Use of herbal formulations for the treatment of circumcision wounds in Eastern and Southern Africa

Medicinal plants used to treat and manage circumcision wounds have remained an integral part of traditional practice in Eastern and Southern Africa. This study reviews the traditional usage of medicinal plants to treat and manage circumcision wounds in Eastern and Southern Africa. Drawing on data from Kenya, Namibia, South Africa and Tanzania, information was collected from different sources including books, theses and electronic scientific search engines such as Scopus, Science Direct, PubMed, SciFinder and Google Scholar. A literature search was also undertaken focusing on medicinal plants used against circumcision wounds that demonstrated antibacterial and anti-inflammatory activities in in vitro studies. Twenty-eight medicinal plants from 15 families are recorded as traditional therapies for circumcision wounds following an extensive literature search. These species used to treat and manage circumcision wounds, and as dressing after circumcision to prevent serious inflammation are mainly (64.3%) members of Amaryllidaceae, Asparagaceae, Asteraceae, Euphorbiaceae and Fabaceae families. Three quarters (75.0%) of these species including Acalypha ornata, Achyranthes aspera, Asparagus africanus, Boophone disticha, Brunsvigia grandiflora, Burkea africana, Colophospermum mopane, Datura stramonium, Dichrostachys cinerea, Helichrysum appendiculatum, H. foetidum, H. longifolium, H. nudifolium, H. pedunculatum, Lippia javanica, Maesa lanceolata, Ptaeroxylon obliquum, Ricinus communis, Searsia natalensis, Triumfetta rhomboidea and Vachellia nilotica have shown antibacterial and anti-inflammatory effects in a set of in vitro models. Further studies are needed such as isolation of phytochemical compounds, in vivo activities, clinical and toxicological studies.


Introduction
Traditional male circumcision is an important cultural ritual in Eastern and Southern Africa. Male circumcision is carried out for cultural reasons, as an initiation ritual and a rite of passage or transition from boyhood to manhood (1)(2)(3)(4). Generally, boys would be taken away from their homes with or without the permission of the head of the families and kept in a secluded place where they will be circumcised and kept for a period of two to four weeks to allow the healing process (1). In Eastern and Southern Africa, traditional male circumcision is seen as a sacred cultural practice, rationalised as a mechanism for the maintenance of social order, associated with ascribed cultural teachings and performance of sexual rites that are sanctioned by society (4,6,7). Approximately 15% of the males aged 15 years or older in Kenya, Namibia, South Africa and Tanzania are circumcised (8)(9)(10). However, an estimated 84% of all Kenyan men are circumcised but the percentage is much lower among the Luo and Turkana ethnic groups with 17% and 40%, respectively (10). In South Africa, several ethnic groups practice male circumcision as a rite of passage from boyhood to manhood and these include Ndebele, Pedi, Sotho, Tsonga, Venda and Xhosa (7,11). The traditional male circumcision procedure is usually performed in a non-clinical setting by a traditional provider with no formal medical training. When carried out as a rite of passage into manhood, traditional male circumcision is mainly performed on adolescents or in early adult life as a shift to puberty, adulthood or marriage (12)(13)(14)(15). Male circumcision is one of the oldest surgical procedures known, and ritual circumcision is the act of severance of the foreskin without anaesthesia (11,(16)(17)(18). Once the foreskin is cut off, the wound is not stitched but bound in traditional medicines to help in the healing process (19)(20)(21)(22)(23). Therefore, traditional male circumcision procedure relies heavily on traditional medicines to Research into medicinal uses, phytochemistry and pharmacological properties of medicinal plants used to treat and manage circumcision wounds offers tremendous potential for developing new pharmaceutical health products and drugs. Although conventional medical circumcision is popular in some urban African cities as the World Health Organisation (WHO) recommended male circumcision as part of a comprehensive programme for preventing human immunodeficiency virus (HIV) transmission in areas with high endemic rates (24)(25)(26)(27)(28)(29)(30)(31), traditional male circumcision is still widely practised in Eastern and Southern Africa (1)(2)(3)(4). Studies are there (29) arguing that the emergency of HIV has brought the ancient traditional male circumcision on spot light as a result of recent studies which have demonstrated that it does not only reduce the rate of HIV infection but the ancient procedure also reduces penile cancer and cervical cancer. This has led to massive male circumcision campaigns in areas with low prevalence of circumcision. However, utilization of traditional medicines will continue to be an important approach to male circumcision in peri-urban, rural and marginalized areas characterized by limited conventional medical services. Moreover, research (32) revealed that medicinal plants are an important component of the daily lives of many people and an important part of the African cultural heritage, and 50% of pharmaceutical drugs and health products in clinical use in the world are derived from natural products isolated from plants. Some of these examples include aspirin derived from a compound called salicin isolated from Salix alba L., artemisin from Artemisia annua L., opium obtained from Papaver somniferum L., paclitaxel from Taxus brevifolia Nutt., quinine, an alkaloid obtained from Cinchona pubescens Vahl and silymarin from Silybum marianum (L.) Gaertn. (32). The ongoing screening of ethnopharmacological properties of Eastern and Southern African plants generated active principles that have great potential in the fight against several global health problems (33)(34)(35)(36)(37)(38). This study, therefore, was aimed at reviewing the traditional usage of medicinal plants to treat and manage circumcision wounds in Eastern and Southern Africa focusing on Kenya, Namibia, South Africa and Tanzania.

