Manual for early infant male circumcision under local anaesthesia

140 Pages·2011·2.52 MB·English

Manual for early infant
male circumcision
under local
anaesthesia
WHO Library Cataloguing-in-Publication Data
Manual for early infant male circumcision under local anaesthesia.
1.Circumcision, Male - utilization. 2.Infant, Newborn. 3.Child. 4.Manuals. 5.Anesthesia, Local. 6.HIV
infections - prevention and control. I.World Health Organization. II.JHPIEGO.
ISBN 978 92 4 150075 3 (NLM classification: WJ 790)
© World Health Organization 2010
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Printed by the WHO Document Production Services, Geneva, Switzerland
Manual for early
infant male
circumcision
under local
anaesthesia
Contents
Abbreviations vi
Definitions vi
Acknowledgements 1
Photo credits 1
Purpose 2
Preface 2
Chapter 1: Male circumcision introduction 3
Chapter 2: Overview of facility and equipment requirements 9
Chapter 3: Group education and individual counselling 12
Chapter 4: Screening for early infant male circumcision 18
Chapter 5: Overview of anaesthesia 22
Chapter 6: Procedure preparation 26
Chapter 7: Overview of surgical devices 42
Chapter 8: Surgical techniques 52
Chapter 9: Postoperative care 77
Chapter 10: Postoperative complications 83
Chapter 11: Standard precautions and instrument processing 91
Chapter 12: Introduction to monitoring and evaluation 99
Chapter 13: Early infant male circumcision service delivery
and programme management 103
Annex 1: Sample checklist for early infant male circumcision equipment 109
Annex 2: Sample information sheet for early infant male circumcision 110
Annex 3: Overview of counselling skills 111
Annex 4: Sample client record form for early infant male circumcision 113
Annex 5: Reported inducers of methaemoglobinaemia 114
Annex 6: Sample checklist for early infant male circumcision procedure 115
Annex 7: Sample consent form for early infant male circumcision 116
Annex 8: Sample documentation form for early infant male
circumcision procedure 117
Annex 9: Overview of suturing and wound closure 118
Annex 10: Sample postoperative information sheet for early infant
male circumcision 120
Annex 12: Sample postoperative bleeding protocol for early infant
male circumcision 122
Annex 13: Sample register for early infant male circumcision 123
Annex 14: Sample monthly site summary form for early infant male
circumcision 124
Annex 15: Essential neonatal and infant care 125
References 127
Abbreviations
AIDS acquired immunodeficiency syndrome
ANC antenatal care
EMLA eutectic mixture of local anaesthetics
HIV human immunodeficiency virus
HPV human papillomavirus
HSV herpes simplex virus
M&E monitoring and evaluation
MNCH maternal, neonatal and child health
PEP post-exposure prophylaxis
PMTCT prevention of mother-to-child transmission
PNC postnatal care
PPE personal protective equipment
UNAIDS Joint United Nations Programme on HIV/AIDS
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund.
USAID United States Agency for International Development
WHO World Health Organization
Definitions
early infant less than 60 days of age
preterm less than 37 completed weeks of gestational age
low birth weight less than 2500 g or 5 lb 9oz
vi
Acknowledgements
This manual is the result of collaborative work between WHO and Jhpiego together with
contributions from a large group of clinical and public health experts. The following people
contributed to the production of the manual:
• Kim Eva Dickson, Julia Samuelson (WHO, Headquarters)
• Tigistu Adamu Ashengo, Kristen Chrouser, Kelly Curran, Emmanuel Otolorin (Jhpiego, USA)
• Anthony Caldamone, David Tomlinson (Brown University School of Medicine, USA)
Special thanks go to the international experts who participated in the Consultation on Neonatal
Male Circumcision: training guidance and service delivery aspects, October 2009, for their insights
and contributions to this document:
• Margaret Agama (UNFPA, South Africa), Raymond Bitchong (Raleigh Fitkin Memorial Hospital,
Swaziland), Kasonde Bowa (University of Zambia, Zambia), Maureen Chilila (Jhpiego, Zambia),
Timothy Hargreave (BUPA Murray Field Hospital, UK), David Linyama (Centre for Infectious
Disease Research, Zambia), Fabian Mwanyumba (UNICEF, Swaziland), Emmanuel Njeuhmeli
(USAID, USA), Sherry Nordstrom (University of Illinois, USA), Theresa Nduku Nzomo (WHO,
Regional Office for Africa), June Odoyo (University of Nairobi, Kenya), Rebeca Plank (Brigham M
a
and Women’s Hospital), Dino Rech (Population Services International, South Africa), David n
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Sokal (Family Health International, USA), Severin Von Xylander (WHO, Headquarters) a
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Thanks also go to the following people who contributed to the manual: r

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• Christopher Bode (Lagos University Teaching Hospital, Nigeria), Jeffrey Greenwald (National a
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Naval Medical Center, USA), Ngozi Onyia (Lagos University Teaching Hospital, Nigeria), Dayo y

