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.

Conclusion: Following numerous interventions by PEPFAR and other stakeholders, GIs are decreasing; however, they have not been eliminated and remain a challenge for the VMMC program. Preventing further cases of complete and partial amputation will likely require additional interventions that prevent use of the FG method in young patients and the Mogen clamp in infants. Improving management of GIs is critical to optimizing outcomes.

Keywords: Amputation; HIV; Intraoperative complications; Male circumcision.

Fig. 1

Number of glans injuries reported to PEPFAR by country, 2015–2018, N = 36. During 2015–2018, 12.8 million male circumcisions were performed in PEPFAR-supported VMMC programs, 11.0 million of these had a known age recorded, of which 5.3 million were among patients aged < 15 years. * eSwatini, Ethiopia, Lesotho, Rwanda, and Uganda reported no GIs over this time period

Fig. 2

Glans injuries clinical management, PEPFAR-supported VMMC programs, 2015–2018. ^*Two outliers excluded: one was an amputation not diagnosed for 2 weeks and one was a strangulation injury not diagnosed for 4 weeks. ^†Ten cases were known to have been referred but referral time was missing. ^‡Eight cases were known to have been repaired but repair time was missing. ^§Healing well implies reattached tissue was viable for repaired amputations or healing without documented impairment for repaired lacerations. Since long-term follow-up not available in reports, permanent sequelae such as tissue atrophy, scarring, urethral strictures, urethral fistulae, and altered sensation are unknown.