Notat om omskæring af drenge - Sundhedsstyrelsen

Weiss et al. BMC Urology 2010, 10:2http://www.biomedcentral.com/1471-2490/10/2Page 9 of 13training had been given to surgical aids and nurses to performcircumcisions. The proportion of boys with complications(2.3%) was reported to be a great improvement onthat by traditional non-medically trained providers [43,59].The high frequency of adverse events following circumcisionby untrained providers in non-sterile settings is strikingin two studies of traditional circumcision which foundalarmingly high prevalence of around 80% [54,60]. Notably,in one of these, the self-reported frequency was muchlower, illustrating the under-ascertainment that can occurin retrospective studies. Mass circumcisions are particularlyrisky,evenwhenundertakeninthehospital.Forexample, the Turkish study of 700 children circumcisedduring a 5 day period recorded a complication frequencyof 8%, likely due to the difficulty in providing sufficientsterile equipment and conditions [46]. The reason for surgerycan also influence the risk of adverse events as seenin the studies of child circumcision where more complicationswere generally seen if circumcision was conductedfor medical rather than religious reasons.Our systematic review was restricted to circumcisioncomplications among boys aged 12 years or under.However, there are several published studies of circumcisioncomplications among adolescent and adult men(Table 6) and these indicate a generally higher frequencyof complications than seen in neonates, infants and children.In the three RCTs of circumcision in adult men,complications were observed in 2-7% of HIV-negativemen [14,61,62], and in 6-8% of HIV positive men[14,62]. The most detailed observational study was conductedamong the Babukusu ethnic group in westernKenya. Of 562 adolescents circumcision by a medicalprovider (or reported as such), 18% had a complication,as did 35% of boys circumcised traditionally [60]. A substudyin the same population directly observed 24 boysundergoing medical and traditional circumcision respectivelyand found that of those circumcised medically,only one boy had no adverse events, and 3 permanentadverse sequalae were reported, including one very seriouslife-threatening case by a ‘medical’ practitioner whowas later found to have no documented medical qualifications[60]. Among the 12 directly observed traditionalcircumcisions, complications were seen in 10 boys(83%), and 4 (33%) were judged to have permanentadverse sequelae. None had fully healed by 30 dayspost-operation. Detailed examination showed that traditionalcircumcision was also associated with slower healing,more swelling, laceration and keloid scarring [60].These results show that under non-sterile conditions,adolescent and adult circumcision can frequently beassociated with severe complications. Other case-seriesof circumcision complications among adolescents andyoung men also report severe morbidity and mortality[63-68]. Reported complications tend to be morecommon in this age group than for neonates andinfants, even when circumcision is conducted under the‘gold standard’ conditions such as in the RCTs.A major challenge in our review was to standardisethe definition of complications. For example, Okeke etal [10] report complications in 20% of boys, of whichhalf were excessive residual foreskin - an adverse eventbut arguably not a medical risk. We excluded thesecases where possible. Similarly, the paper by Gee et al[38] cites a total of 110 complications out of 5521(2.0%) but states that only 14 complications (0.2%)were considered ‘really significant’ (one life-threateninghemorrhage, 4 systemic infections, 8 circumcisions ofinfants with hypospadias and one complete denudationof the penile shaft). The other complications includedbleeding, infection, circumcision of hypospadiasis, anda Plastibell ring that was too tight. The problem ofdefining complications is also highlighted in the early(1961-1962) study from Canada in which moderate orsevere complications (bleeding, infection, meatal ulcer,meatal stenosis and phimosis) were seen in 15 infants(15%) but a further 68 infants had mild bleeding, meatalulcers or infection [29]. Complication risks in thisstudy have previously been reported as 55% [4], whichincludes any bleeding, including oozing. A furtherexample is the Australian study [69] which reportedcomplications in 8% of boys, which included severalcases of mild bleeding which either ceased spontaneouslyor with simple management such as digitalpressure. We have attempted to report ‘severe’ or ‘serious’adverse events as a separate outcome, but dataon this is often limited and it would be useful to producea standard classification of mild, moderate andsevere complications following circumcision so that infuture studies may be more easily comparable. Otherlimitations related to the design of the epidemiologicalstudies. The length of follow-up varies between, andwithin, studies, and may affect the estimated frequencyof complications. For this reason we tend not to termthe frequency as a ‘risk’. It is also possible that thelower frequencies of complications in prospective studiesare due to improved procedures by practitionersor improved hygiene by patients as a result of participatingin the study. Finally, a number of studies aresmall and the estimates of frequency of complicationswill be correspondingly imprecise.We excluded one study of circumcision amongpatients with inherited bleeding disorders [20] as wewere interested in complications in general populations.In this study, of 71 patients diagnosed from 1961-1996,52% had a record of post circumcision bleeding. Inmany settings, boys are not asked about a family historyof bleeding disorders and this can potentially lead tosevere circumcision-related complications.