To Estimate the Prevalence and Determinants of Male Circumcision Procedures Conducted at A. M Shaikh Homoeopathic Hospital, Belagavi - A Descriptive, Retrospective Study

Introduction

Male circumcision have the cultural and religious importance among the oldest surgical procedures traditionally. During the 19th and 20th century this procedure was initiated for both health-related and social reasons for previously non circumcising society. Historically, Male circumcision has been associated with religious practice and ethnic identity. Circumcision was practiced in ancient period among Egyptians and Jews which is inscripted with earlier records around 2300BC, from Egyptian tomb work and wall paintings of the earlier civilization.¹ Traditional male circumcision, termed as ‘‘khatna’’ or ‘‘sunnat’’, was reported to be traditionally performed by circumcisers of the Muslim community or barbers who were designated by various names like zarrah, khalifa, mullah, nai, hajjam and nau.²

Around one third of the global male population is circumcised according to Gatrad et al. 2002. Different religions have different prevalence of male circumcision³ . It is performed since before recorded history (Doyle 2005), the procedure was practiced as a ritual by South Sea Islanders, Australian Aborigines, Sumatrans, Incas, Ancient Egyptians, Aztecs and Mayans (Doyle 2005).⁴ Male circumcision is almost domain in much of the Middle East, North and West Africa and Central Asia including Australia, Eastern Asian countries, Canada and United States of America (USA). It is also prevalent among certain ethnic population in central, eastern and southern Africa. Both Jewish and Islamic rules allows and encourages religious circumcision for males. Circumcision is recommended because of medical benefits in addition to religious sanctions. (Schoen 1997).³

Global prevalence of MC estimates carried out by various nationally represented surveys showed MC prevalence as 38.7 %, out of which Indian Territory covers 13.5% the estimated percentage of circumcised males in each country and territory varies considerably. Half of circumcisions were for religious and cultural reasons.⁵ A 2007 WHO Report estimated that approximately 30% of the world’s males aged 15 years or older were circumcised.⁶ In 2011, estimates by an independent researcher establish global MC prevalence to be 37– 40 %.5 There are no guidelines that indicate the ideal age at which the procedure should be performed (Wiswell et al. 1993). Reports shows that neonatal circumcision reduces the incidence of urinary tract infections, especially in the first year of life (Schoen et al. 2000). Neonatal circumcision was very rare and is common in Israel, United States of America, Canada, Australia, New Zealand, Middle East, Central Asia and West Africa. Only 14.8% of children were circumcised before one year of age but is uncommon in East and southern Africa, where median age at circumcision varies from boyhood to the late teens or twenties. Circumcision practices are different in developed and developing countries aswell.⁷

In United States, circumcision is performed mainly by pediatricians, family practitioners and obstetricians.⁸ Male non-medical people are the traditional circumcisers in developing countries. Since earlier days this procedure is learnt from their master who happens to be a traditional circumciser.According to Barlas 1998 it is common in Turkey previously and still exist in developing countries where medical doctors are not readily available. In this study, 13.3% of circumcisions were performed by traditionalcircumcisers.³ Circumcision is performed for various indications including the prevention of penile and cervical cancer, sexually transmitted infection, particularly HIV and urinary tract infection. Many surgeons would also perform a circumcision as treatment for hypospadiasis.

The following are medical determinants we came across in our study,

Phimosis

Phimosis is defined as the inability to retract the foreskin because of a narrowed preputial opening. Physiological Phimosis is conservatively managed. But the pathological Phimosis requires surgical intervention. Objective data is not confirmative to suggest that having a physiological Phimosis leads to a pathological one at any stage.

Paraphimosis

Paraphimosis is surgical emergency in which retracted foreskin cannot be returned back to its normal position.

Balanoposthitis and Balanitis

Inflammation of glans penis is called as Balanitis.It is a common genitourinary infection affecting 11% of Male population. Inflammation of prepuce is called as posthitis , Inflammation of both glans penis and prepuce is called balanoposthitis The foreskin is non-retractile in 1% of males and occurs in whom there is erythema and edema of the prepuce and glans.

Which presents with purulent discharge, inflammation may spread along the shaft of the penis associated with dysuria. Circumcision must be reserved in those with recurrent Balanoposthitis, although alternative methods, such as Preputioplasty.⁹

The aim of this study is to review the religious and medical determinants of male circumcision and estimate the regional prevalence of MC at the A. M. Shaikh hospital.

Materials and Methods

This is a descriptive, retrospective study done at A M Shaikh Homoeopathic Medical College, Hospital and PG Research Centre on patients who underwent Male Circumcision procedure from the period 2011 to 2020. The study involves purposive sampling technique. This study concentrates mainly on the medical indications for circumcision , the routine ritual circumcision. All the cases which underwent circumcision procedure at the Hospital irrespective of age and Medical indication were considered for the study as inclusive criteria. The study consisted of 1943 patients for circumcision consecutively between 2011 and 2020 at our Hospital. Informed consent was obtained from the patients at the beginning of the Procedure. The indication for surgery for all patients was religious belief and medical determinants. The circumcision procedure was performed by trained health professionals under general and local anesthesia.

