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Manual for Male Circumcision Under Local Anaesthesia

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Manual for Male Circumcision Under Local Anaesthesia Male circumcision under local anaesthesia Version 3.1(Dec09) Page i Male circumcision under local anaesthesia Version 3.1(Dec09) Manual for Male Circumcision under Local Anaesthesia Version 3.1 December 2009 Page ii Male circumcision under local anaesthesia Version 3.1(Dec09) Contents Preface vii Acknowledgements ix Photo credits x Financial support x Abbreviations and acronyms used in this manual xi 1. Benefits and risks of male circumcision Summary 1-1 Introduction 1-1 What is male circumcision? 1-1 How circumcision is performed 1-1 Benefits and risks 1-1 Benefits 1-2 Risks 1-2 Male circumcision and HIV infection 1-3 The evidence linking male circumcision and HIV 1-3 Male circumcision and regional differences in HIV prevalence 1-3 Randomized controlled trials to assess the efficacy of male circumcision in reducing risk of HIV infection 1-5 Possible biological explanations for the protective effect of male circumcision 1-5 Protection for women 1-6 Other health benefits of circumcision 1-6 Acceptability of circumcision among African men 1-6 References 1-7 2. Linking male circumcision to other male sexual and reproductive health services Summary 2-1 Men’s sexual and reproductive health needs and services 2-2 Counselling and testing for HIV infection 2-3 Barriers to male sexual and reproductive health services 2-4 Meeting the sexual and reproductive health needs of men 2-4 Men’s roles in women’s and children’s health 2-5 Who should provide sexual and reproductive health services and information to boys and men? 2-6 Detection and treatment of selected male sexual and reproductive health problems 2-7 Sexually transmitted infections 2-7 Balanitis 2-8 Phimosis 2-9 Paraphimosis 2-10 Urinary tract infections 2-11 Infertility 2-11 References 2-12 3. Educating and counselling clients, and obtaining informed consent Summary 3-1 Education about sexual and reproductive health and male circumcision 3-1 Group education script 3-2 Counselling 3-5 Page iii Male circumcision under local anaesthesia Version 3.1(Dec09) Basic facts about counselling 3-5 Confidentiality 3-5 Counselling skills 3-6 Informed consent for surgery 3-10 General 3-10 Adolescent boys: consent and confidentiality 3-11 Documenting informed consent for surgery 3-12 Infant circumcision 3-12 Integration of traditional circumcision events with clinical circumcision 3-12 Appendix 3.1: Additional script for counselling reproductive health 3-14 Appendix 3.2: Sample information sheet for adult and adolescent clients 3-19 Appendix 3.3: Sample certificate of consent for adults and adolescents 3-23 4. Facilities and supplies, screening patients and preparations for surgery Summary 4-1 Equipment and supplies 4-1 Maintenance and review of equipment 4-3 Screening adult clients 4-4 History 4-4 Physical examination 4-4 HIV testing and informed consent for surgery 4-6 Preoperative washing by the patient 4-7 Scrubbing and putting on protective clothing 4-7 Whether to use a gown 4-10 Face masks and protective eyewear 4-10 Appendix 4.1: Sample client record form for adults and adolescents 4-11 Appendix 4.2: Sample disposable consumables for one adult male circumcision 4-15 Appendix 4.3: Detailed anatomy of the penis 4-17 Appendix 4.4: Selected anatomical abnormalities of the penis 4-21 5. Surgical procedures for adults and adolescents Summary 5-1 Surgical skills required for safe circumcision 5-1 Anatomy of the penis and choice of surgical technique 5-1 Tissue handling 5-1 Haemostasis 5-2 Diathermy 5-4 Suture material 5-5 Suturing 5-5 Tying knots 5-9 Skin preparation and draping 5-10 Skin preparation with povidone iodine 5-10 Draping 5-10 Anaesthesia 5-11 Penile nerve supply 5-11 Maximum dose of local anaesthetic 5-12 Safe injection of local anaesthetic 5-13 Additional analgesia 5-13 Ring block technique 5-13 Retraction of the foreskin and dealing with adhesions 5-14 Marking the line of the circumcision 5-15 Surgical methods 5-17 Page iv Male circumcision under local anaesthesia Version 3.1(Dec09) Forceps-guided method of circumcision 5-17 Dorsal slit method of circumcision 5-23 Sleeve resection method of circumcision 5-27 Dressing 5-31 Appendix 5.1: Variations in technique for minor abnormalities of the foreskin 5-33 6. Circumcision of infants and children Summary 6-1 Screening male babies and young boys for circumcision 6-1 Consent 6-2 Preparation 6-2 Anaesthesia 6-2 Safe injection of local anaesthetic 6-3 EMLA cream 6-4 Glucose by mouth 6-5 Vitamin K 6-5 Skin preparation and draping 6-5 Retraction of the foreskin and division of adhesions 6-6 Paediatric surgical methods 6-7 Suture material 6-8 Dorsal slit method for children 6-9 The Plastibell