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ORIGINAL ARTICLE |
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| Year : 2023 | Volume
: 28
| Issue : 5 | Page : 397-399 |
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Factors affecting parental satisfaction after male circumcision
Reyaz Ahmad Wani, Bilal Yousuf Mir
Department of Paediatric Surgery, Government Medical College, Super Speciality Hospital, Srinagar, Jammu and Kashmir, India
| Date of Submission | 16-Dec-2022 |
| Date of Decision | 01-Jun-2023 |
| Date of Acceptance | 04-Jun-2023 |
| Date of Web Publication | 05-Sep-2023 |
Correspondence Address:
Reyaz Ahmad Wani
Department of Paediatric Surgery, Government Medical College, Super Speciality Hospital, Srinagar, Jammu and Kashmir
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jiaps.jiaps_179_22
 Abstract | | |
Background: The safety of the male circumcision depends on many factors, including the surgeon, type of anesthesia, and associated complications. The scientific knowledge regarding safe MC is not so prevalent among masses.
Aims and Objectives: To study the level of awareness regarding circumcision amongst parents and highlight factors linked to parental satisfaction.
Materials and Methods: Information regarding various factors was gathered with the help of structured questionnaire-based evaluation of parental knowledge and experience. This was followed by clinical examination by a pediatric surgeon for assessment of cosmetic outcome, complications and need for additional surgical procedure.
Results: Most circumcisions were performed by non-surgeons beyond neonatal period. Majority of the procedures were done under local anesthesia and around 17% procedures were done by quacks without anesthesia. More than 20% parents were dissatisfied with the procedure. Around 80% parents considered perioperative period mildly to moderately stressful. The overall complication rates were higher than usual with need for surgical correction in more than 40% patients.
Conclusion: There is lack of awareness regarding safe MC practices in general public. MC by inexperienced people contributes to higher complication rates and need for redo, which in turn is related to parental dissatisfaction.
Keywords: Complications, male circumcision, meatal stenosis, parental satisfaction, surgeon
How to cite this article:
Wani RA, Mir BY. Factors affecting parental satisfaction after male circumcision. J Indian Assoc Pediatr Surg 2023;28:397-9 |
| Introduction | |  |
Male circumcision (MC) is one of the most common surgical procedures done in this part of the world due to the predominant Muslim population. Among the Muslims of Kashmir valley, conventionally, the procedure was done by barbers (Naid circumcision).[1] However, in the present times, the majority of procedures are being done by trained health-care personnel or general and pediatric surgeons. The safety of local anesthesia for MC is well established in the form of penile or ring block.[2] Like any other surgical procedure, complications can occur in circumcision as well. The most common ones include pain, bleeding, incomplete circumcision, surgical site infection, injury to the glans or urethra, or poor cosmesis.[3] Parental anxiety is very common before and after MC.[4] Our aim was to assess the factors that affect parental satisfaction after the procedure.
| Materials and Methods | | |
This is an observational study conducted at a tertiary care institute in Kashmir Valley from July 2021 to July 2022. The parents of all the circumcised pediatric patients who presented to our clinic or outpatient department for unrelated conditions were given a structured questionnaire [Annexure 1] and their responses were collected. Boys up to the age of 5 years were included in the study. The penises of all the kids were examined after informed written consent by a qualified surgeon with a main focus on the position and size of meatus, cosmesis, and any deformity attributable to circumcision [Annexure 2]. The assessment of the meatus and cosmesis was subjective in nature. The size of the meatus was assessed according to grading by Mekayten et al. as follows:[5] Grade 0 – open meatus and mucosa seen; Grade 1 – open meatus and mild mucosa seen; and Grade 2 – pinpoint meatus and no mucosa seen.
The severity of the deformity was judged based on the need for surgical correction. The information collected was analyzed to look for various factors that had an impact on parental satisfaction.
| Results | | |
During the study period, out of the total of 450 potential participants, only 306 responses were completed and thus taken into account. All the boys were examined by a pediatric surgeon. Majority of circumcisions (58.5%) were performed by nonsurgeons. Only 15.68% circumcisions were done in neonates. Around 70% of procedures were done under local anesthesia. Surprisingly, 17.64% circumcisions were done without any form of anesthesia by quacks. Majority of respondent parents (79.41%) considered the perioperative period mildly to moderately stressful. More than 20% of parents were not satisfied with the procedure and the performer. Sizeable numbers of parents (97 out of 306) were highly apprehensive of the need for some sort of redo procedure in their kids after circumcision. About 75% of parents were happy with the cosmetic appearance after MC [Table 1].