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Sowande (Obafemi Awolowo University Teaching Hospital, Ife, Nigeria)
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• Jeffrey Borkan, Roger Fazio (Brown University School of Medicine, USA) t

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• Olugbenga Bejide, Sister Fawole, Yemi Fawole, Cleatus Taiwo, Jeffrey Tomlinson (Catholic a
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Hospital, Ibadan, Nigeria)

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Photo credits m
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Except where otherwise noted, the photographs have been provided by: Anthony Caldamone o
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and David Tomlinson, Brown University School of Medicine, USA; and Christopher Bode, Lagos u
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University Teaching Hospital, Nigeria. d
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Design and layout: Jillian Reichenbach Ott (Genève Design) lo
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Purpose
This manual builds on the World Health Organization’s Manual for male circumcision under local
anaesthesia and focuses entirely on early infant male circumcision. It has been developed by WHO
in collaboration with Jhpiego to help providers and programme managers deliver high-quality safe
infant male circumcision services for the purposes of HIV prevention and other health benefits.
The manual draws from experiences with service provision in Africa, the Eastern Mediterranean
and developed countries and was reviewed by actual and potential providers of male
circumcision services representing a range of health care and cultural settings where demand for
male circumcision services is high.
Preface
Male circumcision is one of the oldest known surgical procedures. Egyptian records show that
male circumcision was being performed as early as 2300 BC. The procedure has been adopted
independently by different cultures all over the world for various medical and non-medical reasons.1
Since the mid-1980s, data from cross-sectional epidemiological studies have shown that
circumcised men have a lower prevalence of HIV infection than uncircumcised men. And, over
the past 5 years, three randomized controlled trials have convincingly demonstrated that male
circumcision is effective in reducing female to male transmission of HIV.2, 3, 4 This opportunity for
disease prevention has resulted in an increased demand for male circumcision in several countries
of high HIV incidence. Guidance for adolescent and adult male circumcision services has been
developed, but technical guidance is lacking on how early infant services can be safely expanded.
There are significant benefits in performing male circumcision in early infancy, and programmes
that promote early infant male circumcision are likely to have lower morbidity rates and lower
costs than programmes targeting adolescent boys and men.
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Chapter 1: Male circumcision introduction
Summary
Male circumcision is the surgical removal of all or part of the foreskin tissue (prepuce)
that typically covers the tip or head of the penis. Derived from the Latin word circumcido,
circumcision means, “cutting around”. During male circumcision, the foreskin is freed from the
head of the penis (glans) and the foreskin is surgically excised.
Figure 1.1. An uncircumcised infant penis (left) and the same penis
two weeks after male circumcision (right).
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Male circumcision is widely practised for religious and traditional reasons, often within the first r
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two weeks after birth or at the beginning of adolescence as a rite of passage into adulthood.5, 6, 7 i
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As a medical procedure, it is performed to treat problems involving the foreskin and as a means a
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to help prevent some diseases. Recently, three randomized controlled trials have convincingly t

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demonstrated that male circumcision reduces female to male heterosexual transmission of HIV. 8,9,10 a
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The decision to have a newborn male circumcised is very personal and should be i
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made after careful consideration of the risks and benefits and cultural, religious, u
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and personal preferences.
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The following information is provided to help families, caregivers, and health-care workers make
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an informed decision about male circumcision. d
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Timing of male circumcision – infancy versus adolescence/adulthood
Male circumcision can be performed at any age. Several factors should be considered when
determining its timing.
One important advantage of infant male circumcision is that the procedure is simpler than
that performed on older boys and men because the penis is less developed and the foreskin
is thinner and less vascular. Healing is quicker and complication rates are lower. The period
of superficial wound healing after infant male circumcision is generally 5−7 days and most
wounds heal completely within 14 days. Performing circumcision in infancy provides several
other advantages:
• the wound typically does not need to be sutured;
• the procedure is not complicated by erections, which can be problematic in adolescent boys
and men;
• infant male circumcision ensures that the wound will be healed before sexual activity begins;
sexual activity can complicate circumcision in adolescents and adult males and can put older
patients who engage in such activity before the wound has healed at higher risk for HIV
transmission.
Another advantage of early infant male circumcision is the reduced risk of urinary tract infections
in the first 6 months of life.11 These infections typically present with signs and symptoms of
systemic involvement and can be associated with significant complications, including sepsis
and renal scarring. The benefit of male circumcision in preventing urinary tract infections in the
first 6 months of life cannot be realized if the procedure is delayed until after infancy. This is
especially pertinent if there is an underlying uropathy, such as vesicoureteral reflux or urinary
tract obstruction.
A concern about early infant male circumcision is that the child cannot give informed consent
for the procedure. Moreover, some of the health benefits, including reducing the risk of HIV
infection, will not be realized until many years later when the person becomes sexually active. If
circumcision is postponed until an older age the patient can evaluate the risks and benefits and
consent to the procedure himself.
Programmes that promote male circumcision in early infancy are likely to have lower
morbidity rates and lower costs than programmes targeting adolescent boys and
men. However, these considerations must be balanced by concerns about consent.
4