Manual for Male Circumcision under Local Anaesthesia

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Male circumcision under local anaesthesia Version 3.1 (Dec09) There are a number of relative contraindications to clinic-based circumcision. Whether circumcision can go ahead in these circumstances will depend on the experience of the surgeon. They include: • A tight foreskin as a result of scar tissue (phimosis). This may make it impossible to retract the foreskin (see illustration in Appendix 4.4). If there is a history of penile discharge or repeated infections (balanitis), the client should be referred to a specialist. Thick adhesions between the glans and foreskin may also require referral to a specialist. • Scar tissue at the frenulum. Sometimes young men suffer from repeated tearing of the frenulum. This can result in thick scar tissue in the frenulum area and may make circumcision and healing more difficult. • Penile warts. Penile warts can cause a lot of bleeding. Whether the circumcision can proceed will depend on the extent of the warts. It is usually possible to proceed with circumcision if there are one or two small warts on the foreskin, as these will be removed with the foreskin. However, if there are extensive warts, circumcision is best undertaken in a specialist hospital where diathermy is available. • Balanitis xerotica obliterans. This is a plaque of scar tissue that extends onto the surface of the glans and involves the urethral meatus and the foreskin. It is also called lichen planus et atrophicus. In mild cases, circumcision can proceed as normal. If the process involves the urethral meatus, the client should be referred to a district hospital or specialist centre where, in addition to the foreskin being removed, the meatus may be widened. • Other abnormalities of the genitalia, such as hydrocele causing scrotal swelling. The patient should be referred to a specialist centre for assessment. HIV testing and informed consent for surgery All men requesting circumcision for HIV prevention should be offered an HIV test, and appropriate post-test counselling. The purpose of this test is to ensure that more people in the community know their HIV status and are thus better able to take care of themselves, either to remain free of HIV infection, or to take medicine that will slow the progression to AIDS. While an HIV test is recommended for all men requesting circumcision to reduce their risk of HIV infection, the test is not mandatory before the operation can be performed. No person should be forced to have an HIV test against his or her will, and men have the right to refuse without affecting their clinical care. The purpose of the HIV test is not to protect the clinic staff from HIV infection – they should, in any case, take Facilities and supplies and preparation for surgery Chapter 4-6
Male circumcision under local anaesthesia Version 3.1 (Dec09) standard precautions to avoid infection with HIV and other organisms, and to avoid passing such infections from one patient to another. Men who are found to be infected with HIV can safely have a circumcision procedure, provided they are clinically healthy, but there is no point in having a circumcision to reduce the risk of acquiring or transmitting HIV infection. It is most important that men with HIV infection take steps to reduce the likelihood of transmitting the virus to others by avoiding penetrative sexual intercourse or always using condoms. The circumcision team should ensure that the client has been informed about the risks and benefits of male circumcision as described in Chapter 3. This information should be given in an understandable way, using everyday local language. The oral information should be backed up by written information sheets in the local language. After receiving the information the client should be allowed to ask questions. He should then be given time to reflect before being asked to sign the certificate of consent. An example information sheet and consent certificate can be found in the appendices to Chapter 3. PREOPERATIVE WASHING BY THE PATIENT On the day of surgery, the client should wash his genital area and penis with water and soap, retracting the foreskin and washing under it. This ensures that the genital area is clean before he comes to the clinic. Immediately before the operation, the skin should be further cleaned with povidone iodine (see Chapter 5). If the pubic hair is long and likely to get in the way of surgery or interfere with the dressing, it should be clipped before the patient enters the operating room. The patient can do this at home on the day of surgery, or it can be done at the clinic. Shaving is not necessary. The patient should be given the opportunity to empty his bladder before going into the operating room. SCRUBBING AND PUTTING ON PROTECTIVE CLOTHING Before entering the operating room area, all members of the surgical team should: • Remove all jewellery and ensure nails are trimmed or filed. • Remove any artificial nails or nail polish. • Wash hands and arms up to the elbow with a nonmedicated soap. • Make sure hands and nails are not visibly soiled. Before the circumcision operation, anyone who will touch the sterile surgical field, the surgical instruments or the wound Facilities and supplies and preparation for surgery Chapter 4-7
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Manual for Male Circumcision under Local Anaesthesia

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