Meatal stenosis (MS) was seen in around 84 (27.45%) patients, out of which 21 (6.86%) had pinpoint meatus. Twelve patients had either a missed hypospadias or postcircumcision urethrocutaneous fistula (UCF), all of them were circumcised by quakes. More than 40% of patients needed some sort of surgical correction [Table 2]. The most common reasons for redo surgeries were incomplete circumcision, symptomatic MS, glans entrapment, cosmetic revision, and repair of hypospadias or UCF.
| Discussion | | |
MC is one of the oldest and the most commonly performed procedures. MC in Muslims is very important ingredient of their faith. Conventionally, when the health care and anesthesia were not so developed, such procedures were done by nonsurgeons. In Kashmir, one such example is “Naid khatna” which means circumcision by traditional barbers. As reported in literature, there is higher rate of complications when MC is done by untrained personnel.[1] With advances in health care, the safe surgical practices have also evolved even in underdeveloped societies like ours. Still, <50% of MCs are done by surgeons, as shown by our study. Furthermore, among the surgeons, majority are being performed by general surgeons, while only 14.70% of procedures are done by pediatric surgeons. The reason seems to be the lesser number of accessible pediatric surgeons due to the nonavailability of superspecialist surgeons in district and subdistrict hospitals.
Surgery on a child is a big concern to the parents; circumcision in this regard is no exception. There are various parental issues such as safe and adequate anesthesia, complication-free surgery, and the best possible outcome. This seems possible only when the procedure is done by a surgeon, preferably a pediatric surgeon or an urologist who is well versed with the normal and abnormal anatomy of the organ. Other potential factors that can have an impact on parental satisfaction after MC include the type of anesthesia, postoperative pain, complications, and cosmesis of the organ. In our study, MC was done by pediatric surgeons, general surgeons, and nonsurgeons in 14.7%, 26.8%, and 58.5%, respectively. Although <50% of procedures were done by surgeons, majority of parents (78.4%) were satisfied with the doer of the procedure and around 63% would even recommend the person to his/her friends. At present, majority of the procedures are being done under local anesthesia. It requires a lot of expertise and proper knowledge to administer local anesthetic agents properly. More than 60% of the parents felt that their children experienced moderate to severe pain due to the procedure. This finding is justified by the fact that <50% of procedures had been done by surgeons. In our study, around 18% of circumcisions were done by quakes without any anesthesia. The frequency of this form of MC is declining; however, it is not obsolete yet. The explanation for this is a lack of awareness and knowledge in the general public belonging to the poor and backward sections of our society.
The overall parental satisfaction rates were also very high (around 79%). Approximately 75% of parents were happy with the cosmetic appearance after circumcision. It is pertinent to mention here that about 31.7% of parents were highly apprehensive of the need for redo procedures in their kids.
MS after MC is a contentious issue, with some investigators ascribing it to the circumcision and others of refuting this observation.[3],[6],[7],[8] In our study, 27.45% of children had MS which is more than the reported prevalence (17.9%) among circumcised male children.[9] This, again could be explained by the fact that a large percentage of children are circumcised by nonsurgeons. There seems to be higher overall complication rates in our study, as supported by the need for surgical correction in more than 40% of our children.
Some other factors that have been investigated in literature are method (device vs. nondevice) and timing of circumcision (neonatal vs. nonneonatal or childhood circumcision).[10],[11],[12] When comparing various circumcision devices among themselves and with the dorsal-slit method, there are no significant differences in complication rates.[10],[11] However, circumcision in the neonatal period or infancy seems to have more advantages as compared to childhood circumcision.[12] In our study, most of the procedures of MC are done with nondevice techniques such as dorsal-slit or guillotine method. Most of the circumcisions in our study were done before 2 years of age, though a very small fraction was done in the neonatal period. The reason for this seems to be the parental preference with the safety of anesthesia in their mind.
