Pre-circumcision screening for genital anomalies: 6-year experience from Pakistan

Pre-circumcision genital screening enables early detection of anomalies that contraindicate the procedure and require specialist management. In Pakistan, where most circumcisions are performed by untrained providers, such screening is rarely practiced. This study evaluated the effectiveness of training health workers (HWs) to identify genital anomalies through a structured Safe Circumcision Program (SCP).

A retrospective data review was conducted of all male infants presenting to the safe circumcision clinic at the Indus Hospital & Health Network (IHHN) Karachi between June 2016 to June 2022. Trained HWs screened infants prior to circumcision, referring those with suspected anomalies to pediatric surgeons. Concordance between HW and specialist diagnoses was analyzed using Cohen's Kappa.

Of 9,898 infants screened, 382 (3.9 %) had suspected genital anomalies. Among 310 infants reviewed by specialists, 353 anomalies were confirmed. The most common anomalies were webbed penis (n = 98, 27.8 %), hydrocele (n = 74, 21.0 %), hypospadias (n = 41, 11.6 %), undescended testes (n = 35, 9.9 %), and chordee (n = 34, 9.6 %). Overall concordance between HWs and specialists was 73.1 %. Discordance was mainly due to false positives, particularly in cases of webbing and hypospadias.

With structured training HWs were able to competently identify genital anomalies prior to circumcision, demonstrating feasibility and safety of task-shifting in low-resource settings. Pre-circumcision screening by trained HWs can prevent unsafe procedures and facilitate early referral for specialist care in countries lacking routine newborn screening programs.