Male Circumcision Complications Under-Reported In Malaysia: Experts

Despite MOH’s guidelines and sustained demand for circumcision in Malaysia, there is little oversight of the procedure, experts say.

PUTRAJAYA, March 21 – Experts in the medical community in Malaysia are raising alarm about serious repercussions that may arise from inadequate oversight and potential complications from male circumcision.

A survey by the Malaysia Association of Paediatric Surgery conducted for one month found 120 male patients with post-circumcision complications. The most common complications were bleeding (45 cases), wound infection (36 cases), and inadequate circumcision or when insufficient foreskin is removed (11 cases).

Other complications reported were hematoma or pooling of blood outside the blood vessels (8 cases), wound dehiscence or when a surgical incision fails to heal properly (7 cases), swelling or edema (4 cases), excessive circumcision (4 cases), glans or penile amputation (4 cases), clamp device-related complication (2 cases), trapped penis (1 case), urinary retention (1 case), circumcision of hypospadias (1 case), urethral injury (1 case), and others.

A total of 131 complication reports were recorded among the 120 patients, meaning that some patients were affected by multiple complications.

“Usually, there will be excessive bleeding and excessive cutting, so there are overlaps (in the data). So, for one patient, maybe there are two or three complications,” said Dr Mohd Tarmizi Mohd Nor, a consultant paediatric surgeon at the Raja Perempuan Zainab II Hospital (HRPZ II) in Kota Bharu, Kelantan. “You can imagine, this is a survey for only one month.”

Dr Mohd Tarmizi was speaking at the Malaysian International Circumcision Conference 2022 (MICC22), organised by MyMedikal Healthcare Sdn Bhd on February 25 and 26, 2023.

The survey covered male children from as early as six months to 12 years of age. Conducted from December 9, 2022, to January 3, 2023, the poll involved distributing Google Forms to paediatric surgeons at 13 government hospitals, Dr Mohd Tarmizi said.

The hospitals were Tunku Azizah Hospital (Kuala Lumpur), Sultanah Nur Zahirah Hospital (Terengganu), Melaka Hospital, Tengku Ampuan Rahimah Hospital (Selangor), Sultanah Aminah Hospital (Johor), HRPZ II (Kelantan), Tuanku Ja’afar Hospital (Negeri Sembilan), Sabah Women and Children Hospital, Sultanah Bahiyah Hospital (Kedah), Pulau Pinang Hospital, Raja Permaisuri Bainun Hospital (Perak), Sarawak General Hospital, and Tengku Ampuan Afzan Hospital (Pahang).

Results from the short survey showed that 55 per cent (66 cases) of the 120 patients with post-circumcision complications underwent circumcision at private clinics, while 15 per cent (18 cases) were performed in mosques.

Roughly 7.5 per cent (9 cases) of the circumcisions were done in government hospitals, 6 per cent (7 cases) at home, 3 per cent (4 cases) at klinik kesihatan, and 2.5 per cent (3 cases) at private hospitals. In some instances, circumcisions were carried out in schools, universities, and even potentially in the tok mudim’s house.

In response to a question from CodeBlue on the prevalence of circumcision complications in Malaysia, Dr Mohd Tarmizi said it was difficult to determine based on the limited sample obtained from the survey. However, he thinks that there are likely many more cases than the survey was able to capture as circumcision complications are often not reported.

Malaysia saw an average of 499,640 live births per year over the past decade. Out of this figure, it is estimated that around 150,000 boys require circumcision annually, which places a significant burden on local health authorities.

Dr Mohd Tarmizi said, “We (paediatric surgeons) know that we are not able to handle this.”

Circumcision is a religious obligation in numerous cultures, and it is primarily practised in the Jewish and Islamic faiths. The aim is to promote personal hygiene by removing the foreskin, which may harbour disease.

Male circumcision has been shown to offer protection against a variety of diseases, including urinary tract infections, syphilis, chancroid, invasive penile cancer, and HIV, according to the World Health Organization (WHO). However, as with any surgical procedure, there are risks involved.

In Muslim-majority countries like Malaysia, hundreds of thousands of male circumcisions are performed each year, sometimes as part of mass events that typically include boys aged between 7 and 12. Neonatal male circumcisions have also become more popular.

The Ministry of Health’s (MOH) circumcision guideline for medical assistants (Garis Panduan Berkhatan Teknik Dorsal Slit Penolong Pegawai Perubatan) states that male circumcision procedures should be carried out in a clean, enclosed room to protect patient privacy and minimise the risk of infection.

Additionally, bright lighting is recommended for the procedure, and the use of headlamps is encouraged. These precautions are intended to ensure the safety and wellbeing of patients undergoing circumcision.

Before undergoing circumcision, patients are typically required to complete several forms, including a consent form, a registration form, and a procedure form. These forms allow patients to be fully informed about the procedure and that all necessary information is recorded for the medical team’s reference.

Little Oversight of Circumcision Procedures

Despite MOH’s guidelines and the sustained demand for circumcision in Malaysia, there is little oversight on the procedure, according to Dr Abdul Rashid Masrom, president of the Malaysian Doctor Circumcision Society (Madocs).

“Every year, there will be circumcisions, and the numbers are plentiful. It can go up to about 300,000 children each year. However, most of the procedures are done in private clinics or hospitals and there is no proper oversight.

“In private settings, the doctors are independent, and there are usually one or two doctors. They will decide what will be done, and there are no surgeons to correct them if they make any mistakes,” Dr Abdul Rashid told CodeBlue and Sinar Harian in a brief press conference with MyMedikal Healthcare director Dr Mohamad Salleh Abd Aziz.

“That’s when we decided that we have to do something about this. In Indonesia, Asdoki (Asosiasi Doktor Khitan Indonesia) has been around for 17 years. Here in Malaysia, we (Madocs) were established just recently in August last year.

“We think it’s important to have Madocs so that most importantly, we have an association to keep an eye on the situation around circumcision and the technique that is applied.

“We want our doctors to be trained and taught or have supervision from someone like Dr Mohamad Salleh, who is a surgeon. Knowledge is not static. There are many situations and conditions to learn from.

“We hope that from all the sharing by our experts and doctors who do circumcisions, the procedure will be taught properly and continuously monitored. Only when it’s performed correctly will we have safe circumcisions,” said Dr Abdul Rashid, a family physician.

Dr Mohamad Salleh, a consultant general surgeon at Hospital Islam Az-Zahrah in Bangi, added that, unlike other medical fields or diseases that have conferences and seminars over several days, there are no major conferences in Malaysia dedicated to circumcision.

“The purpose of the MICC is to bring together experts and practitioners from all over the region to share their experiences and knowledge about the latest techniques and create networks between the government, private sectors, and civil societies,” said Dr Mohamad Salleh.

The next MICC conference is scheduled for 2024.

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