Abstract
Background
The present study aims to assess the anxiety and pain perception in children receiving virtual reality (VR) interventions before circumcision, as well as the impact of VR on postoperative recovery.
Methods
A total of 160 children undergoing circumcision in the hospital operating room from June 2023 to December 2024 were selected as study subjects. Using the random number table method, the children were divided into the Control and Observation groups, each comprising 80 children. The Control group received routine preoperative care, while the Observation group underwent VR intervention before surgery. Children’s anxiety levels were assessed using the Chinese version of the modified Yale Preoperative Anxiety Scale (m-YPAS) at three distinct time points: upon entering the surgical waiting room (T1), during anesthesia induction (T2), and 1 h post-surgery (T3). During surgery, cardiovascular stress indicators in children were recorded using a multiparameter monitor. Postoperative pain was assessed using the visual analog scale (VAS). Postoperative recovery and complications were observed.
Results
At T1, there was no significant difference in m-YPAS scores between the two groups. The m-YPAS scores were highest at T1 and subsequently declined at T2 and T3. At T2 and T3, the m-YPAS scores of the Observation group were significantly lower than those of the Control group (P < 0.05). During surgery, the Observation group exhibited lower heart rate, systolic blood pressure, and diastolic blood pressure compared to the Control group (P < 0.05). Pain levels were highest for both groups at 1 h post-surgery and then declined at 1 d and 7d post-surgery. Additionally, the Observation group had significantly lower VAS scores at 1 h and 1 d post-surgery compared to the Control group (P < 0.05). The pain resolution time and incision healing time in the Observation group were significantly shorter than in the Control group (P < 0.05). There was no statistically significant difference (P > 0.05) between the two groups in the incidence of postoperative complications, including preputial edema (8.75% vs. 6.25%), incision bleeding (7.50% vs. 6.25%), and incision adhesion (2.50% vs. 1.25%). No adverse reactions such as dizziness, nausea, headache, or visual fatigue were reported in the Observation group during the use of the VR devices.
Conclusion
Preoperative VR intervention helps alleviate perioperative anxiety in children undergoing circumcision, stabilizes intraoperative physiological indicators, and shows potential in reducing early postoperative pain and promoting postoperative wound recovery. This study provides preliminary evidence for VR as a promising and safe non-pharmacological adjunctive intervention. However, further large-scale research is needed to validate the generalizability of its clinical benefits.
Keywords: Circumcision, Virtual reality, Anxiety, Pain, Wound recovery
Background
Preputial diseases rank among the most common conditions in pediatric urology, with a prevalence of 45.3% for redundant prepuce or phimosis [1]. Preputial diseases can lead to prolonged retention of smegma inside the foreskin, triggering balanitis, urinary tract infections, and other complications. In severe cases, redundant prepuce or phimosis even affects penile development in children [2, 3]. Therefore, at an appropriate age, children should receive circumcision surgery as early as possible. Although circumcision is a quick and simple procedure, it can elicit significant psychological distress in pediatric patients. This response is primarily due to their immature physical and emotional development, separation from parents prior to anesthesia, and unfamiliarity with the operating room environment. As a result, they are afraid to undergo the surgery and become less cooperative, potentially affecting short-term surgical outcomes [4, 5]. Furthermore, surgical-induced anxiety and stress can make children more sensitive to pain, leading to unconscious reductions in postoperative activity. This will hinder postoperative recovery and even cause negative effects on their psychological and behavioral development [6, 7]. Therefore, effective strategies are needed to alleviate pain, fear, and anxiety in children undergoing this surgery.
Pain and anxiety can be managed by both pharmacological and non-pharmacological approaches. While sedatives and other medications are commonly used to alleviate anxiety and pain, they may lead to side effects and potentially delay postoperative recovery [8]. Non-pharmacological methods include music, reading, and games as distraction techniques. Since an individual’s attention capacity is limited, pain perception requires the involvement of attention. Distraction techniques have been proven to reduce perioperative pain, fear, and anxiety in children undergoing circumcision [9]. Virtual Reality (VR) is an advanced technology integrating multiple technologies such as computer science, multimedia, and networking. Distinguished by its interactivity, perception, and immersion, VR can construct a multi-sensory, multi-dimensional virtual environment. By wearing VR head-mounted displays (HMDs) and headphones, patients are isolated from external environments and sounds, allowing their mind and body to fully immerse in a dynamic scene-based virtual environment. This helps divert their attention and reduces pain perception [10, 11]. Currently, VR has been gradually applied in psychological care, symptom management, anxiety relief, and pain management. It has shown positive effects in enhancing patient cooperation and satisfaction [12, 13]. Gerçeker et al. [14] have demonstrated the effectiveness of VR in reducing pain during pediatric venous incision procedures. They highlight that further research should explore other potential applications of VR in different clinical settings. This study will evaluate the anxiety and pain perception of children who receive VR interventions before circumcision. Besides, this study will analyze the efficacy of VR in reducing pain perception and anxiety levels, as well as its impact on postoperative wound recovery. The findings of this study aim to provide a reference for children undergoing circumcision on the adoption of appropriate clinical interventions and the clinical applicability of VR.
