Clinical Outcomes of Circumcisions and Prevalence of Complications of Male Circumcisions: A Five-Year Retrospective Analysis at a Teaching Hospital in Ghana

Clinical Outcomes of Circumcisions and Prevalence of Complications of Male Circumcisions: A Five-Year Retrospective Analysis at a Teaching Hospital in Ghana | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical Outcomes of Circumcisions and Prevalence of Complications of Male Circumcisions: A Five-Year Retrospective Analysis at a Teaching Hospital in Ghana FRANK OBENG, SYLVESTER APPIAH BOAKYE This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5097130/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Male circumcision surgery is increasing in popularity due to its medical benefits, including reducing the prevalence of HIV. It is commonly performed by both health and nonhealth professionals, with most circumcisions occurring during the neonatal period. Studies suggest that the benefits outweigh the risks, although complications can occur. This study aimed to determine the clinical outcomes of circumcisions and the prevalence of circumcision mishaps in the Volta region of Ghana. Aim: To determine the clinical outcomes of circumcision and estimate the prevalence of circumcision disasters within the Volta region. Methodology: A five-year retrospective descriptive and analytic study was conducted at Ho Teaching Hospital using a structured data extraction sheet to collect demographic, clinical, and circumcision-related data from 186 patients. Results: Among 186 circumcision patients, 23 (12.37%) experienced complications, the most common of which were partial circumcision (43.48%), postcircumcision bleeding (21.74%), and urethrocutaneous fistula and/or wrongfully described congenital hypospadias (13.04%). Low hemoglobin levels and infections were also noted. A significant relationship was found between the presence of a circumcision provider and complication rate (chi-square = 16.975, p = 0.00). Doctors who performed circumcision had the lowest complication rate (4.3%), while nurses and traditional circumcisers had higher complication rates (39.1% and 34.8%, respectively). Circumcision-Revision surgery was the most common salvage surgery for circumcision mishaps (31.82%), with urethroplasty and hypospadias repair (for wronfully circumcised neonates born with hypospadias) accounting for 15.91%. Meatoplasties, glansoplasties, fistulectomy plus primary repair and chordae-release surgeries were also performed. The success rate for salvage surgeries (on first attempt) was 70%. Prompt initial management strategies were significantly associated with good outcomes. Conclusion: In less-trained hands, circumcision can be catastrophic. Salvage surgeries for circumcision mishaps are associated with less favorable outcomes in up to one-third of the patients, suggesting that circumcision mishaps are better prevented than cured/salvaged mishaps are. Training, guidance and policy interventions are needed to reduce the incidence of circumcision-related mishaps. Public health campaigns to disuade nonsurgeon circumcisors to refrain from circumcising children with hypospadias but rather refer to them are urgently needed. Surgery Pediatrics Other Public Policy Circumcision Prevalence of circumcision complications Provider experience Initial management strategies Outcomes of salvage surgeries Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 Figure 15 Figure 16 Figure 17 Introduction Male circumcision is a widely practiced surgical procedure, particularly in regions with religious, cultural, and public health imperatives( 1 ). In Ghana, the practice is almost universal, with a significant portion of the male population undergoing the procedure( 2 ). Despite its recognized benefits, including a reduction in the transmission of HIV and other sexually transmitted infections( 3 )( 4 )( 5 ), circumcision is not without risk. Complications, though generally infrequent, can range from mild to severe and may include infections, excessive bleeding, and, in rare cases, permanent damage to penile structures(6). Understanding the clinical outcomes and the frequency and nature of these complications is crucial for improving patient safety and refining surgical techniques. Circumcision, a widely practiced procedure, has been extensively studied with regard to its technique, benefits, and associated complications( 7 ). We provide a brief background on the prevalence of circumcision complications, common types of complications, the relative incidence of circumcision mishaps among the various providers of the service (circumcisers), initial management of complications, and the success rate of these management strategies. Prevalence of circumcision complications The incidence of circumcision varies globally, with Israel reporting 91.7% and Honduras reporting less than 1%. In Africa, the prevalence is 62%, with 91.6% in Ghana ( 4 ). The incidence of complications is influenced by factors such as anatomical abnormalities, age, surgical technique, and medical comorbidities( 8 ). In the U.S., complication rates are less than 0.5% ( 9 ); however, in rural Ghana, the complication rate among infants is 8.1% ( 10 ). These figures highlight the variability in circumcision complication rates worldwide and suggest a possible link between a country’s development status and complication prevalence. Common Circumcision Complications Complications from circumcision are well documented, with hemorrhage/bleeding being the most common complication occurring in 11.9% of cases in the U.S.( 3 )( 11 ). Other complications include meatal stenosis, infection, edema, penile hematoma, and urethrocutaneous fistula, among others. These complications are classified as early or late ( 6 ) and can vary by region. For example, in Ghana, urethrocutaneous fistula is the most common complication, followed by glans amputation and iatrogenic hypospadias ( 12 ). Circumcision-related complications are common in Ghana, usually because most procedures are performed by less skilled providers ( 13 ) ( 14 ). This study aimed to provide a comprehensive retrospective analysis of male circumcision outcomes over the past five years at Ho Teaching Hospital in the Volta region. By identifying the patterns and prevalence of complications, this research will contribute to better clinical practices and inform public health strategies in the region. The objectives of this study were as follows: To evaluate the clinical outcomes of male circumcisions performed at Ho Teaching Hospital over the past five years. To identify and categorize the complications associated with male circumcision in this population. The factors contributing to successful outcomes and complications were assessed. Conceptual Framework Diagram This study's conceptual framework (see Fig. 1 ) revolves around the relationship between circumcision techniques, healthcare provider experience, and patient outcomes. The clinical outcomes of circumcision are influenced by multiple factors, including the method used, the provider's skill level, and the age of the patient at the time of the procedure ( 15 ). The framework will analyze these factors to determine their impact on the incidence of complications and overall surgical success. Materials and Methods This study was a five-year retrospective descriptive analysis of circumcision at Ho Teaching Hospital (HOTH) that focused on clinical outcomes, the prevalence of complications, and the management of circumcision disasters. Data were collected from the children's ward, male ward, child welfare clinics, and theatre where circumcisions and salvage surgeries for circumcision mishps were performed. Some data on acute presentations of circumcision mishaps were also assessed from emergency room records. The study population included circumcision cases handled at HOTH and complication referrals from other health facilities within the Volta region. All circumcised children attending the child welfare clinic and patients with circumcision complications referred to HOTH between January 1, 2019, and December 31, 2023, were included. Patients with incomplete or duplicated data were excluded. The study used a census approach( 16 ), relying on secondary data from HOTH’s electronic records and archives. A structured MS Excel data extraction tool was used to evaluate patient demographics, clinical presentation, laboratory parameters, and outcomes. The data were collected through personal visits to hospital wards, ensuring completeness and confidentiality. Statistical analysis The data were analyzed via quantitative methods, including descriptive statistics, chi-square tests for categorical data and regression analysis for parametric data, using SPSS version 25. All analyses were conducted at a 95% confidence level with a 5% significance threshold. Results Trends of Circumcisions Performed Over the Past 5 Years Figure 1 shows the trend of cases of circumcision recorded annually from 2019 to 2023 in the study area. The graph indicates a steady increase in the number of circumcision cases over this period. Starting in 2019, the number of cases was less than 20, and a gradual increase was observed in 2020, when the number of cases slightly increased to approximately 20. From 2021 to 2022, the number of cases increased moderately, surpassing 40 in 2022. A sharp increase was noted between 2022 and 2023, when the number of cases increased significantly, reaching a peak of approximately 80 by 2023. The green dotted line shows an upward trajectory of significant and consistent growth in the number of circumcision cases over the five years. Trends of Circumcisions and Salvage Surgeries for Referred Circumcision Mishaps Performed Over the Past 5 Years within the Teaching Hospital Figure 2 reveals that over the past five years, there has been a steady increase in the number of cases documented. In 2019, there were 8 patients, accounting for 13.33% of the total. The number of cases slightly decreased in 2020, with 7 cases (11.67%), but increased again in 2021 to 9 cases (15.00%). This trend will continue to increase in 2022, with 13 cases (21.67%). The highest number of cases was recorded in 2023, with 22 cases, representing 36.67% of the total. Given that we know the total number of circumcision mishaps over the period to be 23, the lower number of cases of circumcision in the Teaching Hospital compared to the same for the entire study area suggests that most inhabitants do not see the Teaching Hospital as their preferred point of call for circumcisions. It could be a pointer that participants of the study opted for nonskilled circumcisions over skilled circumcisions and that could be a major public health bother. Identification of common circumcision complications: Clinical parameters Table 1 Clinical parameters of patients with circumcision complications Variables Frequency (N = 44) Percent (%) Mean S D Hemoglobin Level Low ( 17.2 g/dL) 0 0.0% Not recorded 4 2.2% White Blood Cell Low (< 4,000 µL) 0 0.0% 1418 26.88 Normal (4,000–11,000 µL) 35 18.8% High (11,000 