Materials and Methods
A systematic search for medicinal plants used to treat and manage circumcision wounds in Kenya, Namibia, South Africa and Tanzania ( Fig. 1) was undertaken using a variety ethnobotanical and ethnopharmacological books (32, [40][41][42][43][44][45] and other ethnobotanical pre-electronic sources such as book chapters, journal articles and scientific publications obtained from the University of Fort Hare library. The research articles were searched using Scopus, Science Direct, PubMed, SciFinder and Google Scholar using the following terms as filters, and were searched both alone and as combinations: "circumcision", "circumcision wounds", "ethnobotany", "medicinal plant", "Kenya", "Namibia", "South Africa", "Tanzania" and "traditional medicine". Each plant species identified by this initial search was subjected to a further literature review to establish its antibacterial and anti-inflammatory activities in in vitro studies. All filtered articles were appraised to determine whether they contain any validated in vitro antibacterial and anti-inflammatory models. Where possible, the common and vernacular names were collected, and all scientific names were confirmed or updated using the Plant List website (http://www.theplantlist.org/). A total of 176 articles published between 1938 and 2021 matched the inclusion criteria and were included in this review (Fig. 2).

Medicinal plant diversity
Twenty-eight medicinal plant species from 15 families are recorded as traditional therapies for circumcision wounds in Kenya, Namibia, South  Africa and Tanzania following an extensive literature search ( Table 1). The preparation methods and application of these species are well documented in the common ethnobotanical literature (32, 39,40,44,45). Generally, the use of these medicinal plants in traditional medicine among ethnic groups in the region is well-known. Only two species, Datura stramonium L. and Ricinus communis L. are exotic in the region and naturalized as weeds (46). These results imply that local communities in Eastern and Southern Africa have enriched their indigenous pharmacopoeia through utilization of exotic and weedy plant species as traditional medicines for circumcision wounds. Previous research on exotic plant species showed that these species are utilized as medicinal plants throughout the world (47)(48)(49)(50)(51)(52). Exotic plants are used as traditional medicines due to their use-versatility applications (53). The majority of medicinal plants (64.3%) used against circumcision wounds are from five families (Fig. 3), and these are Fresh leaves used as antiseptic to induce fast healing after circumcision to prevent external inflammation (57,58,(74)(75)(76) Asparagaceae and Euphorbiaceae (2 species each), Amaryllidaceae and Fabaceae sensu lato (4 species each) and Asteraceae (6 species). The rest of the families are represented by only one species (Fig. 3).

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The plant parts used for making herbal preparations used against circumcision wounds are the bark, bulbs, bulb scales, leaf fibre, leaves, roots, stems, twigs and whole plant (Fig. 4). The leaves are the most frequently used (51.0%), followed by bark and roots (9.0% each), bulbs and bulb scales (8.0% each), whole plant (6.0%), leaf fibre, stems and twigs (3.0% each) (Fig. 4). More than half (60.7%) of the species used to treat and manage circumcision wounds are traded as herbal medicines in local, regional and international   Zimbabwe generates economic opportunities for vulnerable groups living in periurban, rural and marginalized areas (38,(96)(97)(98)(107)(108)(109)(110). It was observed that there is an increased trade both at domestic and international levels for medicinal plants with known phytopharmaceutical, nutraceutical and cosmeceutical properties (111).

