<p>Absolute Contraindications to Adult/Adolescent Medical Male Circumcision (MC)</p><p>Anatomical abnormality of the penis: Men whose urethral meatus (external opening of the tube that carries urine from the bladder to the outside of the body) 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.</p><p>Chronic paraphimosis (the foreskin is permanently retracted, thickened, and swollen): The client will indicate that this is a longstanding problem.</p><p>Genital ulcer disease: This should be investigated and treated. Once treatment has been completed, the client may be suitable for medical MC.</p><p>Urethral discharge: This should be investigated and treated. Once treatment has been completed the client may be suitable for medical MC.</p><p>Other obvious visible pathology (e.g., penile cancer): The client should be referred to a specialist.</p><p>Chronic disorders of the penis and foreskin (e.g., filariasis, a parasitic infestation that blocks the lymph ducts and prevents drainage): The client should be referred to a specialist.</p><p>Bleeding disorders (e.g., hemophilia): 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 (for blood clotting), or to give vitamin K or other medication. </p><p>Relative Contraindications to Adult/Adolescent Medical MC (Whether MC can be performed in these circumstances will depend on the experience of the surgeon.)</p><p>A tight foreskin as a result of scar tissue (phimosis): This may make it impossible to retract the foreskin. 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 (head of the penis) and foreskin may also require referral to a specialist.</p><p>Scar tissue at the frenulum (elastic web of tissue that connects the foreskin to the underside of the penis): 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.</p><p>Penile warts (can cause a lot of bleeding): Whether the MC can proceed will depend on the extent of the warts. It is usually possible to proceed with MC if there are one or two small warts on the foreskin, because these will be removed with the foreskin. However, if warts are extensive, MC is best undertaken in a specialist hospital where diathermy (electrocautery) is available.</p><p>Balanitis xerotica obliterans (a plaque of scar tissue that extends onto the surface of the glans and involves the urethral meatus and the foreskin, also called lichen planus et atrophicus): In mild cases, MC can proceed as normal. If the process involves the urethral meatus, the client should be referred to a district hospital or specialist center where, in addition to removing the foreskin, the meatus may be widened.</p><p>Other abnormalities of the genitalia (e.g., hydrocele, a fluid-filled sack in the scrotum that causes scrotal swelling): The patient should be referred to a specialist center for assessment.</p><p>Source: Excerpted and adapted from WHO, UNAIDS, and Jhpiego 2009</p>