µL) 5 2.7% Not recorded 4 2.2% Platelet Count Low ( 450,000 µL) 3 1.6% Not recorded 4 2.2% Hemoglobin Levels Among the 44 patients (Table 1 ) with circumcision complications studied, 24 (12.9%) had low hemoglobin levels, which was below the normal threshold of 13.8 g/dL. The mean hemoglobin level was 12.53 g/dL, with a standard deviation of 2.94. Normal hemoglobin levels were observed in 16 patients (8.6%), while no patients had high hemoglobin levels (> 17.2 g/dL). Additionally, 4 data items (2.2%) were not recorded, potentially affecting the completeness of the data. White Blood Cell Counts The distribution of white blood cell (WBC) counts among the study participants revealed that no patients had low WBC counts (< 4,000 µL). The mean WBC count was 1418 µL, with a standard deviation of 266.88. However, 35 patients (18.8%) had normal WBC counts within the range of 4,000–11,000 µL, while 5 patients (2.7%) exhibited high WBC counts (> 11,000 µL). Again, 4 records (2.2%) were not found. Platelet Counts: For platelet counts, 4 patients (2.2%) had low platelet levels (<150,000 µL), with a mean of 296.59 , and a standard deviation of 143.36. In contrast, 33 patients (17.7%) had normal platelet counts within the range of 150,000–450,000 µL, and 3 patients (1.6%) had high platelet counts (> 450,000 µL). The platelet counts were not recorded for 4 patients (2.2%). Correlations between Presentation Types and Duration of Symptoms Table 2 Analysis of the Presentation Type and Duration of Symptoms in Patients with Circumcision Complications Variables Duration Within the Day After a Day Total Chi-Square Test N N N X² P Value Presentation Acute Emergency (TEWS 4–9) 10 1 11 150.74 1.2e − 34 Cold Presentation (TEWS 0–3) 0 175 175 Total 10 176 186 Source: Field Data, 2024 Table 2 reveals that all 10 patients classified as acute emergencies (TEWS 4–9) presented within the day of symptom onset, indicating no delay in seeking immediate care. In contrast, 1 acute emergency was reported after a day. For cold presentations, all 175 patients (TEWS 0–3) were seen after a day. Additionally, the chi-square test result of 150.74 with a p value of 1.2e − 34 indicated an extremely strong statistically significant association between the type of presentation (acute emergency or cold presentation) and the duration of symptoms. This may suggest that once there is a complication at play, health-seeking behavior among the studied population is good. ision Practices and Referral Dynamics Table 3 An analysis of the location of the circumcision, surgeons performing the circumcision, and decision makers for referral when a circumcision complication occurs. Variables Frequency Percent (%) Location of Circumcision Ho and Surroundings 130 69.9% Nearby Towns and Districts 16 8.6% Other Regions 40 21.5% Total 186 100% Performer of Circumcision Doctors *** 30 16.1% Midwife 72 39.7% Nurse 74 39.8% Wazam 10 5.4% Total 186 100% Referral Decision-Maker Circumcisor 7 15.9% Parents 28 63.6% Other Relatives 9 20.5% Total 44 100% ***Represents specialists, consultants, and medical doctors. Source: Field Data, 2024 Table 3 provides insights into the details of the circumcision process, including the following: Location of Circumcision The majority of circumcisions were conducted in Ho and its environs, accounting for 130 cases—69.9% of the total. Sixteen patients were recorded near towns and districts (8.6%), while 40 patients were recorded in other regions. Performers of Circumcision Among the total cases, doctors, including specialists, consultants, and medical doctors, were responsible for 30 circumcisions, accounting for 16.1% of the total. Midwives and nurses were the most common providers, each performing 72 circumcisions, representing 38.7% of the total cases. There were 10 warm fields, accounting for 5.4%. Referral Decision-Maker The decision-making process for referrals once a circumcision mishap occurs varies. ‘Other Relatives’ were the decision makers in 9 patients, representing 20.5% of the total. Circumcisers made referral decisions in 7 (15.9%) patients, and most referral decisions were made by parents—i.e., 28 referrals—representing 63.6%. Initial Management of Circumcision Complications Examination Findings Figure 3 reveals a significant difference in the nature of the findings. Of the 186 patients, 163 (80.1 % ) were classified as having normal examination results. Conversely, 23 patients ( 12.6% ) were identified as having pathological findings. Table 4 Associated diagnoses of circumcision complications Associated Diagnosis Variables Frequency Percent Valid Percent Cumulative Percent Chordae 1 .5 .5 .5 Hypospadias (that were wrongfully circumcised outside the hospital) 10 5.4 5.4 5.9 Infected Smegma 1 .5 .5 6.5 Scrotal Laceration 1 .5 .5 .5 None 163 87.4 87.4 94.4 Phimosis 2 1.1 1.1 95.5 Urethral Meatal Stenosis/redundant prepuce/bridging skin 8 4.5 4.5 100.0 Total 186 100.0 100.0 Source: Field Data, 2024 Table 4 reveals a diverse range of conditions, each with varying prevalence. The most common pathological condition was not detected, with 163 patients (91.9%) classified as having no associated diagnoses. Hypospadias (wrongfully circumvented) was the second most common diagnosis and was recorded in 10 patients (5.4%). Phimosis, characterized by an inability to retract the foreskin, was observed in 2 patients (1.1%). Other conditions included urethral lethal stenosis (4.5%), scrotal laceration and infected smegma, which were each reported in 1 patient (0.5%). In addition, 1 patient (0.5%) had chordae, a condition in which fibrous bands form on the penis, leading to clinically observable abnormal penile curvature or twisting. From the findings of this study, the percentage of surgeries performed by each provider and the percentage of complications attributable to each provider are summarized in the table below. Table 5 Frequency of Circumcision and frequency of complications per Provider. Healthcare Provider Circumcisions Performed (%) Complications (%) Midwives 38.2 13.04 Nurses 40.3 39.1 Doctors 16.13 3.4 Wanzams 5.38 34.8 Given that the total number of circumcisions in this study was 186 and the total number of circumcision complications was 23, the actual numbers are shown in the table below as a confusion matrix table. Table 6 Confusion Matrix Table for Circumcision Complications Provider Complications (Yes) No Complications Total Circumcisions Midwives 3 68 71 Nurses 9 66 75 Doctors 1 29 30 Wanzams 8 2 10 Total 23 165 186 Table 7 A consolidated table that captures all the key steps, calculations, and results for the odds ratios, z-statistics, and p values for each circumception provider compared to those of the doctors Provider Total Circumcisions Complications (Yes) No Complications Odds of Complication Odds Ratio vs Doctors ln(OR) SE(ln(OR)) Z-statistic p value Doctors 30 1 29 0.0345 Baseline Baseline Baseline Baseline Baseline Midwives 71 3 68 0.0441 1.278 0.2457 1.1757 0.2090 0.834 Nurses 75 9 66 0.1364 3.954 1.375 1.0774 1.276 0.202 Wanzams 10 8 2 4.0000 115.942 4.753 1.2882 3.691 0.0002 Explanation of Table Columns: Total Circumcisions : The total number of circumcisions performed by each provider. Complications (Yes) : The number of circumcisions that resulted in complications. No complications : The number of circumcisions that did not result in complications. Odds of Complication : The odds of complications occurring for each provider (complications ÷ no complications). Odds ratio vs doctors: Odds ratio comparing each provider to doctors (baseline). ln(OR) : The natural logarithm of the odds ratio. SE (ln(OR)) : The standard error of the natural logarithm of the odds ratio. Z-statistic : The Z score was calculated using the odds ratio and standard error. p value : The p value corresponding to the Z value indicates statistical significance (p < 0.05); otherwise, the p value is used. The above table shows that the odds of complications resulting from circumcisions performed according to the interpretation above (Table 7 ) are significantly greater for Wanzams than for doctors (p < 0.05), whereas the odds for midwives and nurses are not significantly different from those for doctors. Management of Complications Figure 16 reveals that among the complicated cases of circumcision analyzed, multiple or single procedures were performed as salvage surgeries, with a total of 44 salvage procedures performed for the 23 circumcision mishaps. The average number of procedures per mishap was two. Revision of circumcision was the most common procedure, accounting for 44% of the surgeries (24 patients). Urethroplasty/hypospadias repair for some urethrocutaneous fistulae or wrongfully circumcised hypospadias was performed for 13% ( 7 ) of the patients. Suturing of the wound was performed in 5.5% ( 3 ) of the patients. Debridement was performed in 5.5% (3 patients), while fistulectomy plus primary repair was needed in 7% (4 patients). Glansoplasty and meatotomy/meatoplasty were performed on 2% (1 patient) and 4% (2 patients), respectively. Patients with chordae needed penile degloving plus release of chordae (without Nesbit’s procedure), in addition to a meatoplasty. Discussion Prevalence of circumcision complications The study revealed a complication rate of 8.1% among the 186 circumcision patients studied. This finding aligns closely with findings from rural Ghana( 10 ), where the complication rate was also approximately 8.1%. This rate is significantly higher than the < 0.5% complication rate reported in the U.S. ( 9 ). This discrepancy underscores the impact of regional factors on complication rates, as noted in the literature( 5 ). The greater prevalence of COVID-19 in less developed regions, such as rural Ghana and the Volta Region, may be attributed to factors including the low availability of advanced surgical techniques, poor health-seeking behavior by the parents of these children, variable provider experience, and differing healthcare infrastructure ( 8 ). It is disheartening to know that cases in which neonates born with hypospadias were circumcised without recourse to referral to the urologist or pediatric surgeon were rife; seven ( 7 ) such cases were encountered. The surgical principle is that until the hypospadias is repaired in the neonate born with this procedure, the prepuce should be preserved since it may serve as a source of a flap for hypospadias repair itself ( 17 ). This hypospadias repair procedure utilizes a preputial flap and is called Duckett repair or Duckett onlay island flap urethroplasty ( 17 ). This technique, as posited by the sentinel article by Duckett JW (1980, 1981), involves using a flap of tissue from the inner layer of the prepuce (foreskin) to reconstruct the urethra in patients with hypospadias, particularly when the defect is more proximal. The preputial tissue provides a well-vascularized flap that helps in the formation of a new urethra, reducing the risk of fistula formation and other complications( 17 ). Common Circumcision Complications The most common complications observed in this study included