Male circumcision has been performed on adolescent boys and men for many years, primarily for religious and cultural reasons, such as a rite of passage to mark the transition to adulthood. Beside compelling scientific evidence is shown that men who are circumcised have a 60% reduced risk of acquiring HIV transmitted through heterosexual contact. This presentation guides to a standardized and save procedure to perform Male Circumcision.

1. Step by Step Practical Guide for Male
Circumcision under Local Anesthesia for
Adolescent Boys and Men
Dr Dirk Grothuesmann MScHI, MDMa & Sister Winie,
http://dg-maternalhealth.de/

3. PREFACE I
• Male circumcision has been performed on adolescent boys and men for many
years, primarily for religious and cultural reasons, such as a rite of passage to
mark the transition to adulthood
• Beside compelling scientific evidence is shown that men who are circumcised
have a 60% reduced risk of acquiring HIV transmitted through heterosexual
contact
• The World Health Organization (WHO) recommends male circumcision as an
additional option for HIV prevention since 2007
• Countries with generalized HIV epidemics were considered priority for
implementing this additional HIV prevention option
© World Health Organization
2018

4. PREFACE II
• Male circumcision should be delivered as part of a minimum package
that includes: information about risks and benefits, counselling on
safer sexual practices, access to HIV testing services and condoms and
management of sexually transmitted infections.
• Male circumcision is provided with full adherence to medical ethics
and human rights principles, including informed consent and
confidentiality.
• Supervision systems for quality assurance should be established along
with referral systems to manage complications.
© World Health Organization
2018

5. Step by Step Practical Guide for Male Circumcision
under Local Anaesthesia for Adolescent Boys and
Men
Objectives of this Power Point Presentation:
• To support male circumcision clinics and providers in providing high-
quality services
• To reducing the risk of adverse events to as low a level as possible.
• To emphasis on preventing the rare but serious life-threatening
adverse events related to bleeding, infection (including tetanus) and
anaesthesia

7. HIV prevention through voluntary medical
male circumcision
© World Health
Organization 2018

8. KEY CONCEPTS AND PRACTICES of
Infection Prevention and Control Practices
• Hand hygiene
• Use of personal protective
equipment
• Environmental cleanliness,
including safe management of
blood or bodily fluid spills
• Decontamination of medical
devices, patient care items and
equipment
• Safe use, handling and disposal
of needles, syringes and sharp
instruments
• Proper disposal of all clinical
waste
• Aseptic practices
• Respiratory hygiene
• Safe management of linens
© World Health Organization 2018

9. Surface anatomy of the penis (uncircumcised
and circumcised)

10. View of the ventral surface (underside) of the penis
with the foreskin retracted to show the frenulum
and coronal sulcus

11. Cross-Section of the Penis

12. Preprocedure skin preparation with povidone
iodine

13. LOCAL ANAESTHESIA
• Local anaesthetic agent(s) most often used is plain lidocaine/
lignocaine 1% or 2%, alone or in combination with plain bupivacaine
0.25% or 0.5%
• The maximum dose of lidocaine/ lignocaine that can safely be given
alone is 3 mg/kg of body weight
• Bupivacaine may be used in clients aged 10 years and older
• Bupivacaine is more potent, and the maximum dose that can be given
is 1.5 mg/kg of body weight—although use of bupivacaine alone is
not recommended

14. Maximum doses of lidocaine/lignocaine (1%)
local anaesthetic agent(s)

15. Maximum doses of lidocaine/lignocaine (1%) and
bupivacaine (0.25%) local anaesthetic agents

16. Maximum doses of lidocaine/lignocaine (2%)
local anaesthetic agent

17. Local anaesthetic techniques
Subcutaneous ring block technique
• The subcutaneous ring block technique involves administering local
anaesthesia around the base of the shaft of the penis, thereby
creating a subcutaneous ring of anaesthetic agent

18. The dorsal nerve block
• In this technique, the anaesthetic agent(s) is deposited close to the
dorsal nerve
• Injection of local anaesthesia for the dorsal nerve block

19. PREPARING THE PENIS FOR SURGERY
Dilation of the aperture of the foreskin
Retracting the foreskin to fully expose the glans, corona
and coronal sulcus, and to separate any adhesion

20. Step by Step Procedure

21. Step by Step Procedure

22. Step by Step Procedure

23. Step by Step Procedure

24. Step by Step Procedure
Cutting the dorsal slit

25. Step by Step Procedure
Cutting of the circumferential at the foreskin

26. Step by Step Procedure

27. Step by Step Procedure

28. Step by Step Procedure
Trimming the inner (mucosal) layer of the foreskin

29. Step by Step Procedure
Alignment of the midline skin raphe on the shaft of the Penis with the line of the Frenulum
The urethra is close the surface in
the 06:00 o’clock position, and this
suture must not be placed too
deeply

30. Step by Step Procedure
Placement of simple sutures between the mattress sutures

31. Step by Step Procedure

32. Step by Step Procedure

33. Step by Step Procedure

34. Step by Step Procedure

35. Step by Step Procedure

36. Step by Step Procedure
Standard dressing

37. POSTOPERATIVE CARE AND MANAGEMENT OF
ADVERSE EVENTS DURING AND AFTER
CIRCUMCISION
• Immediate post-procedure monitoring
• Emergency and unscheduled follow-up
• Routine follow-up at 48–72 hours, seven days and six weeks
• Follow-up education and counselling, to be reinforced at every visit
• Special considerations for younger adolescent boys
• Special considerations for clients who have device-based procedures
• General information and guidance about dealing with adverse events

38. POSTOPERATIVE CARE AND MANAGEMENT OF
ADVERSE EVENTS DURING AND AFTER
CIRCUMCISION
• Keep the dressing in place until the first clinic visit at 48–72 hours
• Keep the wound and dressing dry
• Do not wet the dressing when bathing
• Do not pick or scratch the wound.
• If the dressing comes off at home or gets wet, the client should follow
the clinic’s specific protocols
• Do not remove the wound dressing to urinate
• Wear clean and well-fitting underwear to help keep the dressing in
place

39. References
• MANUAL FOR MALE CIRCUMCISION UNDER LOCAL ANAESTHESIA
AND HIV PREVENTION SERVICES FOR ADOLESCENT BOYS AND MEN
from https://www.who.int › malecircumcision › male-circumcision-
guide-2018
• Personal pictures taken 2019 by http://dg-maternalhealth.de/

41. Aim of my Project
Dr. Dirk Grothuesmann Consultancy
Improving Medical Services like Maternal Health, Gynecological
Services & Others by Training Health Care Providers: Relaying on
standardized training modules I teach evidence-based procedures and
related evaluation tools to local personnel in developed and developing
countries. Completing the programs offered, skills gained enable to
serve people in need in any requested setting. My approaches are
based on a economically, socially, culturally, and environmentally
sustainable foundation.
http://dg-maternalhealth.de/index2.html
http://dg-maternalhealth.de/

42. http://dg-maternalhealth.de/
Dr Dirk Grothuesmann
Consultancy