age-appropriate materials on wound care, are needed to minimize postoperative complications after VMMC.

The Use of Tissue Glue for Circumcision in Children: Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate the efficacy of tissue glue in pediatric circumcision. MATERIALS AND METHODS: A systematic review and meta-analysis of the English literature (1997-2017) was conducted according to the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) statement on children who underwent circumcision with tissue glue. Meta-analysis was conducted using RevMan 5.3, Comprehensive Meta-Analysis 2, and MedCalc 18. P values <.05 were considered significant. RESULTS: The search returned 15 studies for a total of 4567 circumcisions, of which 3045 (66%) were performed with tissue glue. The systematic review indicated that overall complication rates were 4.3% (tissue glue) and 5.9% (sutures). The use of tissue glue was associated with reduced postoperative pain, better cosmetic results, and reduced cost. Meta-analysis showed that there was no difference between the incidence of total postoperative complications (relative risk [RR] 0.86 [95% confidence interval {CI}: 0.62-1.19], P = .36) and wound infection and dehiscence between the 2 groups (RR 0.95 [95% CI: 0.59-1.56], P = .85). Postoperative bleeding and hematoma formation were reduced with the use of tissue glue (RR 0.55 [95% CI: 0.32-0.95], P = .03). Tissue glue also significantly shorten the operative time (mean difference -0.22 [95% CI: -0.39 to -0.05], P = .01). CONCLUSION: The incidence of postoperative bleeding and hematoma formation in pediatric circumcision is reduced with the use of tissue glue. Tissue glue has reduced operative time; furthermore, it might be associated with reduced postoperative pain, less overall cost, and superior cosmetic results.

The quality of voluntary medical male circumcision done by mid-level workers in Tshwane District, South Africa: A retrospective analysis.

BACKGROUND: Voluntary medical male circumcision (VMMC) reduces the acquisition of human immunodeficiency virus (HIV) in heterosexual men by up to 60%. One HIV infection is averted for every 5 to 15 VMMCs. To conduct VMMCs in large populations, large numbers of trained healthcare professionals are needed. Countries in Sub-Saharan Africa have a high burden of HIV and a shortage of healthcare professionals, creating a healthcare conundrum. To bridge this gap, South Africa launched a new cadre of mid-level medical worker called Clinical Associates (CA). We assessed the ability of CAs to perform circumcisions of adequate quality and their subsequent usefulness to meet the demands of VMMCs in a population with a high HIV burden. METHODS: We conducted a retrospective analysis, reviewing patient files (n = 4850) of surgical VMMCs conducted over a 16-month period. Patient files were sourced from clinics and hospitals that provided free VMMCs in Tshwane district in South Africa. FINDINGS: Clinical associates performed 88.66% of the circumcisions and doctors performed the remaining 11.34% (p < 0.001). The number of adverse events did not differ between the two groups. Data on intra-operative adverse events were available for 4 738 patients. Of these, 341 (7.2%) experienced intra-operative adverse events. For the whole sample, 44 (8.1%, n = 543) adverse events occurred during circumcisions done by doctors and 297 (7.1%, n = 4195) occurred during circumcisions done by CAs (p = 0.385). Clinical associates performed circumcisions in shorter times (duration: 14.63 minutes) compared to doctors (duration: 15.25 minutes, t = -7.46; p < 0.001). Recorded pain, bleeding, swelling, infection and wound destruction did not differ between clients circumcised by CAs and doctors. This study is limited by the use of data from a single district. CONCLUSIONS: Clinical associates contribute to the demands for high numbers of VMMCs in Tshwane district, South Africa. Clinical associates perform VMMCs at a clinical standard that is comparable to circumcisions performed by doctors.

[Post-circumcision Tetanus: Epidemiological, Clinical, Prognostic and Evolutionary Aspects of 16 Cases Collected at the Department of Infectious and Tropical Diseases in Fann Hospital (Dakar)]. / Tétanos postcirconcision : à propos de 16 cas colligés à la Clinique des maladies infectieuses du CHNU de Fann (Dakar).