| Conclusion | | |
Parental satisfaction after MC depends on the ease, safety and complications of the procedure, which in turn depends on the expertise of the surgeon. There is a significant deficiency of knowledge regarding safe MC practices in the general public in our society. We recommend that necessary public awareness initiatives regarding MC should be taken so that complication rates and the need for redo surgeries should be reduced.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| Annexures | | |
Annexure 1: Circumcision questionnaire to be filled by either parent. (Please tick the most appropriate answer)
1. Who has done the circumcision in your child?
- Pediatric surgeon
- General surgeon
- Other health-care personnel
- Quake
2. What was the age of the child at the time of circumcision?
- <1 month
- 1 month to 1 year
- 1–2 years
- More than 2 years
3. What type of anesthesia was given to your child?
- General anesthesia + local anesthesia
- General anesthesia
- Local anesthesia
- No anesthesia
4. How painful was the procedure to the child?
- Very severe
- Severe
- Moderate
- Mild
5. How much stress you went through during the perioperative period?
- Severe
- Moderate
- Mild
- No stress
6. How satisfied were you with the person who did the procedure?
- Very satisfied
- Satisfied
- Unsatisfied
- Very unsatisfied
7. Would you recommend the person to someone in your friend circle?
- Highly recommended
- Recommended
- Not recommended
- Highly not recommended
8. How satisfied are you with the overall outcome of the procedure?
- Very satisfied
- Satisfied
- Unsatisfied
- Very unsatisfied
9. How happy are you about the cosmetic result of the circumcision?
- Very happy
- Happy
- Unhappy
- Very unhappy
10. How apprehensive are you about the need for redo surgery in your child?
Annexure 2: Examination by surgeon
A. Meatus
- Abnormally positioned meatus like hypospadiac meatus or UCF
- Pinpoint meatus (Grade 2 meatal stenosis)
- Grade 1 meatal stenosis
- Grade 0 meatal stenosis (normal meatus)
B. Cosmesis
- Very poor
- Poor
- Good
- Very good
C. Deformity
- Surgical correction warranted
- Surgical correction advisable
- Surgical correction not needed
- Cannot be assessed
| References | | |
| 1. | Hassan Y, Rasool H, Rather AA, Ahmad Y, Rasool I. Religious circumcision (Khatna) and circumcision mishaps in Kashmiri children. Afr J Paediatr Surg 2022;19:213-6.  [ PUBMED] [Full text] |
| 2. | Lander J, Brady-Fryer B, Metcalfe JB, Nazarali S, Muttitt S. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision: A randomized controlled trial. JAMA 1997;278:2157-62. |
| 3. | Krill AJ, Palmer LS, Palmer JS. Complications of circumcision. ScientificWorldJournal 2011;11:2458-68. |
| 4. | Mapureti P, Chola L, Skinner D. Factors associated with mothers' decisions on male neonatal circumcision in Swaziland. Afr J AIDS Res 2015;14:127-35. |
| 5. | Mekayten M, Meir E, Ben-Chaim J, Landau EH, Khoury AE, Gofrit ON, et al. Formulation and validation of meatal stenosis grading system. J Pediatr Urol 2020;16:205.e1-205.e5. |
| 6. | Williams N, Kapila L. Complications of circumcision. Br J Surg 1993;80:1231-6. |
| 7. | Morris BJ, Krieger JN. Does circumcision increase meatal stenosis risk?-A systematic review and meta-analysis. Urology 2017;110:16-26. |
| 8. | Morris BJ, Moreton S, Krieger JN. Meatal stenosis: Getting the diagnosis right. Res Rep Urol 2018;10:237-9. |
| 9. | Acimi S, Abderrahmane N, Debbous L, Bouziani N, Mansouri JM, Acimi MA, et al. Prevalence and causes of meatal stenosis in circumcised boys. J Pediatr Urol 2022;18:89.e1-89.e6. |
| 10. | Freeman JJ, Spencer AU, Drongowski RA, Vandeven CJ, Apgar B, Teitelbaum DH. Newborn circumcision outcomes: Are parents satisfied with the results? Pediatr Surg Int 2014;30:333-8. |
| 11. | Nagdeve NG, Naik H, Bhingare PD, Morey SM. Parental evaluation of postoperative outcome of circumcision with Plastibell or conventional dissection by dorsal slit technique: A randomized controlled trial. J Pediatr Urol 2013;9:675-82. |
| 12. | Morris BJ, Waskett JH, Banerjee J, Wamai RG, Tobian AA, Gray RH, et al. A 'snip' in time: What is the best age to circumcise? BMC Pediatr 2012;12:20. |
[Table 1], [Table 2]
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