Case series of glans injuries during voluntary medical male circumcision for HIV prevention — eastern and southern Africa, 2015–2018

Abstract

Background: Male circumcision confers partial protection against heterosexual HIV acquisition among men. The President's Emergency Plan for AIDS Relief (PEPFAR) has supported > 18,900,000 voluntary medical male circumcisions (VMMC). Glans injuries (GIs) are rare but devastating adverse events (AEs) that can occur during circumcision. To address this issue, PEPFAR has supported multiple interventions in the areas of surveillance, policy, education, training, supply chain, and AE management. Methods: Since 2015, PEPFAR has conducted surveillance of GIs including rapid investigation by the in-country PEPFAR team. This information is collected on standardized forms, which were reviewed for this analysis. Results: Thirty-six GIs were reported from 2015 to 2018; all patients were < 15 years old (~0•7 per 100,000 VMMCs in this age group) with a decreasing annual rate (2015: 0.7 per 100,000 VMMCs; 2018: 0.4 per 100,000 VMMC; p = 0.02). Most (64%) GIs were partial or complete amputations. All amputations among 10-14 year-olds occurred using the forceps-guided (FG) method, as opposed to the dorsal-slit (DS) method, and three GIs among infants occurred using a Mogen clamp. Of 19 attempted amputation repairs, reattached tissue was viable in four (21%) in the short term. In some cases, inadequate DS method training and being overworked, were found.

Urethrocutaneous fistulas after voluntary medical male circumcision for HIV prevention—15 African Countries, 2015–2019

“…In this analysis, age under 15 years was associated with the occurrence of a VMMC related fistula. The reported rate of fistula occurrence in < 15 year olds is similar to that found for glans injuries in this same age group [23]. This finding is further supported by the biologic plausibility of a younger patient sustaining injury to less mature (smaller) genitalia during VMMC.…”

“…Although the DS method of circumcision was most commonly seen in this analysis, this is likely related to this method being recommended for use in patients < 15 years of age during VMMCs due to the risk of glans injury with the alternative FG method [ 23 ]. Use of the FG method could also be under-documented due to fear of punishment for using it against policy in patients < 15 years old.…”

Urethrocutaneous Fistula Following VMMC: A Case Series from March 2013 to October 2019 in ZAZIC’s Voluntary Medical Male Circumcision Program in Zimbabwe

“…Six of 7 stula cases were among 10-14 year old clients. Adolescent boys are at a higher risk of serious AEs including rare AEs like stula and glans injuries (4,13,17,26). Recent guidelines to limit circumcisions to males 15 years and older for safety and consent concerns (26, 28) may be the most effective control measure to reduce risk of stula in VMMC programs.…”

“…Reported rates of moderate and severe AEs within VMMC programs in sub-Saharan Africa range from 0.1%-8% (4)(5)(6)(7)(8)(9). Common AEs reported in VMMC programs include infections, bleeding, swelling and pain (4,(10)(11)(12), and occasionally severe AEs such as urethrocutaneous stula (subsequently, stula) and glans amputation (13,14). Fistulae are rare in VMMC programs.…”

“…Fistulae commonly occur at the six o'clock position on the distal ventral aspect of the penis where the urethra is closest to the skin. Like other AEs, when stulae occur, they can lead to costly and time-consuming clinical management; reduced quality of life, possible dis gurement, stigma, and emotional distress for the man; and negative community perception of VMMC (13,19). ZAZIC, a consortium of three partners (the International Training and Education Center for Health (I-TECH), Zimbabwe Association of Church related Hospitals (ZACH) and Zimbabwe Community Health Intervention Research Project (ZiCHIRe)), has been implementing VMMC in coordination with the Ministry of Health and Child Care (MoHCC) in Zimbabwe since 2013.…”