Antibacterial and anti-inflammatory activities
Many of the ethnobotanical books and primary studies published in journal articles showed that different plant parts are used to treat circumcision wounds and also used as dressing after circumcision to prevent serious inflammation (  Table 1). All of these species were reported to be effective against one or more bacterial pathogens and also exhibited in vito antiinflammatory activities. It was argued that any medicinal plant species or natural pharmaceutical product to be classified as a good wound healing agent, it should possess antibacterial and antiinflammatory properties among other pharmacological properties (112,113). The wound healing process begins with the polarisation of cells towards the wound, initiation of protrusion and cell migration, which culminate in closure of the wound area (114,115). Most of these plant species used to treat and manage circumcision appear to accelerate the wound healing process. Majority of these species have been as bandages and to sooth the pain and swelling after circumcision for a long time now and are within reasonable reach of the traditional medical practitioners (39). The remaining 25.0% are yet to be evaluated for in vitro antibacterial and antiinflammatory properties. However, these species which demonstrated promising activities in vitro, should be re-evaluated using appropriate in vivo models. It is thus a future challenge to translate the basic ethnopharmacological knowledge gained from antibacterial and anti-inflammatory assays into meaningful data that can be used to further enhance Eastern and Southern African plants used against circumcision wounds.

Traditional male circumcision is an ancient and common surgical procedure in Eastern and Southern Africa
Circumcision has existed since time immemorial and is the oldest surgical procedure performed since before recorded history (15). In South Africa, traditional male circumcision ritual dates back to at least 1886 (14). Scholars distinguished three phases of the circumcision rites which include the preparation of the ritual, followed by a process of seclusion and reintegration (7,161). In the Xhosa cultural circumcision ritual in South Africa, these three stages are clearly identifiable with the initiate (one who undergoes the cultural circumcision ritual) translocated to a temporary hut built which is isolated from the community. Here, the initiate is circumcised and stays for substantial period, during which he heals and is taught about manhood according to the Xhosa tradition. The initiate is welcomed back to the community and the ritual concludes with a celebration of his newly acquired manhood (7). In some ethnic communities in Kenya, South Africa and Tanzania, the ritual is an integral part to many black customs and cultures (2,8,14,162,163). Circumcision is often associated with factors such as masculinity, social cohesion with boys of the same age being circumcised at the same time, self-identity and spirituality (164). Traditional male circumcision also aims at imparting strength and bravery since anaesthetics are not used, therefore, it is expected that during the act of circumcision, the initiate is expected to show that he is not feeling any pain (165). The educational sessions carried out during the ritual are aimed at disseminating traditional knowledge to the initiates, and therefore, passage of ethnic traditions to succeeding generations. Some scholars are of the view that traditional male circumcision rituals have a purpose of moulding individuals into productive and community oriented adults by guiding young people through the important stages of life (166,167). It is only after circumcision that the boy can marry, own property and speak in public gatherings (4,6,7,14,168,169).
In Eastern and Southern Africa, male circumcision appears to be a common practice for a variety of reasons ranging from being an initiation ritual into adulthood, the belief that it enhances sexual pleasure to claims that it lowers the risk of HIV infection, prevents penile and cervical cancer and lowers the risk of urinary tract infection (4,170,171). Studies conducted in sub-Saharan Africa show that there is high acceptability of medical circumcision even among the traditionally noncircumcising communities for health and hygiene reasons (163,(172)(173)(174)(175). Factors associated with the increase of medical circumcision practices amongst the traditionally non-circumcising communities include education, personal health and hygiene, religion and ethnic mixing (172). However, among the Xhosa people in South Africa, traditional circumcision is more highly valued than medical circumcision for reasons of cultural meaning and identity (7,168,169). Similar research carried out in Tanzania, revealed that traditional male circumcision is important to the social organisation and cultural identity of Kurya clans (2). According to an observation (176), traditional male circumcision is a holistic concept characterized by multiple and interconnected dimensions such as religious, spiritual, social, biomedical, aesthetic and cultural. Literature studies revealed that there is increasing demand for male circumcision in Eastern and Southern Africa and future expansion of circumcision services must be embedded within safe, affordable male circumcision procedures, sociocultural and medical determinants of circumcision.

Conclusion
This review highlights some Eastern and Southern African plant species that are widely used to treat and manage circumcision wounds. The documented plant species are therefore, an important aspect of the daily lives of many people and an important part of the Eastern and Southern African cultural heritage. The documented plant species are part of the indigenous or traditional pharmacopoeia which have ancient origins. Studies have reported that some of the species used against circumcision wounds exhibited antibacterial and anti-inflammatory properties in vitro which are the main mechanisms contributing to wound healing. However, further studies are needed such as isolation of phytochemical compounds, in vivo activities, clinical and toxicological studies to evaluate the suitability of these plant species for therapeutic use. Therefore, there is a need to subject these plant species to 522 MAROYI

Vachellia nilotica
Bark, leaves and roots traded in Algeria, Mozambique, South Sudan and Tanzania (38,96,108,110) clinical studies aimed at corroborating the wound healing properties associated with management of circumcision wounds.