Subjects and methods
Research subjects
A total of 160 children undergoing circumcision in the hospital operating room between June 2023 and December 2024 were selected as the research subjects. Using the random number table method, the children were divided into the Control and Observation groups, with 80 children in each group. Inclusion Criteria: (1) Undergoing circumcision due to phimosis or redundant prepuce; (2) Aged 6–12 years; (3) Classified as grade I or II according to the American Society of Anesthesiologists (ASA) classification system [15]; and (4) Good overall health condition. Exclusion Criteria: (1) Complicated with chronic infection-related scar phimosis or genitourinary system malformations; (2) Complicated with other surgical contraindications; (3) Presence of mental or psychological disorders, intellectual disabilities, hearing or vision impairments; (4) Non-parental caregivers during the perioperative period. This study was approved by the Medical Ethics Committee of the Affiliated Hospital of Ningbo University School of Medicine (Approval Number: KY20220906), and all guardians of the children provided informed consent. This study complies with the Helsinki Declaration.
The sample size of this study was primarily determined based on previous similar research and clinical feasibility. A comparable VR intervention study [16] included approximately 70 children per group. To ensure sufficient clinical operability and allow for potential participant dropout, the sample size in this study was set to 80 children per group, with a total of 160 children.
Methods
After hospital admission, all children received comprehensive examinations to rule out surgical contraindications before scheduling circumcision. For those complicated with foreskin infections, preoperative treatment with cefotaxime sodium or cefuroxime sodium injections should be administered.
Control group: During the perioperative period, the children received standard nursing care. Prior to surgery, thorough communication was conducted with both the children and their families, including health education on the surgical procedure and related knowledge. Meanwhile, encouragement and emotional support were provided to help alleviate anxiety and fear, thereby fostering a cooperative and positive attitude toward the operation. Before surgery, routine tests were conducted, including complete blood count (CBC), urinalysis, and electrocardiogram (ECG). The surgical site was examined for any skin damage, and the hygienic preparation of the perineum, penis, and foreskin was completed 1 d prior to the procedure. On the day of surgery, the nursing staff met with the children and their families in the surgical waiting room. Printed brochures were provided to the family members to explain the surgical procedure and postoperative precautions, so as to reduce parental anxiety. Furthermore, this also helped family members cooperate with nursing staff to comfort the children and stabilize their emotions. Subsequently, the children were guided into the operating room by surgical nurses, and verbal comfort was provided prior to anesthesia induction.
Observation group: 1 d before surgery, the nursing staff conducted a brief communication with the children and their parents in the hospital ward to understand the children’s interests and personality traits. Based on the children’s usual preferences, videos the children wished to watch were selected. Approximately 20–30 min before surgery, the nursing staff met with the children and their families in the surgical waiting room. Printed brochures were provided to the family members to explain the surgical procedure and postoperative precautions, so as to reduce parental anxiety. This also enabled the family members to better cooperate with the nursing staff in comforting the children and stabilizing their emotions. Next, the children were guided into the operating room by surgical nurses. The nursing staff activated the VR HMDs and adjusted them to the pre-selected virtual scenes based on the children’s interests. The screen was set to a supine viewing position. Before wearing the VR HMDs, the children were fitted with a disposable eye mask compatible with the device to prevent cross-infection. After assisting with wearing the VR HMDs, the nursing staff inquired about the children’s feelings and instructed them to communicate with them at any time if there was any discomfort. The intervention employed the PICO 3 all-in-one HMDs, which are equipped with a remote control and designed for user-friendly operation. The duration of each VR session was controlled within 5–10 min, synchronized with the anesthesia preparation and induction phases. The VR content was specifically designed to promote passive viewing, distraction, and immersive experience. The content library included three categories: (1) Age-appropriate animated short clips featuring colorful visuals and gentle storylines, allowing children to select their preferred content before surgery; (2) Cartoon-style scenes of the surgical environment presented in a friendly and non-threatening manner to reduce unfamiliarity; and (3) Simplified animated demonstrations of the surgical procedures to alleviate fear of the unknown. The VR content adopted a passive viewing-focused model rather than highly interactive games. This helped prevent physical movement, emotional excitement, or vital sign fluctuations in children caused by excessive interaction, thereby ensuring better cooperation and safety during the surgical procedure. Additionally, all content excluded sudden loud noises and rapidly flashing visuals. Anesthesia induction was conducted while the children wore the VR HMDs, during which nurses provided active guidance and verbal encouragement throughout the process. While the children were wearing the VR HMDs, nurses monitored and recorded all adverse events potentially related to the VR intervention (such as nausea, vomiting, dizziness, and eye discomfort).
Both groups underwent intravenous anesthesia using propofol injectable emulsion or fentanyl injection. Following anesthesia, circumcision was performed. Whether to use a disposable circumcision device was determined based on the children’s condition and parental willingness. Additionally, for children with preputial adhesions, a concurrent adhesiolysis was conducted. After the surgery, the wound was dressed using self-adhesive elastic bandages, and antibacterial agents were administered according to medical instructions.
