Manual for Male Circumcision under Local Anaesthesia

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Male circumcision under local anaesthesia Version 3.1 (Dec09) • chancroid (soft chancre); • syphilis • lymphogranuloma venereum; • granuloma inguinale (donovanosis); • genital herpes; • genital warts (condylomata acuminata). The most common symptom of an STI is pain on urination, a burning sensation in the penis, or an ulcer on the genitals. Male patients who complain of urethral discharge or pain when passing urine should be examined for evidence of a discharge. If none is seen, the urethra should be gently massaged from the ventral part of the penis towards the meatus. Examination of a urethral smear under a microscope may show an increased number of polymorphonuclear leukocytes. In men, a finding of more than 5 polymorphonuclear leukocytes per highpower field (×1000) is indicative of urethritis. A Gram stain may demonstrate the presence of gonococci. If a urethral discharge or genital ulcer is confirmed, the patient should be managed according to local treatment guidelines and procedures (syndromic approach). For both conditions, non-medically indicated male circumcision should be delayed until the condition has been satisfactorily resolved. Balanitis Balanitis is an inflammation of the foreskin and the glans of the penis. The condition occurs most often in men and boys who have not been circumcised and who have poor personal hygiene. The inflammation can occur if the sensitive inside surface of the foreskin is not washed regularly. Symptoms of balanitis include redness or swelling, itching, rash, pain, and foul-smelling discharge. Factors that predispose to or cause balanitis include: • Phimosis. This is a condition in which the foreskin is too tight to be retracted. Dead skin cells, smegma (a white substance excreted by small glands around the corona of the glans penis) and bacteria accumulate under the foreskin. It is difficult to keep the area clean and inflammation can easily develop. • Dermatitis. This is an inflammation of the skin, with irritation, itching and rash, often caused by an irritating substance or an allergic reaction to chemicals in certain products, such as soaps, detergents, perfumes and spermicides. • Infection with the yeast Candida albicans can result in an itchy, spotty rash. • Certain sexually transmitted infections (including gonorrhoea, herpes and syphilis) can produce symptoms of balanitis. Linking male circumcision and other male SRH services Chapter 2-8
Male circumcision under local anaesthesia Version 3.1 (Dec09) In addition, men with diabetes are at greater risk of balanitis. Glucose (sugar) in the urine that is trapped under the foreskin serves as a breeding ground for bacteria. Treatment for balanitis Treatment for balanitis depends on the underlying cause. If there is an infection, treatment should include an appropriate antibiotic or antifungal medication, according to national guidelines. In cases of severe or persistent inflammation, or if there is difficulty in retracting the foreskin, circumcision is usually recommended. If the diagnosis or treatment of balanitis is uncertain, the patient should be referred to a higher level of care. Maintaining good personal hygiene can help prevent balanitis. In addition, the patient should be advised to avoid strong soaps or chemicals, especially those known to cause a skin reaction. Phimosis Phimosis is a condition in which the foreskin of the penis is so tight that it cannot be pulled back (retracted) from the head of the penis (Fig. 2.2). Fig. 2.2 Phimosis showing that the foreskin cannot be retracted at erection Reproduced with permission from www.netterimages.com (image no. 1468). Causes of phimosis Phimosis can occur at any age and may be present at birth. It may be caused by an infection (balanitis) or by scar tissue formed as a result of injury or chronic inflammation. A tight phimosis can interfere with urination, resulting in a thin urinary stream. In extreme cases, urine may collect between the foreskin and the glans, causing ballooning of the foreskin. In this situation an urgent circumcision is necessary, usually using the dorsal slit method. Linking male circumcision and other male SRH services Chapter 2-9
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Manual for Male Circumcision under Local Anaesthesia

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