Notat om omskæring af drenge - Sundhedsstyrelsen

Weiss et al. BMC Urology 2010, 10:2http://www.biomedcentral.com/1471-2490/10/2Page 8 of 13Table 5 Retrospective studies of frequency of complications in studies of child circumcision undertaken by nonmedicalprovidersAuthor Country Years Setting Number ofmalesAhmed [7] Nigeria 1981-1995 Community 1360(approx)Age atcircumcisionProviderFrequency ofadverse events aMean 4 years Traditional 3.4% -Atikeler [54] Turkey 1999-2002 Community 407 Mean 7 years Traditional 73% cLee [55] Phillipines 2002 Community 114 42% 5-9 years52% 10-14years5% 15-18 years32% medical68%traditionalMyers [56] Nigeria - Community 750 Infant/child 68%traditional25% nurse/midwife4% doctorYegane [77] Iran 2002 Community 1359 71% after 2years of ageTraditionalcircumcisers63% d 3.5%2.8% -2.7%% (latecomplications)Frequency of seriousadverse events ba Cases of minor bleeding stopped with simple pressure or ‘conservative management’ and excessive foreskin/inadequate circumcision are not includedb Includes complications defined as ‘serious’ or ‘severe’ by authors, or with long-term or life-threatening sequalae (partial amputation of glans, urethral laceration,need for re-surgery or plastic surgery)c This very high rate of complications consisted of bleeding (24%), infection (14%), incomplete circumcision (12%), subcutaneous cysts (15%), haematoma (6%),ischaemia (3%), penile adhesion (3%), and other conditions. Of the 97 cases of bleeding, 48 could not be stopped by haemostatic bandage and were sutured.Infections were treated with parenteral or oral antibiotics.d Of these,94% were reported swollen or inflamed penises. Four respondents (3.5%) of those circumcised) reported profuse bleeding0%there was insufficient information to be certain it wascaused by circumcision. A study from Iran reported alate-phase complication frequency of 2.7% following traditionalcircumcision and a further 5% had excessiveresidual foreskin. This was similar to circumcisions performedby urologists or surgeons (2.8%), but lower thanfor GPs/paediatricians (6.1%) or paramedical personnel(9.1%). The authors argue that this is because traditionalcircumcisers in Iran are experienced and paramedicalpersonnel do not receive effective training.DiscussionMale circumcision is a common surgical procedure, butfew epidemiological studies have reported frequency ofadverse events, most commonly bleeding and infection.Our review shows that serious adverse events are rare,but there is wide variation in reported frequencies ofadverse events following circumcision. This is likely tobe due to several factors directly associated with complicationssuch as age at circumcision, training and expertiseof the provider, the sterility of the conditions underwhich the procedure is undertaken and the indication(medical/cultural) for circumcision. In addition, there isvariation due to methodological issues such as durationof follow-up, epidemiological study design, and definitionof complications.In general, complications (reported by parents) occurleast frequently among neonates and infants than amongolder boys, with the majority of prospective studies in neonatesand infants finding no serious complications, andrelatively few other adverse events, which were minor andtreatable. The prospective studies in older boys also foundvirtually no serious adverse events, but a higher frequencyof complications (up to 14%) even when conducted bytrained providers in sterile settings [47]. The lower frequencyof complications among neonates and infants islikely to be attributable to the simpler nature of the procedurein this age group, and the healing capability in thenewborn. Further, a major advantage of neonatal circumcisionis that suturing is not usually necessary, whereas itis commonly needed for circumcisions in the post-neonatalperiod. This advantage is illustrated by the US study inwhich no complications were seen among 98 boys circumcisedin the first month of life, but 30% of boys aged 3-8.5months had significant postoperative bleeding [24]. Thereare alternatives to suturing, either with the disposableclamps, or with alternatives such as cynoacrylate glue [44]and further research in this area is needed.Several studies stress the importance of careful trainingand experience of the provider, and the sterility of the setting.This was most clearly noted in a Nigerian study [27]in which 24% of boys had reported complications (includingretention of excess residual foreskin), but only 1.6% ofthose circumcised at the public (University Teaching) hospitalby medical doctors. Similarly, two case-control studiesfrom Israel have found that UTI are 3-4 times morelikely to occur following circumcised by a traditional,rather than medical provider [57,58]. However, as noted inour review, neonatal circumcision following traditional circumcisionin Israel has low complication rates overall [9].A further example is the study from the Comoros Islandswhich reported results of an exercise in which specific