Observational indicators
Anxiety assessment: Anxiety levels of the children were evaluated using the Chinese version of the modified Yale Preoperative Anxiety Scale (m-YPAS) at three key time points: upon entering the surgical waiting room (T1), during anesthesia induction (T2), and 1 h post-surgery (T3). The m-YPAS in this study comprised language, vocalizations, emotional expression, apparent alertness, and dependency on parents. Total scores were converted to a percentage scale, with higher scores indicating greater anxiety levels [15].
Measurement of cardiovascular stress indicators after anesthesia induction: Intraoperatively, systolic blood pressure, diastolic blood pressure, heart rate, and oxygen saturation of the children were recorded using a multiparameter monitor.
Pain intensity assessment: Postoperative pain was evaluated using the visual analog scale (VAS). The specific steps were as follows. A 10 cm horizontal line was drawn on paper. One end of the line was marked 0, indicating no pain, while the other end was marked 10, representing severe pain. The middle section reflected varying degrees of pain. The children were asked to draw a mark on the line corresponding to their feelings, indicating the degree of pain [17]. 1 h post-surgery, the medical staff inquired about the children’s self-assessment scores. 1 d and 7 d post-surgery, the scores were obtained during follow-up visits. The primary outcome indicators (anxiety and pain scores) were assessed by a dedicated research nurse who was unaware of the group allocation. This nurse did not participate in the perioperative care of the children or the VR intervention; instead, he/she only collected scale data at designated time points and remained blind to the group allocation, so as to avoid measurement bias.
Surgical trauma-related recovery indicators and complications: The postoperative pain resolution time and wound healing time were documented. Pain resolution time was defined as the interval from the end of surgery to the last reported pain complaint or request for analgesia. Additionally, postoperative complications such as preputial edema, hematoma, or incision infection were monitored within 7 d postoperatively.
Statistical methods
The data in this study were statistically analyzed using SPSS 20.0 software. Power analyses were undertaken using G*Power 3.1.2. The normality of continuous variables was assessed using the Kolmogorov-Smirnov test. Normally distributed measurement data were expressed as 
±s. Between-group comparisons were conducted using independent sample t-tests, while within-group comparisons across different time points were conducted using paired t-tests. Non-normally distributed measurement data were represented by the median (Q25, Q75). Between-group comparisons were performed using Mann-Whitney U tests, and within-group comparisons across different time points were performed using Wilcoxon signed-rank tests. Count data were expressed as cases (%), and group comparisons were conducted using the χ² test. P < 0.05 was considered statistically significant.
Results
Comparison of general information between the two groups
The comparison of general information between the two groups of children showed no statistically significant differences (P > 0.05), including age, body weight, and ASA classification. See Table 1.
Table 1.
Comparison of general information between the two groups
| Items | Control group (n = 80) | Observation group (n = 80) | Statistical value | P |
|---|---|---|---|---|
| Age (year) | 8.00(6.00, 9.00) | 8.00(7.00, 9.00) | −0.569 | 0.569 |
| Body weight (kg) | 25.66 ± 4.65 | 25.79 ± 4.10 | −0.181 | 0.856 |
| ASA classification | 0.693 | 0.405 | ||
| Ⅰ | 76(95.00%) | 78(97.50%) | ||
| Ⅱ | 4(5.00%) | 2(2.50%) | ||
| Caregivers | 1.765 | 0.184 | ||
| Father | 9(11.25%) | 15(18.75%) | ||
| Mother | 71(88.75%) | 65(81.25%) | ||
| Caregiver`s education level | 0.238 | 0.625 | ||
| Basic education | 51(63.75%) | 48(60.00%) | ||
| High education | 29(36.25%) | 32(40.00%) | ||
| Surgical reasons | 0.642 | 0.423 | ||
| Redundant prepuce | 36(45.00%) | 31(38.75%) | ||
| Phimosis | 44(55.00%) | 49(61.25%) |
Comparison of anxiety levels between the two groups
There was no significant difference in m-YPAS scores between the two groups at T1. The m-YPAS scores were highest at T1 and decreased at T2 and T3. The m-YPAS scores of the Observation group at T2 and T3 were significantly lower than those of the Control group, with a statistically significant difference (P < 0.05). The Cohen’s d for between-group differences was 0.629 at T2 and 0.529 at T3, indicating that the VR intervention produced a moderate-to-large effect in alleviating anxiety during both anesthesia induction and the postoperative period. See Table 2.
Table 2.
Comparison of m-YPAS scores between the two groups
| Group | T1 (scores) | T2 (scores) | T3 (scores) |
|---|---|---|---|
| Control group (n = 80) | 53.37 ± 12.15 | 46.74 ± 10.62* | 38.20(31.38, 45.73)* |
| Observation group (n = 80) | 51.17 ± 11.64 | 40.64 ± 8.67* | 33.15(27.70, 39.50)* |
| Statistical value | 1.166 | 3.980 | −3.237 |
| P | 0.245 | < 0.001 | 0.001 |
| Cohen’s d | 0.185 | 0.629 | 0.529 |
| Power | 0.214 | 0.977 | 0.870 |
Compared to T1, *P < 0.05. T1: Upon entering the surgical waiting room. T2: During anesthesia induction. T3: 1 h post-surgery
Comparison of intraoperative cardiovascular stress indicators between the two groups
Children in the Observation group exhibited significantly lower intraoperative heart rate, systolic blood pressure, and diastolic blood pressure compared to those in the Control group, with a statistically significant difference (P < 0.05). However, there was no significant difference in intraoperative oxygen saturation between the two groups. See Table 3.