infection, meatal stenosis, and bleeding. These findings are consistent with global patterns where bleeding is often the most prevalent complication( 11 ). In Ghana, the prevalence of urethrocutaneous fistula, as reported by Appiah et al. (2016), contrasts with our findings, where this complication was less common( 12 ). This variation may be attributed to differences in circumcision practices and postoperative care between regions. Our results suggest a greater incidence of infection and meatal stenosis, which could be related to local practices and the use of traditional versus modern techniques. These findings are in line with those of Appiah et al. (2016), who reported similar complications in Ghanaian settings but with different frequencies( 12 ). Relationship between Provider and Outcome This study revealed that circumcision complications were predominantly associated with procedures performed by nurses and surgeons. Among the 186 cases analyzed, 38.2% of the circumcisions were carried out by midwives, 40.3% by nurses, 16.13% by doctors and 5.38% by wanzams. A total of 13.04% of the complications were treated by midwives, 3.4% by doctors, 39.1% by nurses and 34.8% by wanzams. A significant relationship was found between the presence of a circumcision provider and complication rate (chi-square = 16.975, p = 0.00). Our data showed that circumcisions in the Volta region are predominantly performed by midwives and nurses, with a smaller proportion performed by traditional circumcisers and doctors. This distribution is similar to findings in other parts of Ghana, where midwives and nurses perform the majority of procedures( 13 )( 14 ). The high complication rates associated with traditional circumcisers, as highlighted by Kacker & Tobian (2013), reflect the challenges of inadequate training and resources( 15 )( 14 ). However, our study also revealed notable complications in procedures performed by healthcare professionals, indicating that provider experience and training are critical factors, regardless of practitioner background. These findings align with the literature suggesting that both traditional and medical circumcision practitioners in Ghana have been associated with complication rates ( 2 ). Further analysis of complications to determine the true relationship with specific circumcisoors across boards revealed significant variations in risk compared to doctors. The odds ratio (OR) was 1.278 for midwives, but the Z-statistic was 0.209, and the p value was 0.834, indicating that there was no statistically significant difference in the risk for doctors. Nurses exhibited a significantly greater odds ratio (OR) of 3.954, but this greater odds of risk for circumcision mishaps also did not reach statistical significance (Z-statistic of 1.276; p value of 0.202). In contrast, Wanzams had a dramatically elevated odds ratio of 115.942, with a Z-statistic of 3.691 and a highly significant p value of 0.0002, reflecting a substantially increased likelihood of complications compared to doctors (see Tables 5 to 7 ). These findings suggest that traditional providers, such as Wanzams, may pose a much greater complication risk during circumcision, warranting targeted interventions to improve outcomes. Conclusion The study provides valuable insights into circumcision practices and outcomes in the Volta region. With less trained hands, circumcision can be catastrophic. Salvage surgeries for circumcision mishaps are associated with less favorable outcomes in up to one-third of the patients, suggesting that circumcision mishaps are better prevented than cured/salvaged mishaps are. The increasing number of circumcision cases, coupled with the identification of common complications and variations in practice, highlights the need for improved standards, training, and public education. To improve circumcision practices in the Volta Region, several recommendations are proposed. First, healthcare provider training should be standardized to ensure that practitioners are skilled in surgical techniques and postoperative care. Regulations must restrict circumcision to qualified individuals, requiring certification and continuing education. Public awareness campaigns should educate parents and caregivers on the benefits and risks of circumcision, emphasizing the need for circumcision by qualified practitioners, using local languages and community outreach. Additionally, public health campaigns to disuade nonsurgeon circumcisors to refrain from circumcising children with hypospadias but rather refer to them are urgently needed. A comprehensive system should be developed to monitor circumcision cases and outcomes, helping identify trends and improve care. Facilities should maintain detailed records, including pre- and postoperative care. Infection control protocols must be enforced, with practitioners trained in sterilization, aseptic techniques, and early complication management. Collaboration between traditional and modern healthcare providers should be encouraged to ensure safe practices while respecting cultural traditions. Training traditional practitioners on safety and complication management is essential. Finally, strong referral systems should be established to ensure timely care for complications, with clear protocols for specialist referrals. Declarations The study titled "Clinical Outcomes of Circumcisions and Prevalence of Complications of Male Circumcisions: A Five-Year Retrospective Analysis at a Teaching Hospital in Ghana" received ethical approval from the University of Health and Allied Sciences Ethical Review Board. The study was granted approval under the Institutional Review Board (IRB) number UHAS-REC A.10[103] 23-24, ensuring that all protocols followed the necessary ethical guidelines for research involving human subjects. The study was conducted in full conformance with the ethical principles outlined in the Declaration of Helsinki and adhered to all relevant national and institutional guidelines governing medical research involving human subjects. Informed consent was obtained from all participants where applicable, and data confidentiality was maintained throughout the study to ensure the privacy and rights of the individuals involved. The research was also approved by the University of Health and Allied Sciences Ethical Review Board under IRB number UHAS-REC A.10[103] 23-24. ACKNOWLEDGEMENT We acknowledge the Authorities of the Ho Teaching Hospital. Conflict of interest : None of the authors have any financial or personal conflicts of interest to declare. Funding: No funding was obtained for this work. Author Contributions: Sylvester Appiah: study design, methodology, data collection, visualization and dating. Dr Frank Obeng: Conceptualization, study design, supervision, data curation, visualization, first draft outline, editing of the work. Funding: No funding was obtained for this work. Author Contributions: Sylvester Appiah: study design, methodology, data collection, visualization and dating. 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Systematic review of complications arising from male circumcision. BJUI Compass. 2022;3(2):99–123. Appiah KAA, Gyasi-Sarpong CK, Azorliade R, Aboah K, Laryea DO, Otu-Boateng K, et al. Circumcision-related tragedies seen in children at the Komfo Anokye Teaching Hospital, Kumasi, Ghana Pediatric Urology. BMC Urol [Internet]. 2016;16(1):1–8. Available from: http://dx.doi.org/10.1186/s12894-016-0183-1 Osifo OD, Oriaifo IA. Circumcision mishaps in Nigerian children. Ann Afr Med. 2009;8(4):266–70. Maison P, Yahaya I, Appiah K, Ekor O, Apraku C, Egyir E. Circumcision practice among trained circumcisers in Ghana. African Urol. 2023;3(1):35–8. Kacker S, Tobian AAR. Male circumcision: Integrating tradition and medical evidence. Isr Med Assoc J. 2013;15(1):37–8. Motheral B, Brooks J, Clark MA, Crown WH, Davey P, Hutchins D, et al. A checklist for retrospective database studies - Report of the ISPOR task force on retrospective databases. Value Heal. 2003;6(2):90–7. Duckett JW. The island flap technique for hypospadias repair. Urol Clin North Am. 1981 Oct;8(3):503-11. PMID: 7324317. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5097130","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":354667621,"identity":"55d6c22b-2744-4256-bc56-3360e8269fde","order_by":0,"name":"FRANK OBENG","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYBAC9gYeEGXDYADmsgGxBAEtPAfAWtJI13KYFC3svQcfF/w6n7id/fgDhg9lhxnkoxsIaOE5l2w8s+924s6eHAPGGecOMxjeOYBfi71Ejpk0b8/txA0HchiYeduAWmYkELBFIsf8N2/PucQN558/YP5LpBYzZp4fBxI33EgwYGYEapGXIKQF6Bdp3oZk4w033hgc7DmXzmNAUAswxD7z/LGT3XA+/eGDH2XWcvKEHAYGjG0Q+gDIDIMDROhgYPiDxJZvIErLKBgFo2AUjCAAALiVR56+vq5GAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0009-0008-7265-7331","institution":"university of health and allied sciences, ho","correspondingAuthor":true,"prefix":"","firstName":"FRANK","middleName":"","lastName":"OBENG","suffix":""},{"id":354667622,"identity":"b1b63b85-f543-4a85-a553-67b8e2f13e94","order_by":1,"name":"SYLVESTER APPIAH BOAKYE","email":"","orcid":"","institution":"university of health and allied sciences, ho","correspondingAuthor":false,"prefix":"","firstName":"SYLVESTER","middleName":"APPIAH","lastName":"BOAKYE","suffix":""}],"badges":[],"createdAt":"2024-09-16 11:41:13","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false,"coiExplicitlySet":false},"doi":"10.21203/rs.3.rs-5097130/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5097130/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":65305957,"identity":"f18aa057-1e1d-45d7-b676-7c3bcd2edbfd","added_by":"auto","created_at":"2024-09-26 01:13:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":76393,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eFactors influencing the circulation outcome\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eSource: Author’s Construct based on Literature Review, 2024\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5097130/v1/0f22e2b00ec158141eb09846.png"},{"id":65306579,"identity":"fc23e3c0-c933-4900-8c25-23ff868f1c53","added_by":"auto","created_at":"2024-09-26 01:21:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":35360,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 1: \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eRetrospective Analysis of Patients with Circumcision Over Five Years\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003e(Source: Field Data, 2024)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"01.png","url":"https://assets-eu.researchsquare.com/files/rs-5097130/v1/b6a6c1fba4c3daee8bc8a2ab.png"},{"id":65306581,"identity":"6fafa55d-420c-4687-9c85-8558c092e274","added_by":"auto","created_at":"2024-09-26 01:21:59","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":38856,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eFigure 2: Retrospective Analysis of Patients with Circumcision Over Five Years\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003e(Source: Field Data, 2024)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5097130/v1/333ad3a5ca8c7b5b887729c5.png"},{"id":65305962,"identity":"4a1a0e2f-c67c-4447-a0be-89dc703db469","added_by":"auto","created_at":"2024-09-26 