Bloodborne HIV: Don't Get Stuck!

This is a guest blog by Jim Thornton, re-posted from Ripe-Tomato.org. This reposting does not include the disturbing pictures of mutilated baby’s penises. To see the complete posting with pictures, go to: http://ripe-tomato.org/2013/02/16/cock-ups-happen/

The World Health Organisation Manual for Infant Circumcision’s (available at: http://www.who.int/hiv/pub/malecircumcision/manual_infant/en/) sample information sheet for parents (p. 110) is not adequate. Here is the bit on surgical harms:

Complications during male circumcision are rare, being estimated to occur in 1 of every 500 procedures. These complications, which can be severe, include poor cosmetic outcome, bleeding, infection, injury to the penis and the removal of too much or too little skin.

Using “rare” for a 1 in 500 risk, when earlier the benefit of “avoiding the need for circumcision later in life” (about 1 in 2,000) is mentioned without qualification, is biased. The figure also applies to the best series. Less well organised services report rates up to 20%, e.g. Nigeria, available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1560152/?tool=pubmed). Since the manual is for use in developing countries the possibility of higher complication rates should be mentioned. Finally, Complications, which can be severe, include poor cosmetic outcome… is clearly designed to play down severity.

But more importantly, catastrophic complications are omitted altogether. Fully informed consent means telling people everything, however rare, which might alter the decision of a reasonable patient/parent. In gynaecology we mention the 1 in 10,000 risk of temporary colostomy after laparoscopic surgery for example. Unless we have a double standard for Africa, the complications below, which all appear elsewhere in the guide, should be mentioned. Italic text and pictures are all taken from the guide.

HIV, and other blood borne infections.

In male circumcision programmes a major concern is the potential transmission of bloodborne […] HIV and hepatitis B virus, to […] patients. The risk of acquiring HIV from an HIV-infected person through a needle-stick injury is estimated at 0.3% […] . The risk of acquiring hepatitis B virus infection, after being stuck with a needle that has been used on a person with hepatitis B infection, ranges from 6% to 37%, […] Most instances of transmission of infection in health-care facilities can be prevented through the application of standard precautions. If “it is a major concern” and only “most […] can be prevented”, it should be mentioned.

Amputation of the penis [picture available at ripe-tomato.org]

This extremely rare complication can be minimized by using good surgical technique but is unlikely to be eliminated. Unfortunately, even under ideal circumstances and with experienced surgeons [it] continues to occur.

Destruction of the penis by electro cautery.

One should NEVER use an electric current [..] with a metal Gomco clamp. […] The use of electrocautery […] has resulted in total ablation of the penis during male circumcision. To avoid this devastating complication, surgeons must be educated that electrocautery has to be strictly avoided when using a Gomco clamp.

Urinary retention from retained Plastibell rings.

Some of the most serious complications ever seen [retention and bladder rupture] […] have resulted from retained Plastibells. Educating the family to closely monitor the wound and the infant’s urine output is paramount with the use of this device.

Penile necrosis following the Plastibell technique [pictures available at ripe-tomato.org]

These two poor fellows aren’t going to be great in the sack.

Degloving – removal of the skin of the shaft [picture available at ripe-tomato.org]

None of these complications are common, but they all occur. If infant circumcision programmes get rolled out widely in developing countries, it is inconceivable that everyone will read all 140 pages of the WHO manual In the real world sterilisation goes wrong, mismatched Yellen clamps get packed together, and diathermy and wrong sized Plastibells get used. Even if they don’t, infants wriggle. Parents should be told.