Table 3.
Comparison of intraoperative cardiovascular stress indicators between the two groups
| Group | Heart rate (bpm) | Systolic blood pressure (mmHg) | Diastolic blood pressure (mmHg) | Oxygen saturation (%) |
|---|---|---|---|---|
| Control group (n = 80) | 98.28 ± 7.88 | 110.39 ± 9.24 | 75.15 ± 6.30 | 99.00(99.00, 100.00) |
| Observation group (n = 80) | 89.61 ± 7.07 | 102.79 ± 8.56 | 68.53 ± 5.71 | 99.00(99.00, 100.00) |
| Statistical value | 7.319 | 5.397 | 6.965 | −0.600 |
| P | < 0.001 | < 0.001 | < 0.001 | 0.548 |
Comparison of pain levels between the two groups
The VAS scores of both groups were highest at 1 h post-surgery and decreased at 1 d and 7 d post-surgery. The VAS scores of the Observation group at 1 h and 1 d post-surgery were significantly lower than those of the Control group (P < 0.05). There was no significant difference in VAS scores between the two groups at 7 d post-surgery (P > 0.05). The between-group effect sizes (Cohen’s d) at 1 h and 1 d postoperatively were 0.639 and 0.688, respectively, indicating that the VR intervention had a large effect in reducing early postoperative pain. See Table 4.
Table 4.
Comparison of VAS scores between the two groups
| Group | 1 h post-surgery (scores) | 1 d post-surgery (scores) | 7 d post-surgery (scores) |
|---|---|---|---|
| Control group(n = 80) | 5.00(4.00, 5.25) | 3.00(3.00, 4.00)* | 0.00(0.00, 1.00)* |
| Observation group (n = 80) | 4.00(3.00, 5.00) | 2.00(2.00, 3.00)* | 0.00(0.00, 1.00)* |
| Statistical value | −3.999 | −5.529 | −1.843 |
| P | < 0.001 | < 0.001 | 0.065 |
| Cohen’s d | 0.636 | 0.688 | 0.246 |
| Power | 0.960 | 0.980 | 0.448 |
Compared to 1 h post-surgery, *P < 0.05
Comparison of surgery trauma-related recovery indicators between the two groups
The pain resolution time and incision healing time in the Observation group were significantly shorter than those in the Control group, with a statistically significant difference (P < 0.05). See Table 5.
Table 5.
Comparison of surgery trauma-related recovery indicators between the two groups
| Group | Pain resolution time (d) | Incision healing time (d) |
|---|---|---|
| Control group (n = 80) | 4.50(3.00, 7.00) | 11.00(9.00, 13.00) |
| Observation group (n = 80) | 3.00(2.00, 7.00) | 10.00(8.00, 12.00) |
| Statistical value | −3.080 | −2.430 |
| P | 0.002 | 0.015 |
Comparison of postoperative complications between the two groups
There was no statistically significant difference (P > 0.05) in the incidence of postoperative complications between the two groups, including preputial edema (8.75% vs. 6.25%), incision bleeding (7.50% vs. 6.25%), and incision adhesion (2.50% vs. 1.25%). No adverse reactions such as dizziness, nausea, headache, or visual fatigue were reported by children in the observation group during the use of the VR devices. See Table 6.
Table 6.
Comparison of postoperative complications between the two groups
| Group | Preputial edema | Incision bleeding | Incision adhesion |
|---|---|---|---|
| Control group (n = 80) | 7(8.75%) | 6(7.50%) | 2(2.50%) |
| Observation group (n = 80) | 5(6.25%) | 5(6.25%) | 1(1.25%) |
| Statistical value | 0.360 | 0.098 | 0.340 |
| P | 0.548 | 0.755 | 0.560 |
Discussion
Children undergoing circumcision are generally younger, and anxiety is a common psychological response in this population. Anxiety is also a key manifestation of psychological stress reactions. It can lead to reduced compliance, involuntary body movements, and elevated blood pressure in children. Additionally, children’s crying can cause parental anxiety, affecting treatment adherence and postoperative recovery [18]. Therefore, effective interventions to reduce surgical anxiety in children are highly beneficial. Previous studies have verified that playing cartoons and music that children enjoy before surgery can effectively distract their attention, reduce intraoperative fear, and alleviate feelings of loneliness [4, 19].
VR as a non-pharmacological intervention is characterized by its safety, convenience, and engaging nature. Studies have demonstrated its effectiveness in reducing anxiety in patients undergoing colonoscopy, dental procedures, and gynecological oncology treatments [20, 21]. VR is an effective tool for modulating emotional impacts and can exert a positive emotional influence on patients. The therapeutic potential of VR largely stems from its ability to redirect attention away from painful medical interventions. By fully engaging multiple senses, including vision and hearing, VR helps focus children’s attention on the virtual environment, thereby reducing anxiety levels and enhancing treatment compliance [22]. The VR intervention protocol in this study is designed based on specific clinical scenarios and safety considerations. For children about to undergo surgery, maintaining the stability of their physiological status and their cooperation during surgery is of crucial importance. Highly interactive VR experiences may cause physical movements or emotional fluctuations in children, potentially disrupting the medical process. Therefore, the intervention model adopted in this study prioritizes “safe distraction” and “immersion” as its core objectives.
