Manual for Male Circumcision under Local Anaesthesia

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Male circumcision under local anaesthesia Version 3.1 (Dec09) • swelling of the penis or scrotum. • Examine the operation site to assess healing and ensure that there is no infection. • Treat any complications found during the examination (see below), or refer the client to a higher level. • Ask the client whether he is satisfied with the service provided or has any comments to make that will help improve the service. • Document the follow-up visit in the client’s medical record, including any complaints, diagnosis, treatment and comments. Emergency follow-up Clients who come for an emergency follow-up visit should be seen immediately. Staff should be alert to the possibility of excessive bleeding or infection. At an emergency visit: • Examine the client immediately. Check all areas related to his complaint. • Read the medical record, if available. • Ask the client about the sequence of events since the operation. Ask about: any problems during the surgery or in the recovery period; how problems developed; any increase in discomfort; and any medication taken or other treatments obtained. • Arrange for treatment of any problems that can be handled on an outpatient basis. • Refer the client to a higher level of care for treatment of potentially serious complications. • Note on the client record all problems and actions taken. • Inform the facility where the male circumcision was performed about the emergency follow-up visit (if applicable). RECOGNITION AND MANAGEMENT OF COMPLICATIONS This section describes the complications that can be managed in the clinic setting, and the indications for referral to a higher level of care. If complications occur during or after the circumcision, the team should take the time to inform the client, and if possible his family, Postoperative care and management of complications Chapter 7-4
Male circumcision under local anaesthesia Version 3.1 (Dec09) about what has happened and the plans to deal with the complication. Anxiety and fear of the unknown add to the distress caused by complications. These can be greatly reduced if the client is given clear explanations about what is happening. For example, a complaint of increasing penile pain and fever 4–5 days after surgery is indicative of wound infection. If there are signs of infection on examination, the client should be given antibiotics and the situation reviewed after 24–48 hours, depending on the severity of the complaint. In these circumstances, the client and his family should be told there is an infection, that antibiotics are needed, and when the situation will be reviewed. Organizing referrals A circumcision team working in a clinic setting should have a formal arrangement with the nearest referral centre, so that there are no bureaucratic obstacles when referral is required. When strengthening or establishing national or local circumcision services, adequate funding for referrals should be included as part of the cost of the circumcision service. Many complications can be managed in the clinic setting, but occasionally emergency transfer may be needed. When there is a need for emergency transfer, the following general rules apply: • The client should be transferred by ambulance, lying flat. • The client and his family should be given a full explanation of what is happening and why. • A clear note should be sent to the referral centre with the client. • The client should be told not to eat and, depending on the length of the journey, not to drink, as a general anaesthetic may need to be given at the referral centre. Any accompanying family member should also be given this information. Complications occurring during surgery • Excessive adhesions. If the client has phimosis, so that the foreskin cannot be retracted prior to surgery, there is uncertainty about what will be found once the dorsal slit has been made and the foreskin retracted. If there are excessive adhesions, it may be difficult to separate the foreskin from the glans. Depending on the experience of the circumcision team, it may be better to stop the procedure and refer the man to a hospital. In this situation, the dorsal slit will have to be repaired, using stitches to stop bleeding. It will not be possible to put on a dressing because the man will need to urinate. Nevertheless, the area should be kept as clean as possible. The wound should be covered with a gauze swab, which the man can keep in place by wearing tight underpants. Arrangements should be made for the man to attend the local Postoperative care and management of complications Chapter 7-5
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Manual for Male Circumcision under Local Anaesthesia

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