This retrospective, descriptive study carried out in the Infectious Diseases Department of CHNU, Fann from 1st January 2012 to 3st December 2016 aimed to describe the epidemiological aspects and the course of post-circumcision tetanus and to formulate public health recommendations. During our study period, 16 cases of post-circumcision tetanus were collected out of a total of 452 patients with tetanus, equivalent to a rate of 3.5%. The median age was 8 years (3-40). None of the patients had a vaccination card. In 63% of cases, circumcision was performed at home, by a practitioner whose qualification was not documented in 63% of cases. All signs of tetanus were found with trismus (100%), dysphagia (63%) and paroxysms (88%). These were mostly Mollaret stage II forms in 14 cases, and grade 3 Dakar score in 7 cases. The median duration of hospitalization was 10 days [6-15]. Mechanical or infectious complications were noted in two cases, with a lethality rate of 13%. Post-circumcision tetanus is a reality in Senegal. Good community awareness, continuous training of staff and implementation of vaccination catch-up strategies for children of circumcised age should eradicate this form of tetanus.

Cette étude rétrospective descriptive, réalisée à la Clinique des maladies infectieuses du CHNU de Fann du 1er janvier 2012 au 31 décembre 2016 avait pour but de décrire les aspects épidémiologiques et évolutifs du tétanos postcirconcision et de formuler des recommandations en termes de prévention. Durant la période d'étude, 16 cas de tétanos postcirconcision ont été colligés sur un total de 452 patients atteints de tétanos, soit une fréquence hospitalière de 3,5 %. L'âge médian était de huit ans (3­40). Aucun des patients ne disposait de carnet de vaccination. Dans 63 % des cas, la circoncision a été effectuée à domicile, par un praticien dont la qualification n'a pas été documentée dans 63 % des cas. Tous les signes du tétanos ont été retrouvés avec le trismus (100 %), la dysphagie (63 %) et les paroxysmes (88 %). Il s'agissait surtout de formes de moyenne gravité classées au stade II de Mollaret dans 14 cas, et au score 3 de Dakar dans sept cas. La durée médiane d'hospitalisation était de dix jours [6­15]. Des complications mécaniques ou infectieuses ont été notées dans deux cas, avec une létalité de 13 %. Le tétanos postcirconcision est une réalité au Sénégal. Une bonne sensibilisation de la communauté, la formation continue du personnel et la mise en place de stratégies de rattrapage vaccinal des enfants en âge d'être circoncis devraient permettre d'éradiquer cette forme de tétanos.

A systems-based assessment of the PrePex device adverse events active surveillance system in Zimbabwe.

BACKGROUND: Voluntary Medical Male Circumcision (VMMC) is an effective method for HIV prevention and the World Health Organization (WHO) has recommended its expansion in 14 African countries with a high prevalence of HIV and low prevalence of male circumcision. The WHO has recently pre-qualified the PrePex device, a non-surgical male circumcision device, which reduces procedure time, can increase acceptability of VMMC, and can expand the set of potential provider cadres. The PrePex device was introduced in Zimbabwe as a way to scale-up VMMC services in the country. With the rapid scale-up of the PrePex device, as well as other similar devices, a strong surveillance system to detect adverse events (AE) is needed to monitor the safety profile of these devices. We performed a systems-based evaluation of the PrePex device AE active surveillance system in Zimbabwe. METHODS: The evaluation was based on the Centers for Disease Control and Prevention's Updated Guidelines for Evaluating Public Health Surveillance Systems. We adapted these guidelines to fit our local context. The evaluation incorporated the review of the standard operating procedures and surveillance system documents. Additionally, structured, in-person interviews were performed with key stakeholders who were users of the surveillance system at various levels. These key stakeholders were from the Ministry of Health, implementing partners, and health facilities in Harare. RESULTS: Clients were requested to return to the facility for follow-up on days 7, 14 and 49 after placement of the device. In the event of a severe AE, a standard report was generated by the health facility and relayed to the Ministry of Health Child and Care and donor agencies through predefined channels within 24 hours of diagnosis. Clinic staff reported difficulties with the amount of documentation required to follow up with clients and to report AEs. The surveillance system's acceptability among users interviewed was high, and users were motivated to identify all possible AEs related to this device. The surveillance system was purely paper-based and both duplicate and discrepant reporting forms between sites were identified. CONCLUSION: The PrePex AE active surveillance system was well accepted among participants in the health system. However, the amount of documentation which was required to follow-up with patients was a major barrier within the system, and might lead to decreased timeliness and quality of reporting. A passive surveillance system supported by electronic reporting would improve acceptance of the program.