01:13:59","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":34031,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eFigure 3: Examination Findings in Circumcision Patients: Pathological \u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003evs\u003c/strong\u003e\u003cem\u003e\u003cstrong\u003e. Normal Patients\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003e(Source: Field Data, 2024)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5097130/v1/debc565395ef25031a5425a2.png"},{"id":65306580,"identity":"e0c28c0c-aab6-45e6-8c94-68435774fd83","added_by":"auto","created_at":"2024-09-26 01:21:59","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":304444,"visible":true,"origin":"","legend":"\u003cp\u003eFIGURE 4: CIRCUMCISION MISHAP: GLANULAR AMPUTATION \u003cem\u003e\u003cstrong\u003e(Source: Field Data, 2024)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5097130/v1/8a9781be5e4fa663a9d32a54.png"},{"id":65305961,"identity":"a9a19e43-9e1e-4698-ac3a-0f6881256e9b","added_by":"auto","created_at":"2024-09-26 01:13:59","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":204423,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 5: CIRCUMCISION COMPLICATION: URETHROCUTANEOUS FISTULA \u003cem\u003e\u003cstrong\u003e(Source: Field Data, 2024)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-5097130/v1/2cceade0869af5fdd0ef4e3a.png"},{"id":65306585,"identity":"06a499be-0eae-40e7-9dec-9cfd9c943e35","added_by":"auto","created_at":"2024-09-26 01:21:59","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":540610,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 6: CIRCUMCISION COMPLICATION: URETHROCUTANEUS FISTULA \u003cem\u003e\u003cstrong\u003e(Source: Field Data, 2024)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-5097130/v1/a19352c1565afa842e128e17.png"},{"id":65307226,"identity":"5a67f473-cd41-44ba-9a42-c2e477426e1b","added_by":"auto","created_at":"2024-09-26 01:29:59","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":450877,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 7: CIRCUMCISION COMPLICATION: PERIMEATAL STENOSIS AND REMNANT PREPUCE \u003cem\u003e\u003cstrong\u003e(Source: Field Data, 2024)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-5097130/v1/27014641d032d46083db2ee4.png"},{"id":65305963,"identity":"df5699ae-9ae6-4541-8bcc-c056c73f8fa2","added_by":"auto","created_at":"2024-09-26 01:13:59","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":933781,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 8: CIRCUMCISION COMPLICATION: PHIMOSIS AND INCLUSION DERMOID CYST \u003cem\u003e\u003cstrong\u003e(Source: Field Data, 2024)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-5097130/v1/22ff5085ea90ffcc1a2d0eaa.png"},{"id":65306583,"identity":"bed73f62-d476-46ad-a2a5-480a70325d98","added_by":"auto","created_at":"2024-09-26 01:21:59","extension":"png","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":356712,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 9: CIRCUMCISION COMPLICATION: REMNANT REDUNDANT PREPUCE; ALSO HAS SOME GLANULO-PENILE SKIN ADHESIONS/BRIDGING SKIN \u003cem\u003e\u003cstrong\u003e(Source: Field Data, 2024)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"9.png","url":"https://assets-eu.researchsquare.com/files/rs-5097130/v1/4d8eb0f3b1ae603cdd3e609d.png"},{"id":65305968,"identity":"2d06dc65-4185-4a9a-8953-f12ecf008105","added_by":"auto","created_at":"2024-09-26 01:13:59","extension":"png","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":300756,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 10: CIRCUMCISION COMPLICATION: MEATAL STENOSIS AND REDUNDNT PREPUCE WITH INCLUSION DERMOID CYST \u003cem\u003e\u003cstrong\u003e(Source: Field Data, 2024)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"10.png","url":"https://assets-eu.researchsquare.com/files/rs-5097130/v1/6257c8ddf9ab1723178928b1.png"},{"id":65306584,"identity":"e095f319-82bb-406c-8896-2d4c0f68e69d","added_by":"auto","created_at":"2024-09-26 01:21:59","extension":"png","order_by":12,"title":"Figure 12","display":"","copyAsset":false,"role":"figure","size":417442,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 11: CIRCUMCISION COMPLICATION: REMNANT PREPUCE AND INCLUSION DERMOID CYST. ALSO, GLANDULO-PENILE BRIDGING SKIN/ADHESIONS \u003cem\u003e\u003cstrong\u003e(Source: Field Data, 2024)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"11.png","url":"https://assets-eu.researchsquare.com/files/rs-5097130/v1/c8144bdc002eea8d2c6deb1e.png"},{"id":65305966,"identity":"2ec66135-5c01-4b2a-a622-52b43a8be70a","added_by":"auto","created_at":"2024-09-26 01:13:59","extension":"png","order_by":13,"title":"Figure 13","display":"","copyAsset":false,"role":"figure","size":560436,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 12: CIRCUMCISION COMPLICATION: REMANT PREPUCE: ALSO, GLANULO-PENILE SKIN ADHESIONS. THIS CHILD HAS AN OVERIDING SCROTUM (PENOSCROTAL TRANSPOSITION) AS WELL. \u003cem\u003e\u003cstrong\u003e(Source: Field Data, 2024)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"12.png","url":"https://assets-eu.researchsquare.com/files/rs-5097130/v1/0ee6252fc62dc051795329e6.png"},{"id":65305970,"identity":"a073e5ad-419c-4200-b5cd-e54d9009d584","added_by":"auto","created_at":"2024-09-26 01:13:59","extension":"png","order_by":14,"title":"Figure 14","display":"","copyAsset":false,"role":"figure","size":623467,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 13: CIRCUMCISION COMPLICATION: MEATAL STENOSIS, PHIMOSIS, INCLUSION DERMOID CYST \u003cem\u003e\u003cstrong\u003e(Source: Field Data, 2024)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"13.png","url":"https://assets-eu.researchsquare.com/files/rs-5097130/v1/bc22911ed3c077547549cfcf.png"},{"id":65305972,"identity":"7089d219-a4fe-45e0-95c1-aaeadf76a042","added_by":"auto","created_at":"2024-09-26 01:13:59","extension":"png","order_by":15,"title":"Figure 15","display":"","copyAsset":false,"role":"figure","size":763405,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 14: CIRCUMCISION COMPLICATION: REMNANT PREPUCE, INCLUSION DERMOID CYST \u003cem\u003e\u003cstrong\u003e(Source: Field Data, 2024)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"14.png","url":"https://assets-eu.researchsquare.com/files/rs-5097130/v1/8c9b85770998080fb3d125dd.png"},{"id":65305973,"identity":"44273c30-4122-417a-92cf-7e69d778165e","added_by":"auto","created_at":"2024-09-26 01:14:00","extension":"png","order_by":16,"title":"Figure 16","display":"","copyAsset":false,"role":"figure","size":534235,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 15: ANTERIOR SCROTAL WALL TISSUE LACERATION AT CIRCUMCISION \u003cem\u003e\u003cstrong\u003e(Source: Field Data, 2024)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"15.png","url":"https://assets-eu.researchsquare.com/files/rs-5097130/v1/c2f3ab9b1848bf85d1ba8529.png"},{"id":65305959,"identity":"bcbcaaa5-a833-44b4-b706-19126f44ceab","added_by":"auto","created_at":"2024-09-26 01:13:59","extension":"png","order_by":17,"title":"Figure 17","display":"","copyAsset":false,"role":"figure","size":39120,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eFigure 16: Types of salvage surgeries performed\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003e(Source: Field Data, 2024)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"16.png","url":"https://assets-eu.researchsquare.com/files/rs-5097130/v1/1b6d7ce5e8d90c16516a01d7.png"},{"id":65307538,"identity":"29439fc1-70f9-48b4-8e8e-b534d31332c7","added_by":"auto","created_at":"2024-09-26 01:38:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":10975610,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5097130/v1/0928f0bc-4f1c-442b-a159-602670a3e874.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eClinical Outcomes of Circumcisions and Prevalence of Complications of Male Circumcisions: A Five-Year Retrospective Analysis at a Teaching Hospital in Ghana\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMale circumcision is a widely practiced surgical procedure, particularly in regions with religious, cultural, and public health imperatives(\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e). In Ghana, the practice is almost universal, with a significant portion of the male population undergoing the procedure(\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e). Despite its recognized benefits, including a reduction in the transmission of HIV and other sexually transmitted infections(\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e)(\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e)(\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e), circumcision is not without risk. Complications, though generally infrequent, can range from mild to severe and may include infections, excessive bleeding, and, in rare cases, permanent damage to penile structures(6). Understanding the clinical outcomes and the frequency and nature of these complications is crucial for improving patient safety and refining surgical techniques.\u003c/p\u003e\n\u003cp\u003eCircumcision, a widely practiced procedure, has been extensively studied with regard to its technique, benefits, and associated complications(\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e). We provide a brief background on the prevalence of circumcision complications, common types of complications, the relative incidence of circumcision mishaps among the various providers of the service (circumcisers), initial management of complications, and the success rate of these management strategies.\u003c/p\u003e\n\u003ch3\u003ePrevalence of circumcision complications\u003c/h3\u003e\n\u003cp\u003eThe incidence of circumcision varies globally, with Israel reporting 91.7% and Honduras reporting less than 1%. In Africa, the prevalence is 62%, with 91.6% in Ghana (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e). The incidence of complications is influenced by factors such as anatomical abnormalities, age, surgical technique, and medical comorbidities(\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e). In the U.S., complication rates are less than 0.5% (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e); however, in rural Ghana, the complication rate among infants is 8.1% (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e). These figures highlight the variability in circumcision complication rates worldwide and suggest a possible link between a country\u0026rsquo;s development status and complication prevalence.\u003c/p\u003e\n\u003ch3\u003eCommon Circumcision Complications\u003c/h3\u003e\n\u003cp\u003eComplications from circumcision are well documented, with hemorrhage/bleeding being the most common complication occurring in 11.9% of cases in the U.S.