2. Objectives
By the end of this lesson, you should be able to:
Define circumcision
Outline indications of circumcision
Outline contra-indications of circumcision
Describe pre-operative preparation
Discuss the various circumcision methods
Discuss post-operative care of circumcision
Identify complications of circumcision
3. Definition
It is the surgical removal of the foreskin
(prepuce) of the penis usually performed
under local anaethesia
- It is an ancient practice that has its origin in
cultural and religious rites
- In many communities, it is often performed
within the 1st two weeks or at the beginning of
adolescence as a rite of passage to adulthood
4. Indications
1. Medical indications
Phimosis- narrowing of preputial opening
Paraphimosis- tight prepuce which ones retracted
fails to return
Prevention of sexually transmitted infections incl.
HIV
Prevention of penile cancer
Prevention of urinary tract infections in boys with
urological abnormalities
6. Contraindications
Absolute contraindications
Prematurity
Hypospadias- urethra opening on ventral aspect of the
penis- preputial skin utilized during surgical repair
Epispadias- urethra opening on the dorsal aspect of the
penis- preputial skin utilized during surgical repair
Micropenis
Concealed or buried penis
7. Contraindications cont.
Webbed penis
Ambiguous genitalia
Chronic Paraphimosis
Genital ulcer disease
Urethral discharge
Penile cancer
Chronic disorders of the foreskin e.g filariasis
Bleeding disorders such as haemophilia
8. Contraindications cont.
Relative contraindications
Scar tissue at the frenulum
Extensive penile warts
Balanitis xerotica obliterans
Sickle cell disease
Other abnormalities of the genitalia e.g hydrocele
9. Pre-operative preparation
Take history
Monitor vital signs
Carefully examine the genitalia
Obtain an informed (written) consent- after
explaining the procedure to the client incl. benefits
and risks
Advice the client to wash the genital area with soap
and water
NB: Shaving of pubic hair is not recommended since
it damages the skin & promotes infections
Assemble the instruments and other supplies
13. Pre-operative preparations cont.
Suture material –chromic catgut 3-0 or 4-0 with
reverse-cutting needle
Sterile gloves, masks, caps and apron
Sterile marker pen or gentian violet solution
Couch bed
14. Procedure
The surgeon/clinician and the assistants should
scrub
Dry hands with a sterile towel and hold the hand
s and arms away from the body & higher than the
elbow until sterile gown and sterile gloves have
been put on
Ensure the instruments and supplies are
assembled
15. Procedure cont.
Let the client remove pants and lay on the coach
Clean the skin with povidone iodine starting with
the glans and the shaft of the penis and moving
out to the periphery, foreskin should be retracted
so as to clean the glans
Drape the patient with ‘O’ drape
16.
17. Procedure cont.
Administering local anaethesia (lignocaine)
Use 1% or 2% lignocaine without adrenaline
Dosage is 3mg per kg body weight
Do a dorsal and ring block
- Dorsal block- on top of the penis near the base at 11 & 1
o'clock sites
- Ring block- administered round on the penile skin taking
care not to give into the penile tissue (corpora)
Release all adhesions between the prepuce and glans
18.
19.
20.
21. Procedure cont.
Marking of the incision site
It is done using either marker pen, gentian violet or
pinches using a toothed dissecting forceps
It is made over the penile skin just proximal to the
corona
A V shaped mark is made at the region of the
frenulum
39. Procedure cont.
Wound closure
Approximate the edges starting with frenulum
region (6 o’clock) and suture with horizontal
mattress suturing technique
Approximate the dorsal region (12 o’clock) with
vertical mattress suturing technique
Approximate the edges at 3 o’clock and 9 o’clock
with vertical mattress sutures
Approximate the regions in between 6,12,3 & 9
o'clock with simple interrupted sutures
40.
41.
42. Procedure cont.
Wound dressing
Clean the site with normal saline
Wrap with suflatulle and then with thin gauze
bandage
Dress with co adhesive bandage
Assist the client wear inner wear with the penis
facing upwards
43. Procedurecont.
Wound dressing
Clean the incision site with normal saline, apply
suflatulle and then sterile gauze and wrap with co
adhesive bandage
44. Post-operative management
Before discharge:
- Monitor vital signs
- Check for bleeding
- Give analgesics
- Record details of the procedure in clients card & in the
register
45. Post operative management
Advise the client to:
Come back if he experiences; bleeding, excessive
pain, fever, swelling, inability to pass urine,
gapping wound and pus discharge
Wear well fitting cotton inner wear
Not to contaminate the site with urine
Remove dressing after 48 hours
46. Post-operative management cont.
Bathe twice daily and clean/take care of the site
Come back for review after 7 days
Avoid sexual intercourse and masturbation for 6
weeks after the procedure to prevent breakdown
of the wound
Use a condom for every sexual activity for at least
6 months
47. Complications
1. During surgery
Excessive bleeding
Accidental injury- associated with forceps guided
method
2. 1 to days after surgery
Bleeding
Haematoma formation
Wound disruption
48. Complications cont.
3. 1-2 weeks after surgery
Wound infection
Wound disruption and cutting out of stitches
Fournier’s gangrene of penis and scrotum
Tetanus infection
4. Late complications
Decreased glans sensitivity
Oversensitivity of glans
Unsightly ragged scar and cosmetic concerns
49. Complications cont.
Persistent adhesions of the corona and inclusion
cysts
Keloid formation
Erectile discomfort
Torsion (misalignment) of the skin of the penile
shaft