method 6-13 The Mogen clamp method 6-17 The Gomco clamp method 6-20 Appendix 6.1: Information for parents considering circumcision for their child 6-25 Appendix 6.2: Sample consent document for a minor 6-27 7. Postoperative care and management of complications Summary 7-1 Postoperative care 7-1 Postoperative monitoring 7-1 Instructions for the client 7-2 Transfer of client records 7-3 Follow-up visits 7-3 Routine follow-up 7-3 Emergency follow-up 7-4 Recognition and management of complications 7-4 Organizing referrals 7-5 Complications occurring during surgery 7-5 Complications occurring within the first 48 hours after surgery 7-7 Complications that occur within the first two weeks after surgery 7-8 Late complications 7-8 Appendix 7.1: Sample postoperative instructions for men who have been circumcised 7-10 8. Prevention of infection Summary 8-1 Basic concepts 8-2 Standard precautions 8-3 Hand hygiene 8-3 Washing hands with soap and water 8-5 Alcohol-based handrub 8-6 Page v Male circumcision under local anaesthesia Version 3.1(Dec09) Surgical hand scrub 8-7 Personal protective equipment 8-7 Gloves 8-7 Masks, caps and protective eyewear 8-8 Aprons and the surgeon’s gown 8-9 Footwear 8-9 Immunizations 8-9 Safe handling of hypodermic needles and syringes 8-10 Tips for safe use of hypodermic needles and syringes 8-10 Sharps containers 8-10 Processing of instruments, environmental cleaning and management of spills 8-11 Disinfection 8-11 Cleaning 8-12 High-level disinfection 8-12 Sterilization 8-12 Environmental cleaning 8-13 Management of spills 8-13 Safe disposal of infectious waste materials 8-14 Waste management 8-14 Tips for safe handling and disposal of infectious waste 8-14 Disposing of sharp items 8-14 Burning waste containers 8-15 Encapsulating waste containers 8-15 Burying waste 8-15 Post-exposure prophylaxis 8-16 Managing occupational exposure to hepatitis B, hepatitis C and HIV 8-16 Management of exposure to hepatitis B 8-16 Management of exposure to hepatitis C 8-17 Post-exposure prophylaxis for HIV 8-18 Clinic staff should know their HIV status 8-21 9. Managing a circumcision service Summary 9-1 Record keeping, monitoring and evaluation 9-1 Indicators 9-1 What is monitoring? 9-2 What is evaluation? 9-2 Why evaluate male circumcision programmes? 9-2 What is a monitoring system? 9-2 Monitoring performance in male circumcision programs 9-3 Evaluation 9-3 What are “good data”? 9-4 Quality assurance 9-4 Supervision 9-5 The goal 9-6 The style 9-6 The process 9-6 Appendix 9.1: Sample stock card 9-9 Appendix 9.2: Sample stock-taking card for consumables 9-10 Appendix 9.3: Sample male circumcision adverse event form 9-11 Appendix 9.4: Sample male circumcision register 9-15 Page vi Male circumcision under local anaesthesia Version 3.1(Dec09) PREFACE Male circumcision has been performed on boys and young men for many years, primarily for religious and cultural reasons or as a rite of passage to mark the transition to adulthood. Data from cross-sectional epidemiological studies conducted since the mid-1980s showed that circumcised men have a lower prevalence of HIV infection than uncircumcised men. This finding was supported by data from prospective studies that showed a lower incidence of HIV infection in circumcised men than in uncircumcised men. Although the analysis adjusted for cultural and social factors associated with male circumcision, it was not clear from these studies whether promoting male circumcision among men who would not otherwise be circumcised would result in a lower incidence of HIV infection. To address this question, three randomized controlled trials were launched in Kenya, Uganda and South Africa in 2004. The results from the South African study were published in late 2005, and showed a 60% lower incidence of HIV infection among men randomly assigned to undergo immediate circumcision compared with those assigned to delayed circumcision. Confirmatory results from the two other trials were released in December 2006. These data led WHO and UNAIDS to recommend in 2007 that male circumcision should be considered an additional way of reducing risk of HIV infection in men and programmes for safe male circumcision should be expanded rapidly in countries and settings with generalized HIV epidemics and low prevalence of circumcision. There is increased demand for male circumcision in several countries with a high incidence of HIV, but there is little technical guidance on how services can be safely expanded given the limited resources available. Reports of high complication rates following circumcisions performed on young men by traditional circumcisers in southern and eastern Africa are common, but the true incidence is not known. Technical guidance on the provision of safe male circumcision services is therefore necessary.
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