Nontherapeutic Circumcision of Minors as an Ethically Problematic Form of Iatrogenic Injury.

Nontherapeutic circumcision (NTC) of male infants and boys is a common but misunderstood form of iatrogenic injury that causes harm by removing functional tissue that has known erogenous, protective, and immunological properties, regardless of whether the surgery generates complications. I argue that the loss of the foreskin itself should be counted, clinically and morally, as a harm in evaluating NTC; that a comparison of benefits and risks is not ethically sufficient in an analysis of a nontherapeutic procedure performed on patients unable to provide informed consent; and that circumcision violates clinicians' imperatives to respect patients' autonomy, to do good, to do no harm, and to be just. When due consideration is given to these values, the balance of factors suggests that NTC should be deferred until the affected person can perform his own cost-benefit analysis, applying his mature, informed preferences and values.

Use of the ShangRing circumcision device in boys below 18 years old in Kenya: results from a pilot study.

INTRODUCTION: Male circumcision is a proven prevention strategy against the spread of HIV. The World Health Organization's new 2016-2021 strategic framework on voluntary medical male circumcision (VMMC) targets 90% of males aged 10-29 years to receive circumcision by 2021 in 14 priority sub-Saharan countries while anticipating an increase in the demand for infant circumcision. It also states that the use of circumcision devices is a safe and efficient innovation to accelerate attainment of these goals. The primary objective of this pilot study was to evaluate the safety and acceptability of the ShangRing, a novel circumcision device, in boys below 18 years of age. METHODS: A total of 80 boys, 3 months to 17 years old, were circumcised using the no-flip ShangRing technique. All rings were removed 5-7 days later. Participants were evaluated weekly until the wound was completely healed. Data on procedure times, adverse events (AEs), time to clinical wound healing and satisfaction were recorded and analysed. RESULTS: Nearly all (79/80, 98.8%) circumcisions were successfully completed using the no-flip ShangRing technique without complications. In one (1.2%) case, the outer ring slipped off after the foreskin was removed and the procedure was completed by stitching. The mean circumcision and ring removal times were 7.4 ± 3.2 and 4.4 ± 4.2 min, respectively. There were four (5%) moderate AEs, which were managed conservatively. No severe AEs occurred. The mean time to complete clinical healing was 29.8 ± 7.3 days. Participants or their parents liked ShangRing circumcision because it improved hygiene, was quick and possessed an excellent cosmetic appearance. Most (72/80, 94.7%) were very satisfied with the appearance of the circumcised penis, and all (100%) said they would recommend circumcision to others. CONCLUSIONS: Our results suggest that no-flip ShangRing VMMC is safe and acceptable in boys below 18 years of age. Our results are to be compared those seen following ShangRing VMMC in African men. Further study with larger sample sizes are needed to explore the scalability of the ShangRing in larger paediatric cohorts in Africa. We believe that the ShangRing has great potential for use in all age groups from neonates to adults, which would simplify device implementation.

Between Moral Relativism and Moral Hypocrisy: Reframing the Debate on "FGM".

The spectrum of practices termed "Female Genital Mutilation" (or FGM) by the World Health Organization is sometimes held up as a counterexample to moral relativism. Those who advance this line of thought suggest the practices are so harmful in terms of their physical and emotional consequences, as well as so problematic in terms of their sexist or oppressive implications, that they provide sufficient, rational grounds for the assertion of a universal moral claim--namely, that all forms of FGM are wrong, regardless of the cultural context. However, others point to cultural bias and moral double standards on the part of those who espouse this argument, and have begun to question the received interpretation of the relevant empirical data on FGM as well. In this article I assess the merits of these competing perspectives. I argue that each of them involves valid moral concerns that should be taken seriously in order to move the discussion forward. In doing so, I draw on the biomedical "enhancement" literature in order to develop a novel ethical framework for evaluating FGM (and related interventions--such as female genital "cosmetic" surgery and nontherapeutic male circumcision) that takes into account the genuine harms that are at stake in these procedures, but which does not suffer from being based on cultural or moral double standards.

Risks, benefits, complications and harms: neglected factors in the current debate on non-therapeutic circumcision.

