Manual for Male Circumcision under Local Anaesthesia

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Male circumcision under local anaesthesia Version 3.1 (Dec09) • Do the points meet accurately (crossed points are a common problem with old instruments) • If toothed, are the teeth worn SCREENING ADULT CLIENTS The circumcision team needs to ensure that clients are fit for surgery, are well informed about the surgery and are suitable for circumcision under local anaesthesia in their clinic. If there is any doubt as to a client’s suitability, he should be referred to the district hospital or higher level of care. The circumcision team should take a focused medical history and perform a clinical examination of the penis. Both the history and the examination should be documented (see sample record form in Appendix 4.1). History When taking the medical history, enquire about: • current general health; • whether the client is taking any medicines; • whether the client has any known allergies to medicines; • history of haemophilia, bleeding disorders or anaemia; • any current genital infection, ulcer or penile discharge (see Chapter 2); • whether the client has problems with penile erection or any other concerns about sexual function. There are few medical contraindications to circumcision under local anaesthesia. However, as for all elective surgery, circumcision should not be performed on anyone suffering from an acute disorder, infection or febrile illness. In this case, the operation should be postponed until the problem has been resolved. Physical examination The anatomy and structure of the normal penis are described and illustrated in Appendix 4.3. When examining the penis, retract the foreskin and inspect the glans. The urinary opening (urethral meatus) should be near the tip of the glans, and should not be scarred or diseased. The foreskin should be easily retractable and not inflamed or narrowed. If the penis, glans, meatus and foreskin are healthy, the client is suitable for circumcision in the clinic. Facilities and supplies and preparation for surgery Chapter 4-4
Male circumcision under local anaesthesia Version 3.1 (Dec09) Scrotum (or bag) containing testicles Foreskin covering head of penis A Glans or head of the penis B Urethral meatus (opening of urinary passage) should be at tip of penis Fig. 4.1 Appearance of the normal penis. A: Uncircumcised. B: Circumcised Absolute contraindications to clinic-based circumcision include: • Anatomical abnormality of the penis. Men whose urethral meatus is on the underside of the penis (hypospadias) or on the upper side of the penis (epispadias) must not be circumcised, because the foreskin may be needed in a repair operation (see illustrations in Appendix 4.4). • Chronic paraphimosis. In this situation the foreskin is permanently retracted. It is thickened and swollen, and the client will indicate that this is a longstanding problem (see illustration in Appendix 4.4). • Genital ulcer disease. This should be investigated and treated (see Chapter 2). Once treatment has been completed, the client may be suitable for clinic-based circumcision. • Urethral discharge. This should be investigated and treated (see Chapter 2). Once treatment has been completed the client may be suitable for clinic-based circumcision. • Other obvious visible pathology, such as penile cancer. The client should be referred to a specialist. • Chronic disorders of the penis and foreskin, such as filariasis (a parasitic infestation that blocks the lymph ducts and prevents drainage). The client should be referred to a specialist. • Bleeding disorders, such as haemophilia. The client should be referred to a higher level. Careful preoperative assessment and medical preparation are required, and there may be a need to give a preoperative infusion of factor VIII, or to give vitamin K or other medication. Facilities and supplies and preparation for surgery Chapter 4-5
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Manual for Male Circumcision under Local Anaesthesia

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