(\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e)(\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e). Other complications include meatal stenosis, infection, edema, penile hematoma, and urethrocutaneous fistula, among others. These complications are classified as early or late (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e) and can vary by region. For example, in Ghana, urethrocutaneous fistula is the most common complication, followed by glans amputation and iatrogenic hypospadias (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e). Circumcision-related complications are common in Ghana, usually because most procedures are performed by less skilled providers (\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e) (\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThis study aimed to provide a comprehensive retrospective analysis of male circumcision outcomes over the past five years at Ho Teaching Hospital in the Volta region. By identifying the patterns and prevalence of complications, this research will contribute to better clinical practices and inform public health strategies in the region.\u003c/p\u003e\n\u003ch3\u003eThe objectives of this study were as follows:\u003c/h3\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eTo evaluate the clinical outcomes of male circumcisions performed at Ho Teaching Hospital over the past five years.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eTo identify and categorize the complications associated with male circumcision in this population.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eThe factors contributing to successful outcomes and complications were assessed.\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003ch3\u003eConceptual Framework Diagram\u003c/h3\u003e\n\u003cp\u003eThis study\u0026apos;s conceptual framework (see Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e) revolves around the relationship between circumcision techniques, healthcare provider experience, and patient outcomes. The clinical outcomes of circumcision are influenced by multiple factors, including the method used, the provider\u0026apos;s skill level, and the age of the patient at the time of the procedure (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e). The framework will analyze these factors to determine their impact on the incidence of complications and overall surgical success.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis study was a five-year retrospective descriptive analysis of circumcision at Ho Teaching Hospital (HOTH) that focused on clinical outcomes, the prevalence of complications, and the management of circumcision disasters. Data were collected from the children's ward, male ward, child welfare clinics, and theatre where circumcisions and salvage surgeries for circumcision mishps were performed. Some data on acute presentations of circumcision mishaps were also assessed from emergency room records.\u003c/p\u003e \u003cp\u003eThe study population included circumcision cases handled at HOTH and complication referrals from other health facilities within the Volta region. All circumcised children attending the child welfare clinic and patients with circumcision complications referred to HOTH between January 1, 2019, and December 31, 2023, were included. Patients with incomplete or duplicated data were excluded.\u003c/p\u003e \u003cp\u003eThe study used a census approach(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), relying on secondary data from HOTH\u0026rsquo;s electronic records and archives. A structured MS Excel data extraction tool was used to evaluate patient demographics, clinical presentation, laboratory parameters, and outcomes. The data were collected through personal visits to hospital wards, ensuring completeness and confidentiality.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe data were analyzed via quantitative methods, including descriptive statistics, chi-square tests for categorical data and regression analysis for parametric data, using SPSS version 25. All analyses were conducted at a 95% confidence level with a 5% significance threshold.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eTrends of Circumcisions Performed Over the Past 5 Years\u003c/h2\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\n \u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e shows the trend of cases of circumcision recorded annually from 2019 to 2023 in the study area. The graph indicates a steady increase in the number of circumcision cases over this period. Starting in 2019, the number of cases was less than 20, and a gradual increase was observed in 2020, when the number of cases slightly increased to approximately 20. From 2021 to 2022, the number of cases increased moderately, surpassing 40 in 2022. A sharp increase was noted between 2022 and 2023, when the number of cases increased significantly, reaching a peak of approximately 80 by 2023. The green dotted line shows an upward trajectory of significant and consistent growth in the number of circumcision cases over the five years.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTrends of Circumcisions and Salvage Surgeries for Referred Circumcision Mishaps Performed Over the Past 5 Years within the Teaching Hospital\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\n \u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e reveals that over the past five years, there has been a steady increase in the number of cases documented. In 2019, there were 8 patients, accounting for 13.33% of the total. The number of cases slightly decreased in 2020, with 7 cases (11.67%), but increased again in 2021 to 9 cases (15.00%). This trend will continue to increase in 2022, with 13 cases (21.67%). The highest number of cases was recorded in 2023, with 22 cases, representing 36.67% of the total. Given that we know the total number of circumcision mishaps over the period to be 23, the lower number of cases of circumcision in the Teaching Hospital compared to the same for the entire study area suggests that most inhabitants do not see the Teaching Hospital as their preferred point of call for circumcisions. It could be a pointer that participants of the study opted for nonskilled circumcisions over skilled circumcisions and that could be a major public health bother.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eIdentification of common circumcision complications: Clinical parameters\u003c/h2\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eClinical parameters of patients with circumcision complications\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e(N\u0026thinsp;=\u0026thinsp;44)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercent \u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eS D\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eHemoglobin Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow (\u0026lt;\u0026thinsp;13.8 g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e12.53\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.94\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNormal (13.8\u0026ndash;17.2 g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh (\u0026gt;\u0026thinsp;17.2 g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot recorded\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhite Blood Cell\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow (\u0026lt;\u0026thinsp;4,000 \u0026micro;L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1418\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e26.88\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNormal (4,000\u0026ndash;11,000 \u0026micro;L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh (11,000 \u0026micro;L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot recorded\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlatelet Count\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow (\u0026lt;\u0026thinsp;150,000 \u0026micro;L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e296.59\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e143.36\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNormal (150,000\u0026ndash;450,000 \u0026micro;L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh (\u0026gt;\u0026thinsp;450,000 \u0026micro;L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot recorded\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003cp\u003e\u003cstrong\u003eHemoglobin Levels\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAmong the 44 patients (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e) with circumcision complications studied, 24 (12.9%) had low hemoglobin levels, which was below the normal threshold of 13.8 g/dL. The mean hemoglobin level was 12.53 g/dL, with a standard deviation of 2.94. Normal hemoglobin levels were observed in 16 patients (8.6%), while no patients had high hemoglobin levels (\u0026gt;\u0026thinsp;17.2 g/dL). Additionally, 4 data items (2.2%) were not recorded, potentially affecting the completeness of the data.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eWhite Blood Cell Counts\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe distribution of white blood cell (WBC) counts among the study participants revealed that no patients had low WBC counts (\u0026lt;\u0026thinsp;4,000 \u0026micro;L). The mean WBC count was 1418 \u0026micro;L, with a standard deviation of 266.88. However, 35 patients (18.8%) had normal WBC counts within the range of 4,000\u0026ndash;11,000 \u0026micro;L, while 5 patients (2.7%) exhibited high WBC counts (\u0026gt;\u0026thinsp;11,000 \u0026micro;L). Again, 4 records (2.2%) were not found.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cstrong\u003ePlatelet Counts:\u0026nbsp;\u003c/strong\u003eFor platelet counts, 4 patients (2.2%) had low platelet levels (\u0026lt;150,000 \u0026micro;L), with a mean of \u003cstrong\u003e296.59 , and a standard deviation of 143.36.\u003c/strong\u003e\u003c/div\u003e\n \u003c/div\u003e\n \u003cp\u003eIn contrast, 33 patients (17.7%) had normal platelet counts within the range of 150,000\u0026ndash;450,000 \u0026micro;L, and 3 patients (1.6%) had high platelet counts (\u0026gt;\u0026thinsp;450,000 \u0026micro;L). The platelet counts were not recorded for 4 patients (2.2%).