UNLABELLED: Much of the contemporary debate about the propriety of non-therapeutic circumcision of male infants and boys revolves around the question of risks vs. BENEFITS: With its headline conclusion that the benefits outweigh the risks, the current circumcision policy of the American Academy of Pediatrics [AAP] (released 2012) is a typical instance of this line of thought. Since the AAP states that it cannot assess the true incidence of complications, however, critics have pointed out that this conclusion is unwarranted. In this paper it is argued that the AAP's conclusion is untenable not only for empirical reasons related to lack of data, but also for logical and conceptual reasons: the concept of risk employed-risk of surgical complications-is too narrow to be useful in the circumcision debate. Complications are not the only harms of circumcision: the AAP and other parties debating the pros and cons of circumcision should conceptualize their analysis more broadly as risk of harm vs. prospect of benefit, thereby factoring in the value of the foreskin to the individual and the physical and ethical harms of removing it from a non-consenting child.

Low adverse event rates following voluntary medical male circumcision in a high HIV disease burden public sector prevention programme in South Africa.

INTRODUCTION: The provision of voluntary medical male circumcision (VMMC) services was piloted in three public sector facilities in a high HIV disease burden, low circumcision rate province in South Africa to inform policy and operational guidance for scale-up of the service for HIV prevention. We report on adverse events (AEs) experienced by clients following the circumcision procedure. METHODS: Prospective recruitment of HIV-negative males aged 12 and older volunteering to be circumcised at three select public health facilities in KwaZulu-Natal between November 2010 and May 2011. Volunteers underwent standardized medical screening including a physical assessment prior to the surgical procedure being performed. AEs were monitored at three time intervals over a 21-day period post-operatively to determine safety outcomes in this pilot demonstration programme. RESULTS: A total of 602 volunteers participated in this study. The median age of the volunteers was 22 years (range 12-56). Most participants (75.6%) returned for the 48-hour post-operative visit; 51.0% for day seven visit and 26.1% for the 21st day visit. Participants aged 20-24 were most likely to return. The AE rate was 0.2% intra-operatively. The frequency of moderate AEs was 0.7, 0.3 and 0.6% at 2-, 7- and 21-day visits, respectively. The frequency of severe AEs was 0.4, 0.3 and 0.6% at 2-, 7- and 21-day visits, respectively. Swelling and wound infection were the most common AEs with mean appearance duration of seven days. Clients aged between 35 and 56 years presented with most AEs (3.0%). CONCLUSIONS: VMMC can be delivered safely at resource-limited settings. The intensive three-visit post-operative review practice may be unfeasible due to high attrition rates over time, particularly amongst older men.

Neonatal circumcision: new recommendations & implications for practice.

Neonatal male circumcision is the most common surgical procedure performed on pediatric patients. While the rate of neonatal circumcision in the United States has been dropping, circumcision continues to be frequent, ranging from 42% to 80% among various populations. While the cultural debate over circumcision continues, recent evidence of medical benefits led to a revision of the American Academy of Pediatrics (AAP) circumcision policy statement. In contrast to the 1999 AAP policy statement, the 2012 policy asserts that the preventive benefits of neonatal circumcision outweigh the risk of the procedure, which is well tolerated when performed by trained professionals, under sterile conditions, and with appropriate pain management. This Circumcision Policy Statement has also been endorsed by the American College of Obstetricians and Gynecologists and a similar policy statement is in place from the American Urologic Association. Despite the new recognized health benefits found by the 2012 Task Force of Circumcision (TFOC), circumcision remains controversial even among medical professionals. Other well recognized medical organizations including The American Academy of Family Practice and some international pediatric societies have not adopted such a strong endorsement of circumcision. The policy statements from these organizations continue to more closely resemble the 1999 AAP policy statement that stated, "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision." In this review we will summarize historical, cultural and ethical factors in neonatal circumcision and briefly compare common surgical techniques including anesthesia. In addition, we will discuss recent information regarding the benefits and risks of neonatal circumcision. Finally, we will discuss the financial reimbursement of practitioners and the benefits of standardized circumcision curriculum for trainees.

[Circumcision and orchiopexy: management of complications]. / Zirkumzision und Orchidopexie: Komplikationsmanagement.

