Pediatr Surg Int (2014) 30:333–338 DOI 10.1007/s00383-013-3430-5
ORIGINAL ARTICLE
Newborn circumcision outcomes: Are parents satisfied with the results? Jennifer J. Freeman • Ariel U. Spencer • Robert A. Drongowski • Cosmas J. M. Vandeven Barbara Apgar • Daniel H. Teitelbaum
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Accepted: 1 November 2013 / Published online: 29 November 2013 Ó Springer-Verlag Berlin Heidelberg 2013
Abstract Background/purpose Although physician-reported complications following circumcision are very low, parental satisfaction is not well documented. This study examined parental opinions and compared these with those of the medical professional. Methods Physicians independently assessed complications and cosmetic outcome following the circumcision. Six weeks post-circumcision, parental report of complications, cosmetic outcome, and overall satisfaction were assessed. Results Newborn infants (n = 710) were prospectively recruited and underwent either a Gomco [n = 552 (78 %)] or PlastibellÒ [n = 158 (22 %)] circumcision. Physician assessed complication rates were equivalent (Gomco 4.3 % versus Plastibell 5.1 %; p = 0.67), however, parental assessment found a much lower complication rate for Gomco 5.6 % versus Plastibell 12.0 % (p \ 0.001). There was no difference between who performed the procedure nor between the techniques in regards to parental rating of overall satisfaction (excellent/good: Gomco 96.9 % versus Plastibell 95.6 %, p = 0.45). However, perceived postoperative pain as scored by parents was significantly higher J. J. Freeman (&) A. U. Spencer R. A. Drongowski D. H. Teitelbaum Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA e-mail:
[email protected] C. J. M. Vandeven Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109, USA B. Apgar Department of Family Medicine, University of Michigan, Ann Arbor, MI 48109, USA
in patients undergoing Plastibell procedure (6.4 % too much pain) versus Gomco (2.7 %; p = 0.05). Gomco accounted for 72.7 % of parental cosmetically unsatisfactory cases. Conclusions Clinicians and parents differed considerably in terms of opinion of cosmetic outcome and occurrence of post-operative complications. This study emphasizes the need for clinicians to better understand and address parental concerns before and after circumcision. Keywords Circumcision Redundant foreskin Post-operative hemorrhage Parental satisfaction
Introduction Circumcision is one of the oldest and most common surgical procedures performed worldwide [1]. While the utilization of this procedure varies widely throughout the world, in the United States, from 1999 to 2010, the inhospital newborn (\1 month old) male circumcision rate was about 57.6 % [2]. The National Health and Nutrition Examination Survey (NHANES) between 1999 and 2004 found that 79 % of men 14–59 years old reported being circumcised [2]. Circumcision is performed for medical, religious, cultural, and social reasons. While still an issue that has to be discussed between the physician and child’s family, the American Academy of Pediatrics (AAP) recently reviewed the literature from 1995 to 2010; the AAP found that the preventative health benefits of elective circumcision (such as reductions in risk of urinary tract infection in the first year of life, heterosexual acquisition of HIV and human papilloma virus, as well as the secondary decline in the development of AIDS and penile and cervical carcinoma)
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outweigh the risks of the procedure [3]. While these health benefits are appreciated, globally, circumcision is most commonly carried out for religious and cultural reasons [4]. Although the literature provides a great deal of data on surgical outcomes after newborn circumcision [5–7], very little is known about parental satisfaction following the procedure. Clinical experience suggests that the rate of parental dissatisfaction may be significantly higher than previously reported complication rates imply, but the actual rate has not been precisely measured. In addition, differences in outcomes may relate to the type of circumcision performed. A recent study from India stated that almost 20 % of parents were dissatisfied with the esthetics of the conventional dissection technique versus 2.1 % with the Plastibell device (originally Hollister, Inc, now Briggs Manufactured Products LLE, West Des Moines, IA) [1]. Although there is literature that shows no difference in patient satisfaction with physicians at different levels of residency training [8], there is no literature directly comparing satisfaction following similar procedures performed by different specialties of training (i.e., pediatrician, obstetrician, or a pediatric surgeon). In addition, anecdotal evidence suggests that parents may often express dissatisfaction with the outcome of a circumcision, even though no technical complications occurred. Based on our empiric experience, we hypothesized that short-term parental satisfaction with neonatal circumcision will not correlate with successful circumcision outcomes as judged by clinicians.
Surgical techniques varied between specialties. OBGYN and FP groups used a Gomco device (Gomco Surgical Manufacturing Corporation of Buffalo, NY, USA) and the PS group performed a Plastibell type circumcision. No Mogen clamp devices were used during this time period. Despite differences in operative procedure, both groups used either lidocaine (1 %) or a mixture of Marcaine (0.25 %) and lidocaine (1 %) to preoperatively anesthetize the penis using a dorsal nerve and ring block. Level of practitioner given credit for the case performed the critical aspects of the procedure. The clinician who performed the circumcision independently assessed complications and cosmetic outcome immediately following the circumcision using a provided table. Pain was graded by parents based on how much discomfort they believed their child felt postoperatively while recovering from the procedure. Intraoperative pain control was not assessed. Six weeks post-circumcision, parental report of complications, cosmetic outcome, and overall satisfaction were assessed using an 11-question telephone survey (See Table 1). Overall complication rate included any complication (i.e., bleeding, infection, penile injury, difficulty with urination, etc.) that occurred during the study period. Cosmetic outcome is a rating by the parents or clinicians of how the circumcision looks at the time of data collection. Data are expressed as a tally or the mean ±SD and were analyzed using Chi Square and regression analysis. p \ 0.05 was considered to be significant.