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003eCorrelations between Presentation Types and Duration of Symptoms\u003c/h2\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAnalysis of the Presentation Type and Duration of Symptoms in Patients with Circumcision Complications\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"3\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eDuration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWithin the Day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAfter a Day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChi-Square\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTest\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eX\u0026sup2;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003ePresentation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAcute Emergency (TEWS 4\u0026ndash;9)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e11\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e150.74\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.2e\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e\u0026minus;\u0026thinsp;34\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCold Presentation (TEWS 0\u0026ndash;3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e175\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e175\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e10\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e176\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e186\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eSource: Field Data, 2024\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e reveals that all 10 patients classified as acute emergencies (TEWS 4\u0026ndash;9) presented within the day of symptom onset, indicating no delay in seeking immediate care. In contrast, 1 acute emergency was reported after a day. For cold presentations, all 175 patients (TEWS 0\u0026ndash;3) were seen after a day. Additionally, the chi-square test result of 150.74 with a p value of \u003cstrong\u003e1.2e\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e\u0026minus;\u0026thinsp;34\u003c/strong\u003e\u003c/sup\u003e indicated an extremely strong statistically significant association between the type of presentation (acute emergency or cold presentation) and the duration of symptoms. This may suggest that once there is a complication at play, health-seeking behavior among the studied population is good.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003ch2\u003eision Practices and Referral Dynamics\u003c/h2\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAn analysis of the location of the circumcision, surgeons performing the circumcision, and decision makers for referral when a circumcision complication occurs.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercent \u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation of Circumcision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHo and Surroundings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNearby Towns and Districts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther Regions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e186\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e100%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerformer of Circumcision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDoctors\u003cstrong\u003e***\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMidwife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWazam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e186\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e100%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eReferral Decision-Maker\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCircumcisor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther Relatives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e44\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e100%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003e***Represents specialists, consultants, and medical doctors.\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eSource: Field Data, 2024\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e provides insights into the details of the circumcision process, including the following:\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLocation of Circumcision\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe majority of circumcisions were conducted in Ho and its environs, accounting for 130 cases\u0026mdash;69.9% of the total. Sixteen patients were recorded near towns and districts (8.6%), while 40 patients were recorded in other regions.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePerformers of Circumcision\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAmong the total cases, doctors, including specialists, consultants, and medical doctors, were responsible for 30 circumcisions, accounting for 16.1% of the total. Midwives and nurses were the most common providers, each performing 72 circumcisions, representing 38.7% of the total cases. There were 10 warm fields, accounting for 5.4%.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eReferral Decision-Maker\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe decision-making process for referrals once a circumcision mishap occurs varies. \u0026lsquo;Other Relatives\u0026rsquo; were the decision makers in 9 patients, representing 20.5% of the total. Circumcisers made referral decisions in 7 (15.9%) patients, and most referral decisions were made by parents\u0026mdash;i.e., 28 referrals\u0026mdash;representing 63.6%.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n \u003ch2\u003eInitial Management of Circumcision Complications\u003c/h2\u003e\n \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e\n \u003ch2\u003eExamination Findings\u003c/h2\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\n \u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e reveals a significant difference in the nature of the findings. Of the 186 patients, 163 (80.1\u003cstrong\u003e%\u003c/strong\u003e) were classified as having normal examination results. Conversely, 23 patients (\u003cstrong\u003e12.6%\u003c/strong\u003e) were identified as having pathological findings.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u0026nbsp;\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAssociated diagnoses of circumcision complications\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003e\u003cem\u003eAssociated Diagnosis\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eValid Percent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCumulative Percent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"8\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChordae\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHypospadias (that were wrongfully circumcised outside the hospital)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInfected Smegma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eScrotal Laceration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhimosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrethral Meatal Stenosis/redundant prepuce/bridging skin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e100.0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e186\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e100.0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e100.0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\u003cbr\u003eSource: Field Data, 2024\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e reveals a diverse range of conditions, each with varying prevalence. The most common pathological condition was not detected, with 163 patients (91.9%) classified as having no associated diagnoses. Hypospadias (wrongfully circumvented) was the second most common diagnosis and was recorded in 10 patients (5.4%). Phimosis, characterized by an inability to retract the foreskin, was observed in 2 patients (1.1%). Other conditions included urethral lethal stenosis (4.5%), scrotal laceration and infected smegma, which were each reported in 1 patient (0.5%). In addition, 1 patient (0.5%) had chordae, a condition in which fibrous bands form on the penis, leading to clinically observable abnormal penile curvature or twisting.\u003c/p\u003e\n \u003cp\u003eFrom the findings of this study, the percentage of surgeries performed by each provider and the percentage of complications attributable to each provider are summarized in the table below.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eFrequency of Circumcision and frequency of complications per Provider.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHealthcare Provider\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCircumcisions Performed (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eComplications (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMidwives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e38.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e39.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDoctors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWanzams\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e34.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eGiven that the total number of circumcisions in this study was 186 and the total number of circumcision complications was 23, the actual numbers are shown in the table below as a confusion matrix table.\u003c/strong\u003e\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eConfusion Matrix Table for Circumcision Complications\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eProvider\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eComplications (Yes)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo Complications\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal Circumcisions\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMidwives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDoctors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWanzams\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e165\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e186\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Tab7\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eA consolidated table that captures all the key steps, calculations, and results for the odds ratios, z-statistics, and p values for each circumception provider compared to those of the doctors\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"10\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eProvider\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal Circumcisions\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eComplications (Yes)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo Complications\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOdds of Complication\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOdds Ratio vs Doctors\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eln(OR)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSE(ln(OR))\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eZ-statistic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDoctors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0345\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMidwives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0441\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.278\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.2457\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.1757\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.2090\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.834\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.1364\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.954\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.375\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0774\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.276\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.202\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWanzams\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.0000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e115.942\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.753\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.2882\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.691\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\n \u003ch2\u003eExplanation of Table Columns:\u003c/h2\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Circumcisions\u003c/strong\u003e: The total number of circumcisions performed by each provider.