This study used the m-YPAS scores to assess children’s anxiety levels. The results showed that both groups had the highest m-YPAS scores upon entering the surgical waiting room, indicating that the children were generally in a high state of anxiety. This could be triggered by fear of the upcoming surgery, unfamiliar hospital environments, and separation from parents. The Observation group exhibited significantly lower m-YPAS scores during anesthesia induction and after surgery compared to the Control group. These findings demonstrated that VR played a significant role in preoperative intervention. By providing an immersive virtual environment, VR can effectively distract children’s attention and alleviate their tension. This distraction helps shift the children’s focus away from preoperative fear and anxiety, thereby effectively reducing their anxiety scores.
Further observation of intraoperative cardiovascular stress indicators revealed that the Observation group exhibited lower heart rate, systolic blood pressure, and diastolic blood pressure compared to the Control group. Anxiety can excite the sympathetic nervous system, resulting in increased heart rate and elevated blood pressure. By reducing preoperative anxiety, VR attenuates sympathetic nervous system hyperactivity, allowing blood pressure and heart rate to remain relatively stable. This not only facilitates smoother surgical procedures but also benefits postoperative recovery [23, 24]. A study by Hoffman et al. [25] has found that, compared to other pain distraction tools, VR significantly reduces pain and anxiety scores in children with burn injuries during dressing changes. Therefore, VR is a useful tool beyond pharmacological interventions.
Pain is defined as a sensory and emotional experience that causes discomfort to an individual following actual or perceived tissue damage. Analgesia can be achieved by interrupting the body’s normal mechanisms for detecting pain. Previous studies have indicated that the regulation of the descending pain control system may underlie the influence of attention and emotion on pain perception [26, 27]. The interaction between the anterior cingulate cortex and the amygdala can modulate the activity of the descending pain control system and affect pain perception. This finding explains why emotions such as tension and anxiety usually lead to an intensified pain experience in patients. In a study by Chayadi et al. [28] on the effects of attention and anxiety on pain perception, they reveal that attention is significantly correlated with pain perception, and pain-related anxiety serves as a key modulator of the attenuation of attention and pain. VR may thus exert analgesic effects. Through engaging higher-order brain functions such as focus, attention, and memory, VR reduces the cognitive resources allocated to processing pain and anxiety signals. It can also reduce pain sensitivity by diverting attention away from pain via the anterior cingulate cortex [29, 30]. The VR headsets fully cover the children’s visual field, redirecting attention from the unpleasant medical environment to a pleasant and engaging virtual world. This positive emotional engagement may suppress pain-facilitating activity within the amygdala, enhancing analgesic effects and improving regulation of negative emotions [31, 32].
This study revealed that the VAS scores in both groups were highest at 1 h post-surgery and decreased at 1 d and 7 d post-surgery. However, the VAS scores of the Observation group at 1 h and 1 d post-surgery were lower than those of the Control group. These results highlighted that VR also exerts positive effects on postoperative pain management. Preoperative VR application may help children achieve a more relaxed state that persists postoperatively, potentially attenuating pain perception and responses [33]. Reduced pain in children leads to fewer episodes of resistance and crying, thereby enhancing their cooperation during treatment. This improved compliance can, in turn, contribute positively to postoperative recovery [12]. Further follow-up observations in this study demonstrated that the pain resolution time and incision healing time in the Observation group were significantly shorter than those in the Control group. This may be attributed to the decreased pain levels. Pain reduction allows children to resume normal activities earlier, promoting local blood circulation and thereby facilitating incision healing. However, there is no clear consensus on the minimal clinically important difference for the absolute difference in VAS scores among pediatric populations. Nevertheless, the effect size observed in this study (Cohen’s d > 0.5) falls into the moderate-to-large effect range, suggesting that the between-group differences still hold clinical value. Combined with the significantly shortened pain relief duration and incision healing time in the VR group, the analgesic effect of VR intervention is likely to be clinically relevant. Future research should further incorporate more objective indicators, such as children’s functional recovery and analgesic consumption, and compare them with the recognized minimal clinically important difference values. This approach would allow for a more robust and comprehensive evaluation of the clinical significance of VR interventions.