Circumcision and orchidopexy are among the most frequently performed pediatric urological procedures. Although they may be classified as surgical interventions suitable for junior surgeons, either procedure can lead to serious consequences including the loss of the respective organ. In this paper, the general aspects of pediatric urological surgery (e.g., distinctive features of informing underage patients, the handling of children in the operating room, and relevant pediatric anesthesiological aspects) are described first. Then, the most important sources of error will be highlighted and potential complications and their management during all stages of the procedure will be illustrated. Apart from the so-called freehand circumcision, this paper also deals with potential complications when using the Plastibell® device. In regard to orchidopexy, laparoscopic procedure shall be discussed in addition to the standard procedure.

Community and healthcare providers' perspectives on male circumcision: a multi-centric qualitative study in India.

BACKGROUND: Although male circumcision (MC) is recommended as an HIV prevention option, the religious, cultural and biomedical dimensions of its feasibility, acceptability and practice in India have not been explored till date. This study explores beliefs, experiences and understanding of the community and healthcare providers (HCPs) about adult MC as an HIV prevention option in India. METHODS: This qualitative study covered 134 in-depth interviews from Belgaum, Kolkata, Meerut and Mumbai cities of India. Of these, 62 respondents were the members of circumcising (CC)/non-circumcising communities (NCC); including medically and traditionally circumcised men, parents of circumcised children, spouses of circumcised men, and religious clerics. Additionally, 58 registered healthcare providers (RHCPs) such as general and pediatric surgeons, pediatricians, skin and venereal disease specialists, general practitioners, and operation theatre nurses were interviewed. Fourteen traditional circumcisers were also interviewed. The data were coded and analyzed in QSR NUD*IST ver. 6.0. The study has not explored the participants' views about neonatal versus adult circumcision. RESULTS: Members of CC/NCC, traditional circumcisers and RCHPs expressed sharp religious sensitivities around the issue of MC. Six themes emerged: Male circumcision as the religious rite; Multiple meanings of MC: MC for 'religious identity/privilege/sacrifice' or 'hygiene'; MC inflicts pain and cost; Medical indications outweigh faith; Hesitation exists in accepting 'foreign' evidence supporting MC; and communication is the key for acceptance of MCs. Medical indications could make members of NCC accept MC following appropriate counseling. Majority of the RHCPs demanded local in-country evidence. CONCLUSION: HCPs must educate high-risk groups regarding the preventive and therapeutic role of MC. Communities need to discuss and create new social norms about male circumcision for better societal acceptance especially among the NCC. Feasibility studies on MC as an individual specific option for the high risk groups in health care setting needs to be explored.

Perceived medical benefit, peer/partner influence and safety and cost to access the service: client motivators for voluntary seeking of medical male circumcision in Iganga district eastern Uganda, a qualitative study.

INTRODUCTION: Although voluntary medical male circumcision (VMMC) in Iganga district was launched in 2010 as part of the Uganda national strategy to prevent new HIV infections with a target of having 129,896 eligible males circumcised by 2012, only 35,000 (27%) of the anticipated target had been circumcised by mid 2012. There was paucity of information on why uptake of VMMC was low in this setting where HIV awareness is presumably high. This study sought to understand motivators for uptake of VMMC from the perspective of the clients themselves in order to advocate for feasible approaches to expanding uptake of VMMC in Iganga district and similar settings. METHODS: In Iganga district, we conducted seven key informant interviews with staff who work in the VMMC clinics and twenty in-depth interviews with clients who had accepted and undergone VMMC. Ten focus-group discussions including a total of 112 participants were also conducted with clients who had undergone VMMC. RESULTS: Motivators for uptake of VMMC in the perspective of the circumcised clients and the health care staff included: perceived medical benefit to those circumcised such as protection against acquiring HIV and other sexually transmitted diseases, peer/partner influence, sexual satisfaction and safety and cost to access the service. CONCLUSION: Since perceived medical benefit was a motivator for seeking VMMC, it can be used to strengthen campaigns for increasing uptake of VMMC. Peer influence could also be used in advocacy campaigns for VMMC expansion, especially using peers who have already undergone VMMC. There is need to ensure that safety and cost to access the service is affordable especially to rural poor as it was mentioned as a motivator for seeking VMMC.