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eComplications (Yes)\u003c/strong\u003e: The number of circumcisions that resulted in complications.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eNo complications\u003c/strong\u003e: The number of circumcisions that did not result in complications.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eOdds of Complication\u003c/strong\u003e: The odds of complications occurring for each provider (complications\u0026thinsp;\u0026divide;\u0026thinsp;no complications).\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eOdds ratio vs\u003c/strong\u003e doctors: Odds ratio comparing each provider to doctors (baseline).\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eln(OR)\u003c/strong\u003e: The natural logarithm of the odds ratio.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eSE (ln(OR))\u003c/strong\u003e: The standard error of the natural logarithm of the odds ratio.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eZ-statistic\u003c/strong\u003e: The Z score was calculated using the odds ratio and standard error.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003ep value\u003c/strong\u003e: The p value corresponding to the Z value indicates statistical significance (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05); otherwise, the p value is used.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eThe above table shows that the odds of complications resulting from circumcisions performed according to the interpretation above (Table \u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003e) are significantly greater for Wanzams than for doctors (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), whereas the odds for \u003cstrong\u003emidwives\u003c/strong\u003e and \u003cstrong\u003enurses\u003c/strong\u003e are not significantly different from those for doctors.\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\n \u003ch2\u003eManagement of Complications\u003c/h2\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\n \u003cdiv id=\"Sec29\" class=\"Section3\"\u003e\n \u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e16\u003c/span\u003e reveals that among the complicated cases of circumcision analyzed, multiple or single procedures were performed as salvage surgeries, with a total of 44 salvage procedures performed for the 23 circumcision mishaps. The average number of procedures per mishap was two. Revision of circumcision was the most common procedure, accounting for 44% of the surgeries (24 patients). Urethroplasty/hypospadias repair for some urethrocutaneous fistulae or wrongfully circumcised hypospadias was performed for 13% (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e) of the patients. Suturing of the wound was performed in 5.5% (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e) of the patients. Debridement was performed in 5.5% (3 patients), while fistulectomy plus primary repair was needed in 7% (4 patients). Glansoplasty and meatotomy/meatoplasty were performed on 2% (1 patient) and 4% (2 patients), respectively. Patients with chordae needed penile degloving plus release of chordae (without Nesbit\u0026rsquo;s procedure), in addition to a meatoplasty.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003ePrevalence of circumcision complications\u003c/h2\u003e \u003cp\u003eThe study revealed a complication rate of 8.1% among the 186 circumcision patients studied. This finding aligns closely with findings from rural Ghana(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), where the complication rate was also approximately 8.1%. This rate is significantly higher than the \u0026lt;\u0026thinsp;0.5% complication rate reported in the U.S. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). This discrepancy underscores the impact of regional factors on complication rates, as noted in the literature(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The greater prevalence of COVID-19 in less developed regions, such as rural Ghana and the Volta Region, may be attributed to factors including the low availability of advanced surgical techniques, poor health-seeking behavior by the parents of these children, variable provider experience, and differing healthcare infrastructure (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt is disheartening to know that cases in which neonates born with hypospadias were circumcised without recourse to referral to the urologist or pediatric surgeon were rife; seven (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) such cases were encountered. The surgical principle is that until the hypospadias is repaired in the neonate born with this procedure, the prepuce should be preserved since it may serve as a source of a flap for hypospadias repair itself (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). This hypospadias repair procedure utilizes a preputial flap and is called \u003cb\u003eDuckett repair\u003c/b\u003e or \u003cb\u003eDuckett onlay island flap urethroplasty\u003c/b\u003e(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). This technique, as posited by the sentinel article by Duckett JW (1980, 1981), involves using a flap of tissue from the inner layer of the prepuce (foreskin) to reconstruct the urethra in patients with hypospadias, particularly when the defect is more proximal. The preputial tissue provides a well-vascularized flap that helps in the formation of a new urethra, reducing the risk of fistula formation and other complications(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eCommon Circumcision Complications\u003c/h2\u003e \u003cp\u003eThe most common complications observed in this study included infection, meatal stenosis, and bleeding. These findings are consistent with global patterns where bleeding is often the most prevalent complication(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In Ghana, the prevalence of urethrocutaneous fistula, as reported by Appiah et al. (2016), contrasts with our findings, where this complication was less common(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This variation may be attributed to differences in circumcision practices and postoperative care between regions. Our results suggest a greater incidence of infection and meatal stenosis, which could be related to local practices and the use of traditional versus modern techniques. These findings are in line with those of Appiah et al. (2016), who reported similar complications in Ghanaian settings but with different frequencies(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003eRelationship between Provider and Outcome\u003c/h2\u003e \u003cp\u003eThis study revealed that circumcision complications were predominantly associated with procedures performed by nurses and surgeons. Among the 186 cases analyzed, 38.2% of the circumcisions were carried out by midwives, 40.3% by nurses, 16.13% by doctors and 5.38% by wanzams. A total of 13.04% of the complications were treated by midwives, 3.4% by doctors, 39.1% by nurses and 34.8% by wanzams. A significant relationship was found between the presence of a circumcision provider and complication rate (chi-square\u0026thinsp;=\u0026thinsp;16.975, p\u0026thinsp;=\u0026thinsp;0.00).\u003c/p\u003e \u003cp\u003eOur data showed that circumcisions in the Volta region are predominantly performed by midwives and nurses, with a smaller proportion performed by traditional circumcisers and doctors. This distribution is similar to findings in other parts of Ghana, where midwives and nurses perform the majority of procedures(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The high complication rates associated with traditional circumcisers, as highlighted by Kacker \u0026amp; Tobian (2013), reflect the challenges of inadequate training and resources(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). However, our study also revealed notable complications in procedures performed by healthcare professionals, indicating that provider experience and training are critical factors, regardless of practitioner background. These findings align with the literature suggesting that both traditional and medical circumcision practitioners in Ghana have been associated with complication rates (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurther analysis of complications to determine the true relationship with specific circumcisoors across boards revealed significant variations in risk compared to doctors. The odds ratio (OR) was 1.278 for midwives, but the Z-statistic was 0.209, and the p value was 0.834, indicating that there was no statistically significant difference in the risk for doctors. Nurses exhibited a significantly greater odds ratio (OR) of 3.954, but this greater odds of risk for circumcision mishaps also did not reach statistical significance (Z-statistic of 1.276; p value of 0.202). In contrast, Wanzams had a dramatically elevated odds ratio of 115.942, with a Z-statistic of 3.691 and a highly significant p value of 0.0002, reflecting a substantially increased likelihood of complications compared to doctors (see Tables\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e to \u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). These findings suggest that traditional providers, such as Wanzams, may pose a much greater complication risk during circumcision, warranting targeted interventions to improve outcomes.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study provides valuable insights into circumcision practices and outcomes in the Volta region.\u003c/p\u003e \u003cp\u003eWith less trained hands, circumcision can be catastrophic. Salvage surgeries for circumcision mishaps are associated with less favorable outcomes in up to one-third of the patients, suggesting that circumcision mishaps are better prevented than cured/salvaged mishaps are.\u003c/p\u003e \u003cp\u003eThe increasing number of circumcision cases, coupled with the identification of common complications and variations in practice, highlights the need for improved standards, training, and public education.\u003c/p\u003e \u003cp\u003eTo improve circumcision practices in the Volta Region, several recommendations are proposed. First, healthcare provider training should be standardized to ensure that practitioners are skilled in surgical techniques and postoperative care. Regulations must restrict circumcision to qualified individuals, requiring certification and continuing education. Public awareness campaigns should educate parents and caregivers on the benefits and risks of circumcision, emphasizing the need for circumcision by qualified practitioners, using local languages and community outreach. Additionally, public health campaigns to disuade nonsurgeon circumcisors to refrain from circumcising children with hypospadias but rather refer to them are urgently needed.