Postoperative complications are an important factor affecting the treatment outcomes of circumcision. Common complications include incision bleeding and preputial edema. In this study, the incidence of postoperative complications such as redundant prepuce edema (8.75% vs. 6.25%), incision bleeding (7.50% vs. 6.25%), and incision adhesion (2.50% vs. 1.25%) was generally low in both groups, with no statistically significant differences observed. These findings indicate that under standardized surgical procedures and nursing protocols, the risk of surgical complications is low, which is consistent with the findings of previous studies on similar surgeries [34]. Additionally, no adverse reactions such as dizziness, nausea, headache, or visual fatigue were reported in the Observation group during the use of the VR devices. The intervention employed non-invasive HMDs that primarily delivered animated content. These devices did not require significant physical movement, thereby increasing their acceptability among the children and their families. Although VR demonstrated beneficial effects in improving children’s anxiety and pain, it is primarily a non-pharmacological measure targeting the preoperative psychological state of children. The mechanism of VR lies in relieving anxiety and pain, rather than directly affecting the biological processes of tissue healing. Furthermore, its direct impact on postoperative complications is limited. The occurrence of postoperative complications may be more closely related to surgical techniques and postoperative care [35, 36]. Nevertheless, the possibility of an indirect effect on surgical complications still exists. When children are in a more relaxed state with less pain, it may be more conducive for parents to perform postoperative cleaning and care. Theoretically, this could create a better environment for incision healing. However, larger-sample studies are needed to explore whether VR interventions exert an indirect effect on the incidence of complications.
This study has several limitations. First, no a priori sample size calculation was performed. Although the total sample size was sufficient to detect differences in the primary outcomes (anxiety and pain scores), the statistical power for analyzing low-frequency outcomes such as complications may be limited. The study was not prospectively registered on an international clinical trial registry platform. However, all prespecified outcome indicators (anxiety scores, pain scores, physiological indicators, and postoperative recovery status) have been fully reported. Moreover, the entire study was conducted under the supervision of the hospital’s ethics committee, ensuring maximal integrity and transparency of the study. Second, although outcome assessors were blinded, blinding was not feasible for the children and intervention providers, which may have introduced performance bias. Third, the absence of preoperative baseline anxiety assessment limits the ability to distinguish between trait anxiety and state anxiety. Additionally, the VAS pain scale used in this study may not be fully appropriate for younger children. Future studies should consider more age-appropriate tools such as the Wong-Baker FACES Scale. Finally, while the personalization of VR content improved participant engagement, it also introduced heterogeneity in the intervention, potentially affecting the precision of effect estimates. These limitations provide important directions for improvement in future research.
Conclusion
Preoperative VR intervention demonstrates potential in alleviating perioperative anxiety and pain in children undergoing circumcision and may also promote the early recovery of postoperative wounds. This study provides preliminary evidence for VR as a promising and safe non-pharmacological adjuvant intervention. However, given the limitations in sample size and methodology, future larger-scale and methodologically rigorous studies are needed to validate the findings of this study and explore in depth the optimal implementation protocol for VR interventions.
Acknowledgements
Not applicable.
Authors’ contributions
Lifeng Shen, Changying Mei and Hongxia Wang analyzed and interpreted the patient data. Anni Xia and Tingting Fu was a major contributor in writing the manuscript. Lifeng Shen and Hong Zhu revised this manuscript. All authors read and approved the final manuscript.
Funding
This research was funded by Zhejiang Provincial Medical and Health Science and Technology Program (2023KY289).
Data availability
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was approved by Medical Ethics Committee of the Affiliated Hospital of Ningbo University School of Medicine (Approval Number: KY20220906), and all guardians of the children provided informed consent. This study complies with the Helsinki Declaration.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Lifeng Shen, Email: 184235127@163.com.
Hong Zhu, Email: zhuhong0418@163.com.
References
- 1.Morris BJ, Matthews JG, Krieger JN. Prevalence of Phimosis in Males of All Ages: Systematic Review. Urology. 2020;135:124–32. 10.1016/j.urology. 2019.10.003IF: 2.1 Q2. Epub 2019 Oct 23. PMID: 31655079. [DOI] [PubMed] [Google Scholar]
