In its most common form, the term circumcision (posthectomy) designates the total or partial removal of the foreskin [1]. It is practiced on all continents and according to the WHO 30.0% of the world’s male population over the age of fifteen is circumcised [2]. Posthectomy is a surgical procedure indicated for surgical conditions or for the reduction of transmission of Human Immunodeficiency Virus (HIV) from women to men [3] [4] [5]. But most often, it is performed as part of a religious, ethnic or social ritual by personnel of various qualifications: traditional circumcisers, nurses, doctors [2] [6] [7]. Still classified under the rubric of “minor surgery”, circumcision carries immediate health risks and can lead to serious complications. The complication rate in medical settings is between 0.4% and 2.0%. On the other hand, outside any medical environment, the complication rate is much higher and could reach 35.0% to 48.0% [2]. Owon’Abessolo et al. in 2020 found that circumcision accidents constituted 2.0% of urological emergencies at the Yaoundé Central Hospital [8]. The heavy surgical procedures indicated for the correction of complications justify that circumcision, if it is not reserved for expert hands, should be supervised when it is performed [9]. No similar study has been published. Thus, in order to establish a framework for better training of people empowered to perform circumcision; in order to establish a framework for a better training of people authorized to perform circumcision, we carried out this study in order to assess the level of knowledge, attitudes and practices of general practitioners on circumcision and its complications in Central Region District Hospitals.

We conducted a multicenter descriptive cross-sectional study of the CAP (Knowledge, Attitudes and Practices) type which took place from March 9 to June 30, 2021 (16 weeks). Our study covered 25 District Hospitals of the Central Region chosen by lot. The study population were general practitioner, out of 189 physicians. We included 138 physicians present and having agreed to participate in the study. This recruitment was done according to the non-probability sampling model; and the data were collected in four stages: The first being based on the selection by lot of 25 district hospitals out of 29 present. The second stage was based on the distribution of work by district hospital; 5 working days in some and 3 working days in others. The third step included the list of general practitioners and the fourth step, the strategy of inclusion of the study populations. The variables collected were: socio-demographic characteristics: age, sex, region of origin, marital status, religion, number of years of service; knowledge about circumcision and its complications; attitudes towards circumcision and its complications; practices regarding circumcision and its complications. We entered the data in Census and Survey Processing System (CSPro) version 7.5 analysis software and analyzed using Statistical Package for Social Science (SPSS) version 23.0.

The majority of general practitioners who participated in the study were women. This reflects the sex ratio at the level of higher education in Cameroon. On the other hand, according to Ekenze et al., in Nigeria, there were more men (85.3%) than women [10]. The young age of the participants explained why professional seniority was reduced with a median of 3 years.

Almost all of the participants knew how to define circumcision. However, the contraindications for circumcision were not sufficiently known. The et al. found that no participant could correctly identify all the contraindications for circumcision [11]. The majority of general practitioners recommended having the child circumcised after the neonatal period. Machmouchi et al. in their series in Saudi Arabia in 2007 found that circumcision at 5 months resulted in significantly fewer serious complications than circumcision in the neonatal period [12]. However, circumcision in the neonatal period is favored by Warner [13]. According to Mouafo in Cameroon in 2012, the variability of age can be explained by the fact that in African countries, the age of circumcision is dependent on the habits and customs of the populations. Thus in our environment, circumcision is practiced late in early childhood and constitutes a sacred act which confers on the child the recognition of his belonging to the male sex, and the anticipation of a flawless sexuality to the child adulthood [14]. Complications of circumcision are very common in our study. This corroborates what Sylla found, who explained this by the fact that circumcision was still carried out in the vast majority

of cases, in a traditional way or by unqualified paramedical agents. The knowledge of general practitioners about circumcision and its complications was insufficient. This knowledge came mainly from colleagues and not from basic or continuing education. While, Ekenze et al. in Nigeria in 2015 found that 36.2% had received formal training in circumcision [10]. In the USA, Le et al. revealed that 44.0% had received formal training [11]. Demaria et al. emphasized the importance of proper training and follow-up [15].

Our study shows that the general practitioners questioned rarely explained the procedure to parents before performing the procedure. According to the American Academy of Pediatrics in 2012, clinicians should explain the potential benefits and risks of circumcision before circumcision is performed [16]. The attitude of doctors to a complication was often inadequate. Surgical exploration for intractable bleeding was not the rule for all participants. Surgical management for an infection or glans amputation was not known to all general practitioners. The majority of the doctors questioned proposed firstly to do a “counseling” relating to the respect of care in the postoperative period, then to carry out the dressing only in the hospital, and finally to prohibit the application of vegetable substances on the circumcision wound. This is consistent with what the American Academy of Pediatrics recommended in 2012 [16]. Overall, the majority of respondents had bad attitudes towards circumcision and its complications, which reflects their lack of initial and continuing training.

Half of the participants could not describe the normal procedure for performing a circumcision. A significant proportion of physicians performing circumcision were unaware of the technique they had used. According to Ekenze et al. a significant proportion of physicians faced with circumcision felt that their training was not optimal enough [10]. The average number of circumcisions performed per year was low. According to Demaria et al. 48.0% of non-surgeons performed more than 50 circumcisions per year [15]. This can be explained by the fact that in our environment circumcision is much more practiced by paramedics and traditional circumcisers in out-of-hospital settings. Local anesthesia was the most used. Dorsal penile nerve block with ring block is the most effective technique for providing anesthesia during neonatal circumcision [17]. In our survey, 38.1% of general practitioners who performed circumcision had already had a complication at least once. In a series including 29 cases of circumcision complication, Diabaté et al. had objectified 7.0% of circumcisions made by doctors [18]. According to the participants, 16.2% were comfortable during the management of the bleeding, none were comfortable during the treatment of the stenosis of the urethral meatus versus 63.0% and 10.0% respectively of non- surgeons according to Demaria et al. in Canada [15]. According to Mouafo et al. in his study in 2016 on circumcision accidents at the gynecology-obstetrics and pediatric hospital in Yaoundé, the accidents generated by the untimely practice of circumcision in our environment are numerous and serious enough for circumcision to be considered an act surgery in its own right [9]. Faced with the observation of inadequate practices vis-à-vis circumcision and its complications, the time has come to study the proposals of authors such as Dieth et al. in Côte d’Ivoire in 2008 which would consist of integrating circumcision into the programs of medical students [19]. Because of the limitation of our study, we were unable to go through all the 28 District Hospitals of the Central Region. The study is limited to 25 District Hospitals in the Central Region. In addition, nothing guarantees the objectivity of the answers given by the participants of this study. Similar studies should be carried out in other regions of Cameroon with a larger sample size to generalize the results.

At the end of our study, it appears that the majority of general practitioners have not received formal education on circumcision. This can result in a lack of knowledge of contraindications, complications of circumcision, the performance of inadequate surgery and the lack of satisfactory pre and postoperative care.

The authors declare no conflicts of interest regarding the publication of this paper.

René, B.P., Achille, M., Daniel, B.B., Joël, K.A., Cyprien, Z., Belemlilga, G.L.H., Yabré, N., Keita, N. and Magloire, B.S. (2021) Knowledge, Attitude and Practice of General Practitioners on Circumcision and Its Complications in the District Hospitals of the Center Region. Open Journal of Urology, 11, 509-517. https://doi.org/10.4236/oju.2021.1112051