\u003c/p\u003e \u003cp\u003eA comprehensive system should be developed to monitor circumcision cases and outcomes, helping identify trends and improve care. Facilities should maintain detailed records, including pre- and postoperative care. Infection control protocols must be enforced, with practitioners trained in sterilization, aseptic techniques, and early complication management.\u003c/p\u003e \u003cp\u003eCollaboration between traditional and modern healthcare providers should be encouraged to ensure safe practices while respecting cultural traditions. Training traditional practitioners on safety and complication management is essential. Finally, strong referral systems should be established to ensure timely care for complications, with clear protocols for specialist referrals.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe study titled \u0026quot;Clinical Outcomes of Circumcisions and Prevalence of Complications of Male Circumcisions: A Five-Year Retrospective Analysis at a Teaching Hospital in Ghana\u0026quot; received ethical approval from the University of Health and Allied Sciences Ethical Review Board. The study was granted approval under the Institutional Review Board (IRB) number UHAS-REC A.10[103] 23-24, ensuring that all protocols followed the necessary ethical guidelines for research involving human subjects.\u003c/p\u003e\n\u003cp\u003eThe study was conducted in full conformance with the ethical principles outlined in the Declaration of Helsinki and adhered to all relevant national and institutional guidelines governing medical research involving human subjects. Informed consent was obtained from all participants where applicable, and data confidentiality was maintained throughout the study to ensure the privacy and rights of the individuals involved. The research was also approved by the University of Health and Allied Sciences Ethical Review Board under IRB number UHAS-REC A.10[103] 23-24.\u003c/p\u003e\n\u003cp\u003eACKNOWLEDGEMENT\u003c/p\u003e\n\u003cp\u003eWe acknowledge the Authorities of the Ho Teaching Hospital.\u003c/p\u003e\n\u003cp\u003eConflict of interest : None of the authors have any financial or personal conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003eFunding: No funding was obtained for this work.\u003c/p\u003e\n\u003cp\u003eAuthor Contributions:\u003c/p\u003e\n\u003cp\u003eSylvester Appiah: study design, methodology, data collection, visualization and dating.\u003c/p\u003e\n\u003cp\u003eDr Frank Obeng: Conceptualization, study design, supervision, data curation, visualization, first draft outline, editing of the work.\u003c/p\u003e\n\u003cp\u003eFunding:\u003c/p\u003e\n\u003cp\u003eNo funding was obtained for this work.\u003c/p\u003e\n\u003cp\u003eAuthor Contributions:\u003c/p\u003e\n\u003cp\u003eSylvester Appiah: study design, methodology, data collection, visualization and dating.\u003c/p\u003e\n\u003cp\u003eConflict of interest \u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of the authors have any financial or personal conflicts of interest to declare.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAhinkorah BO, Hagan JE, Seidu AA, Torgbenu E, Budu E, Schack T. Understanding the linkages between male circumcision and multiple sexual partnership among married Ghanaian men: Analysis of data from the 2014 Ghana demographic and health survey. SSM - Popul Heal [Internet]. 2020;11:100622. Available from: https://doi.org/10.1016/j.ssmph.2020.100622\u003c/li\u003e\n \u003cli\u003eWHO. Neonatal and child male circumcision: a global review. Unaids. 2010;\u003c/li\u003e\n \u003cli\u003eLawal TA, Olapade-Olaopa EO. Circumcision and its effects in Africa. Transl Androl Urol. 2017;6(2):149\u0026ndash;57.\u003c/li\u003e\n \u003cli\u003eMorris BJ, Wamai RG, Henebeng EB, Tobian AAR, Klausner JD, Banerjee J, et al. Estimation of country-specific and global prevalence of male circumcision. Popul Health Metr [Internet]. 2016;14(1):1\u0026ndash;13. Available from: http://dx.doi.org/10.1186/s12963-016-0073-5\u003c/li\u003e\n \u003cli\u003eMorris BJ, Krieger JN, Klausner JD. CDC\u0026rsquo;s Male Circumcision Recommendations Represent a Key Public Health Measure. Glob Heal Sci Pract. 2017;5(1):15\u0026ndash;27.\u003c/li\u003e\n \u003cli\u003eSiroosbakht S, Rezakhaniha B. A comprehensive comparison of the early and late complications of surgical circumcision in neonates and children: A cohort study. Heal Sci Reports. 2022;5(6).\u003c/li\u003e\n \u003cli\u003eXi RC, Sheng YR, Chen WH, Sheng L, Gang JJ, Tong Z, et al. Male circumcision performed with 8-Figure non-Absorbable suture technique. Can Urol Assoc J. 2014;8(3\u0026ndash;4):e142\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eKrill AJ, Palmer LS, Palmer JS. Complications of Circumcision. 2011;2458\u0026ndash;68.\u003c/li\u003e\n \u003cli\u003eBcheraoui C El, Zhang X, Cooper CS, Rose E, Kilmarx PH, Chen RT. Rates of Adverse Events Associated with Male Circumcision in. 2015;168(7):625\u0026ndash;34.\u003c/li\u003e\n \u003cli\u003eGyan T, McAuley K, O\u0026rsquo;Leary M, Strobel NA, Edmond KM. Healthcare seeking patterns of families of infants with circumcision-related morbidities from two population-based cohort studies in Ghana. BMJ Open. 2017;7(8).\u003c/li\u003e\n \u003cli\u003eIacob SI, Feinn RS, Sardi L. Systematic review of complications arising from male circumcision. BJUI Compass. 2022;3(2):99\u0026ndash;123.\u003c/li\u003e\n \u003cli\u003eAppiah KAA, Gyasi-Sarpong CK, Azorliade R, Aboah K, Laryea DO, Otu-Boateng K, et al. Circumcision-related tragedies seen in children at the Komfo Anokye Teaching Hospital, Kumasi, Ghana Pediatric Urology. BMC Urol [Internet]. 2016;16(1):1\u0026ndash;8. Available from: http://dx.doi.org/10.1186/s12894-016-0183-1\u003c/li\u003e\n \u003cli\u003eOsifo OD, Oriaifo IA. Circumcision mishaps in Nigerian children. Ann Afr Med. 2009;8(4):266\u0026ndash;70.\u003c/li\u003e\n \u003cli\u003eMaison P, Yahaya I, Appiah K, Ekor O, Apraku C, Egyir E. Circumcision practice among trained circumcisers in Ghana. African Urol. 2023;3(1):35\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eKacker S, Tobian AAR. Male circumcision: Integrating tradition and medical evidence. Isr Med Assoc J. 2013;15(1):37\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eMotheral B, Brooks J, Clark MA, Crown WH, Davey P, Hutchins D, et al. A checklist for retrospective database studies - Report of the ISPOR task force on retrospective databases. Value Heal. 2003;6(2):90\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eDuckett JW. The island flap technique for hypospadias repair. Urol Clin North Am. 1981 Oct;8(3):503-11. PMID: 7324317.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"university of health and allied sciences, ho","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Circumcision, Prevalence of circumcision complications, Provider experience, Initial management strategies, Outcomes of salvage surgeries","lastPublishedDoi":"10.21203/rs.3.rs-5097130/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5097130/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Male circumcision surgery is increasing in popularity due to its medical benefits, including reducing the prevalence of HIV. It is commonly performed by both health and nonhealth professionals, with most circumcisions occurring during the neonatal period. Studies suggest that the benefits outweigh the risks, although complications can occur. This study aimed to determine the clinical outcomes of circumcisions and the prevalence of circumcision mishaps in the Volta region of Ghana.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim:\u003c/strong\u003e To determine the clinical outcomes of circumcision and estimate the prevalence of circumcision disasters within the Volta region.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology:\u003c/strong\u003e A five-year retrospective descriptive and analytic study was conducted at Ho Teaching Hospital using a structured data extraction sheet to collect demographic, clinical, and circumcision-related data from 186 patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Among 186 circumcision patients, 23 (12.37%) experienced complications, the most common of which were partial circumcision (43.48%), postcircumcision bleeding (21.74%), and urethrocutaneous fistula and/or wrongfully described congenital hypospadias (13.04%). Low hemoglobin levels and infections were also noted. A significant relationship was found between the presence of a circumcision provider and complication rate (chi-square = 16.975, p = 0.00). Doctors who performed circumcision had the lowest complication rate (4.3%), while nurses and traditional circumcisers had higher complication rates (39.1% and 34.8%, respectively). Circumcision-Revision surgery was the most common salvage surgery for circumcision mishaps (31.82%), with urethroplasty and hypospadias repair (for wronfully circumcised neonates born with hypospadias) accounting for 15.91%. Meatoplasties, glansoplasties, fistulectomy plus primary repair and chordae-release surgeries were also performed. The success rate for salvage surgeries (on first attempt) was 70%. Prompt initial management strategies were significantly associated with good outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e In less-trained hands, circumcision can be catastrophic. Salvage surgeries for circumcision mishaps are associated with less favorable outcomes in up to one-third of the patients, suggesting that circumcision mishaps are better prevented than cured/salvaged mishaps are. Training, guidance and policy interventions are needed to reduce the incidence of circumcision-related mishaps. Public health campaigns to disuade nonsurgeon circumcisors to refrain from circumcising children with hypospadias but rather refer to them are urgently needed.\u003c/p\u003e","manuscriptTitle":"Clinical Outcomes of Circumcisions and Prevalence of Complications of Male Circumcisions: A Five-Year Retrospective Analysis at a Teaching Hospital in Ghana","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-26 01:13:54","doi":"10.21203/rs.3.rs-5097130/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ab57d893-8a55-4bb0-b0c9-c1bee4c1f6ca","owner":[],"postedDate":"September 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":37927397,"name":"Surgery"},{"id":37927398,"name":"Pediatrics"},{"id":37927399,"name":"Other Public Policy"}],"tags":[],"updatedAt":"2024-09-26T01:13:54+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-26 01:13:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5097130","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5097130","identity":"rs-5097130","version":["v1"]},"buildId":"J0_U0BvcaRcwD8yVFaRlm","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}