- 2.Morris B, Rivin BE, Sheldon M, Krieger JN. Neonatal male circumcision: clearly beneficial for public health or an ethical dilemma? Syst Rev Cureus. 2024;16(2):e54772. 10.7759/cureus.54772. PMID: 38405642; PMCID: PMC10889534. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Naha U, Arora HC, Walton RF, Rosoklija I, Skibley LM, Johnson EK. Neonatal circumcision availability in the United States: a physician survey. BMC Urol. 2021;21(1):148. 10.1186/s12894-021-00911-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Tas FQ, van Eijk CAM, Staals LM, Legerstee JS, Dierckx B. Virtual reality in pediatrics, effects on pain and anxiety: a systematic review and meta-analysis update. Paediatr Anaesth. 2022;32(12):1292–304. 10.1111/pan.14546. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Vinay AP, Karna ST, Ahmad Z, Waindeskar V, Ahmed R, Kuttan KA. Utility of interactive videogame in allaying preoperative anxiety in pediatric surgical patients - a randomized controlled study. J Postgrad Med. 2024;70(4):198–203. 10.4103/jpgm.jpgm_465_24. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Jung MJ, Libaw JS, Ma K, Whitlock EL, Feiner JR, Sinskey JL. Pediatric distraction on induction of anesthesia with virtual reality and perioperative anxiolysis: A randomized controlled trial. Anesth Analg. 2021;132(3):798–806. PMID: 32618627; PMCID: PMC9387568. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Buyuk ET, Odabasoglu E, Uzsen H, Koyun M. The effect of virtual reality on children’s anxiety, fear, and pain levels before circumcision. J Pediatr Urol. 2021;17(4):567.e1-567.e8. 10.1016/j.jpurol.2021.04.008. [DOI] [PubMed] [Google Scholar]
- 8.Lee-Archer PF, von Ungern-Sternberg BS, Reade M, Betts M, Haenke D, Keys A, Rance T, Gibbons K, Long D. The effect of dexmedetomidine on postoperative behaviour change in children: a randomised controlled trial. Anaesthesia. 2020;75(11):1461–8. 10.1111/anae.15117. [DOI] [PubMed]
- 9.Wang X, Liu H, Tang G, Sun F, Wu G, Wu J. The effect of distraction techniques on pain, fear, and anxiety in children undergoing circumcision: a meta-analysis of randomized controlled trials. Am J Mens Health. 2024;18(1):15579883241230166. 10.1177/15579883241230166. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Park JW, Nahm FS, Kim JH, Jeon YT, Ryu JH, Han SH. The effect of mirroring display of virtual reality tour of the operating theatre on preoperative anxiety: a randomized controlled trial. IEEE J Biomed Health Inform. 2019;23(6):2655–60. 10.1109/JBHI.2019.2892485. [DOI] [PubMed] [Google Scholar]
- 11.Domene SS, Fulginiti D, Briceno Silva GD, Frei P, Perez Santiago GA, Gasbarra M, Peters I, O’Connell A, Calderon Martinez E. Virtual reality on perioperative anxiety in pediatric patients: A narrative review. Digit Health. 2025;11:20552076251331304. PMID: 40162171; PMCID: PMC11951881. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Simonetti V, Tomietto M, Comparcini D, Vankova N, Marcelli S, Cicolini G. Effectiveness of virtual reality in the management of paediatric anxiety during the peri–operative period: A systematic review and meta-analysis. Int J Nurs Stud. 2022;125:104115. Epub 2021 Oct 23. PMID: 34781118. [DOI] [PubMed] [Google Scholar]
- 13.Eijlers R, Utens EMWJ, Staals LM, de Nijs PFA, Berghmans JM, Wijnen RMH, Hillegers MHJ, Dierckx B, Legerstee JS. Systematic review and Meta-analysis of virtual reality in pediatrics: effects on pain and anxiety. Anesth Analg. 2019;129(5):1344–53. PMID: 31136330; PMCID: PMC6791566. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Gerçeker GÖ, Binay Ş, Bilsin E, Kahraman A, Yılmaz HB. Effects of virtual reality and external cold and vibration on pain in 7- to 12-Year-Old children during phlebotomy: A randomized controlled trial. J Perianesth Nurs. 2018;33(6):981–9. Epub 2018 Mar 17. PMID: 29559294. [DOI] [PubMed] [Google Scholar]
- 15.Ryu JH, Park SJ, Park JW, Kim JW, Yoo HJ, Kim TW, et al. Randomized clinical trial of immersive virtual reality tour of the operating theatre in children before anaesthesia. Br J Surg. 2017;104(12):1628–33. 10.1002/bjs.10684. [DOI] [PubMed] [Google Scholar]
- 16.Wong CL, Choi KC. Effects of an immersive virtual reality intervention on pain and anxiety among pediatric patients undergoing venipuncture: a randomized clinical trial. JAMA Netw Open. 2023;6(2):e230001. 10.1001/jamanetworkopen.2023.0001. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Erdogan B, Aytekin Ozdemir A. The Effect of Three Different Methods on Venipuncture Pain and Anxiety in Children: Distraction Cards, Virtual Reality, and Buzzy® (Randomized Controlled Trial). J Pediatr Nurs. 2021;58:e54-62. 10.1016/j.pedn.2021.01.001. Epub 2021 Jan 21. PMID: 33485746. [DOI] [PubMed] [Google Scholar]
- 18.Bellieni CV. Neonatal infant pain scale in assessing pain and pain relief for newborn male circumcision. Int J Impot Res. 2023;35(3):282–5. 10.1038/s41443-022-00551-x. [DOI] [PubMed] [Google Scholar]
- 19.Merino-Lobato C, Rodríguez-Gallego I, Pabón-Carrasco M, Romero-Castillo R, Jiménez-Picón N. Virtual reality vs. buzzy®. efficacy in pain and anxiety management during pediatric venipuncture. Systematic review and meta-analysis. J Pediatr Nurs. 2023;73:22–33. 10.1016/j.pedn.2023.08.014. Epub 2023 Aug 19. PMID: 37603924. [DOI] [PubMed] [Google Scholar]