Methods
Results
After acquiring Institutional Review Board (IRB) approval (#2003-0687) at the C.S. Mott Children’s Hospital, male newborn infants and their parents were prospectively enrolled at the time of circumcision. Written parental consent was obtained prior to the surgery. Newborn male infants with hypospadias or any other genital anatomic abnormality and those who had previously undergone any type of genital surgical procedure were excluded from the study. The circumcision was performed by the Obstetric and Gynecology (OBGYN) Department, Family Practice (FP) Department, or the Section of Pediatric Surgery (PS), depending on the site in the hospital and the attending group caring for the newborn. Specifically, circumcisions for healthy newborns were predominately performed by the OBGYN group, unless the infant was delivered or seen for the newborn exam by the FP group. Newborns cared for in the neonatal intensive care unit (NICU) or undergoing cardiac surgery had circumcisions performed by the PS team prior to discharge.
From January 2004 through January 2005, 710 newborn male infants were prospectively recruited and underwent a circumcision using either a Gomco clamp (n = 552; 78 %) or Plastibell device (n = 158; 22 %). Circumcisions were performed by resident physicians (n = 367; 51.5 %), attending physicians (n = 213; 30.0 %), nurse practitioners (n = 129; 18.2 %), or medical students (n = 2; 0.3 %). Overall, an attending physician was present for 60.4 % of procedures (n = 429). Maternal age ranged from 14 to 45 years, with a mean of 29.7 ± 5.6 years (missing data, n = 33). The most common reasons for circumcision were to ‘‘be like dad’’ (69 %) and social acceptance among peers (69 %), which were closely followed by health reasons (59 %). Religious reasons were cited for only 11 % of cases. Clinicians reported 14 minor complications (2.0 %) during the procedure, which were equivalent between the two techniques (p = 0.67), and were uniformly considered irrelevant to the actual outcome of the circumcision. These included extra maneuvers to gain hemostasis, such as
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Table 1 Telephone survey questions and results Questions
Answer Choices
Gomco, n = 552 (%)
Plastibell, n = 158 (%)
p values
Did any of the following reasons influence you to have your child circumcised?
To ‘‘be like dad’’ Religious reasons Health reasons Social reasons Other reasons Excellent Good Fair Poor Very poor No pain Minimal pain Acceptable pain More than acceptable Much more pain Yes No Yes No Yes No Ambivalent Completely satisfied Somewhat satisfied Neutral Somewhat dissatisfied Very dissatisfied Too much bleeding Plastibell did not come off completely Plastibell caused bleeding when it came off Infection Penile Injury Had to seek medical attention for a problem related to the circumcision Difficulty Urinating Other problem Yes Probably yes Neutral/not sure Probably not No Yes No
388 (70) 57 (10) 317 (57) 376 (68) 50 (9) 456 (83) 79 (14) 13 (2) 3 (1) 1 (0) 158 (30) 84 (15) 295 (51) 10 (2) 5 (1) 11 (2) 541 (98) 24 (4) 528 (96) 514 (93) 18 (3) 20 (4) 500 (91) 28 (5) 7 (1) 12 (2) 5 (1) 13 (2) N/A
102 18 103 112 10 121 30 5 1 1 50 18 79 5 6 5 153 4 154 144 5 9 135 14 2 5 2 6 10
0.54
Could you please rate the outcome of your child’s circumcision?
Could you please rate how much pain your child suffered from the circumcision?
Do you think that TOO MUCH foreskin was removed by the circumcision? Do you think that NOT ENOUGH foreskin was removed by the circumcision? Does your child’s circumcision look the way you expected it to look? How do you feel about the result of your child’s circumcision?
I will list a number of possible problems some people experience with circumcision Please respond with either ‘‘yes’’ or ‘‘no’’ to indicate whether you experienced any of these problems at any point since the circumcision
If you were faced with the choice again whether to have your son circumcised or not, would you make the same decision?
As a result of the circumcision, did you have to call the doctor or the clinic, visit the clinic, visit the Emergency room, or go to the doctor?
(65) (11) (65) (71) (6) (77) (19) (3) (1) (1) (32) (11) (50) (3) (4) (3) (97) (3) (97) (91) (3) (6) (85) (9) (1) (3) (1) (4) (6)
N/A
6 (4)
5 (1) 2 (0) 2 (0)
3 (2) 2 (1) 3 (2)
0 (0) 18 (3) 526 (95) 17 (3) 5 (1) 1 (0) 3 (1) 20 (4) 532 (96)
1 6 148 7 0 1 2 19 139
(1) (4) (94) (4) (0) (1) (1) (12) (88)
0.47
0.05
0.38 0.50 0.51
0.41