Results

It is data of circumcision procedure conducted retrospective at A. M. Shaikh Homoeopathic medical college and PG research centre, Belagavi, Karnataka, India. Total number of patients who underwent the procedures were 1943, between 2011 to 2020. Entire patients were divided into two groups Group A (0- 18yrs) and Group B (above 18 yrs). Total number of patients under Group A was 1709 and Group B 234. Category Group A with patients aged below 18yrs (i.e.) from neonates to 18yr old young adults had following number of procedures conducted in 9 yrs (Refer Table 1 and Figure 1). From the year 2011- 2012 there were 64 procedures done with 63 cases of religious purposes and 1 Phimosis as an indication. In the year 2012-2013 out of 136 procedures, 118 were religious and 18 with Phimosis. In year 2013-2014, among 166 procedures 154 were religious and 12 were Phimosis. In year 2014- 2015 out of 165 patients, 156 were religious and 9 were Phimosis. Out of 256 patients, 213 were with religious purpose and 7 with Phimosis indication in 2015-2016, in the year 2016-2017 there were 198 religious and 10 Phimosis, year 2017-2018 255 patients were religious purpose and 15 were with Phimosis indication, in the year 2018 – 2019 out of 302 procedures 242 were of religious and 24 Phimosis and in the Year 2019-2020 out of 241 total procedures 197 were of religious purpose and 17 patients were with the indication of Phimosis respectively.

Graph 1 (Comparison of Medical determinants, Phimosis and Religious purpose in Group A category)

Group B (Refer Table 2 and Figure 2) category with patients aged above 18yrs had the following number of procedures conducted with different indications. Year 2011-2012 had 2 procedures done with no religious purpose only Phimosis as an indication, in 2012-2013 there were 23 cases with Phimosis, in the year 2013- 2014 21 patients underwent the procedure with Phimosis as indication, 27 patients with Phimosis indication in 2014-2015, in the year 2015-2016 there were 31 cases of Phimosis 3 patients of Balanitis, in 2016-2017 29 cases of Phimosis , in the year 2017-2018 35 patients of Phimosis 2 Paraphimosis 1 Phimosis with Hydrocele were conducted, 2018-2019 there were 35 patients with Phimosis and 25 patients of Phimosis indication in the year 2019-2020 respectively.

Among the total 1943 procedures conducted from 2011 to 2020 (Table 3 and Figure 3), 1596 patients underwent the MC procedure with religious purpose which was seen in Group A (0-18yrs) category. The number of medical indications for Circumcision in this category was very less as compared with religious purpose. Group B (above 18yrs) category of patients who underwent the procedure weremore of Medical indications of Circumcision like Phimosis (228 cases), Balanitis (2), Paraphimosis (2) and 1 case of Phimosis with Hydrocele.

Estimation of Medical Determinants and Religious Circumcision procedure conducted in both group A and group B from year wise from 2011 to 2020 

Discussion

Approximately about 120 million population undergo circumcision and is seen living together with 900 million non circumcising populations in India.¹⁰

Illiteracy and conservativeness are found major obstacles in MC procedures as stated by Chandiok et al. studies. Out of 1943 (Ref. Table 3 and Figure 3) procedures conducted from 2011 to 2020, 1596 (82.14%) patients underwent MC procedure with religious purpose which was seen in Group A (0-18yrs) category only with no religious applications in Group B.

Many studies have shown that male circumcision also protects against urinary tract infections in infants and children hence considered as one of the medical determinant.¹¹

Cathcart P et al. Trends in pediatric circumcision the most frequent medical reason for male circumcision is Phimosis. In the year 1997 to 2003, United Kingdom reported 90% of medically determinanats of circumcisions were for phimosis.¹¹ In current study the major medical determinant surfaced for MC is Phimosis 341 (17.5%) cases. Among total Phimosis cases which was a prominent medical determinant with 113 (5.8%) patients belong to Group A Category (0-18yrs) and 228 (11.7%) patients in Group B (>18 yrs) category. Other less common, medical indications for circumcision are untreatable Paraphimosis 2 (0.10%) and Balanitis 3 (0.15%) a risk factor for penile cancer and the only absolute indication for circumcision another case of Phimosis with Hydrocele 1 (0.05%) In addition, though preputial neoplasm’s, excessive skin and tears in the frenulum are also rare medical indications for adult circumcision no such medical determinants of MC were identified.¹² Hence Table 3 and Graph 3 are suggestive of predominant medical determinants in Group B and religious predominance in Group A category.

Outcome of this study (Ref Table 4 and Figure 4) is descriptive of religious predominance for MC procedures 1596 (82.14%) cases out of total 1943, 347 ( 17.85%) cases with medical determinants as indications out of total procedures conducted. 

Conclusion

Global prevalence studies showed percentage of circumcised males in Indian Territory to be 13.5% with no clarity in estimates of prevalence with regards to religious and medical determinants. We therefore considered it timely to conduct a pilot study of much more thorough evaluation aimed at determining the latest MC prevalence figures in this part of country. Among the patients who visited the Hospital for MC procedures from 2011 to 2020 religious prevalence was derived as 82.14% and those with Medical determinants as 17.75%. Current prevalence is derived for further exploration of efficacy of Structured Homoeopathic medicines as an Adjunct to Standard care of Wound Healing in Post Surgical Cases of Circumcision as therapeutic measure at A. M. Shaikh Hospital.

Acknowledgement

The authors would like to express their regards to senior medical officer Dr. I A. Khatib for his support in reviving the data. Deep regards to departmental colleagues Dr Irshad, Dr Padmaja and Dr Deepa for their cooperation provided in completion of this study. We acknowledge the institutional ethical committee, Hospital staff and patients of A. M. Shaikh Homoeopathic Medical College and PG research centre, Belagavi for their valuable assistance.

Financial support and sponsorship

No financial support and sponsorship was taken for this study

Conflicts of interest

None declared