- 20.Schmid BC, Marsland D, Jacobs E, Rezniczek GA. A preparatory virtual reality experience reduces anxiety before surgery in gynecologic oncology patients: a randomized controlled trial. Cancers (Basel). 2024;16(10):1913. 10.3390/cancers16101913. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Chiu PL, Li H, Yap KY, Lam KC, Yip PR, Wong CL. Virtual Reality-Based intervention to reduce preoperative anxiety in adults undergoing elective surgery: A randomized clinical trial. JAMA Netw Open. 2023;6(10):e2340588. 10.1001/jamanetworkopen.2023.40588. PMID: 37906193; PMCID: PMC10618840. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Xiang H, Shen J, Wheeler KK, Patterson J, Lever K, Armstrong M, et al. Efficacy of smartphone active and passive virtual reality distraction vs standard care on burn pain among pediatric patients: a randomized clinical trial. JAMA Netw Open. 2021;4(6):e2112082. 10.1001/jamanetworkopen.2021.12082. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Ahmed AE, Daak LI, Alayidh MA, Filfilan RR, Alathath RM, Rehbini AA, Alshabrami TA, Alqahatani SA, Alzahrani RA, Althobaiti HS. The role of preoperative virtual reality for anxiety reduction in pediatric surgical patients: A systematic review and Meta-Analysis. Cureus. 2025;17(1):e77077. 10.7759/cureus.77077. PMID: 39917152; PMCID: PMC11801400. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Gao Y, Xu Y, Liu N, Fan L. Effectiveness of virtual reality intervention on reducing the pain, anxiety and fear of needle-related procedures in paediatric patients: a systematic review and meta-analysis. J Adv Nurs. 2023;79(1):15–30. 10.1111/jan.15473. [DOI] [PubMed] [Google Scholar]
- 25.Hoffman HG, Meyer WJ 3rd, Ramirez M, Roberts L, Seibel EJ, Atzori B, Sharar SR, Patterson DR. Feasibility of articulated arm mounted oculus rift virtual reality goggles for adjunctive pain control during occupational therapy in pediatric burn patients. Cyberpsychol Behav Soc Netw. 2014;17(6):397–401. PMID: 24892204; PMCID: PMC4043256. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.deCharms RC, Maeda F, Glover GH, Ludlow D, Pauly JM, Soneji D, et al. Control over brain activation and pain learned by using real-time functional MRI. Proc Natl Acad Sci U S A. 2005;102(51):18626–31. 10.1073/pnas.0505210102. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Mayeli A, Misaki M, Zotev V, Tsuchiyagaito A, Al Zoubi O, Phillips R, Smith J, Stewart JL, Refai H, Paulus MP, Bodurka J. Self-regulation of ventromedial prefrontal cortex activation using real-time fMRI neurofeedback-Influence of default mode network. Hum Brain Mapp. 2020;41(2):342–52. Epub 2019 Oct 21. PMID: 31633257; PMCID: PMC7267960. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Chayadi E, McConnell BL. Gaining insights on the influence of attention, anxiety, and anticipation on pain perception. J Pain Res. 2019;12:851–64. 10.2147/JPR.S176889. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Patterson DR, Drever S, Soltani M, Sharar SR, Wiechman S, Meyer WJ, et al. A comparison of interactive immersive virtual reality and still nature pictures as distraction-based analgesia in burn wound care. Burns. 2023;49(1):182–92. 10.1016/j.burns.2022.02.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Liu KY, Ninan SJ, Laitman BM, Goldrich DY, Iloreta AM, Londino AV. Virtual reality as distraction analgesia and anxiolysis for pediatric otolaryngology procedures. Laryngoscope. 2021;131(5):E1714-21. 10.1002/lary.29148. [DOI] [PubMed] [Google Scholar]
- 31.van Spaendonck Z, Leeuwenburgh KP, Dremmen M, van Schuppen J, Starreveld D, Dierckx B, et al. Comparing smartphone virtual reality exposure preparation to care as usual in children aged 6 to 14 years undergoing magnetic resonance imaging: protocol for a multicenter, observer-blinded, randomized controlled trial. JMIR Res Protoc. 2023;12:e41080. 10.2196/41080. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Hoag JA, Karst J, Bingen K, Palou-Torres A, Yan K. Distracting through procedural pain and distress using virtual reality and guided imagery in Pediatric, Adolescent, and young adult patients: randomized controlled trial. J Med Internet Res. 2022;24(4):e30260. 10.2196/30260. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Eijlers R, Legerstee JS, Dierckx B, Staals LM, Berghmans J, van der Schroeff MP, et al. Development of a virtual reality exposure tool as psychological preparation for elective pediatric day care surgery: methodological approach for a randomized controlled trial. JMIR Res Protoc. 2017;6(9):e174. 10.2196/resprot.7617. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Kalyenci B, Benlioglu C, Ölçücü MT, Teke K, Sever S, Çift A, et al. Retrospective analysis of clinical outcomes and early complications of conventional circumcision techniques and thermocautery-assisted circumcision. Sci Rep. 2025;15(1):7139. 10.1038/s41598-025-91730-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Prabhakaran S, Ljuhar D, Coleman R, Nataraja RM. Circumcision in the paediatric patient: a review of indications, technique and complications. J Paediatr Child Health. 2018;54(12):1299–307. 10.1111/jpc.14206. [DOI] [PubMed] [Google Scholar]
- 36.Thorup J, Thorup SC, Ifaoui IB. Complication rate after circumcision in a paediatric surgical setting should not be neglected. Dan Med J. 2013;60(8):A4681 PMID: 23905566. [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.