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Circumcision
Circumcision is a procedure to remove the hood or foreskin of the penis called the prepuce, which has large concentrations of receptor cells where HIV attaches to infect men called Langerhan cells. As a result, the head of the penis (glans penis) is exposed. Circumcision has been proven to have a huge benefit in reducing the transmission of HIV and other Sexually Transmitted Infections (STIs). The other benefit of the procedure is that the penis is easier to clean, which lowers the risk of developing urinary tract infections (UTIs), foreskin trauma and infections and enhances good genital hygiene.

Indications for Circumcision
The major medical indication for circumcision is the reduction of the risk of contracting and transmission of HIV and STIs in men and their partners and correcting foreskin conditions such as phimosis, and paraphimosis, which is a surgical emergency.
The other indications for circumcision are for cultural or religious practices, especially among many ethnic groups in Africa, Asia and particularly in South Africa, where circumcision is a ritual of passage to manhood. Phimosis is a condition which prevents the foreskin from retracting over the head of the penis. It is a very common condition in boys up to about seven years of age. It may persist beyond this age. Discolouration or redness around the penis, swelling due to infection, pain, and discomfort when urinating can worsen when phimosis is left untreated.
Paraphimosis is a surgical emergency which occurs when the retracted foreskin becomes trapped and cannot be released beyond the head of the penis. The swelling forms a very tight ring around the neck of the penis (corona) and, if left untreated, can cause more swelling and intense painful discomfort and infection of the foreskin. Urgent surgical intervention is needed to prevent these complications.
Procedure
Generally, circumcision is a safe procedure that can be performed from as early as the 1st week after birth in male infants, as is the practice in many cultures of the world. After infancy, it can also be safely performed in any age group up to adulthood.
First, the penis is cleaned with an antiseptic solution, and an anaesthetic cream may be applied to numb the base of the penis before the local anaesthetic solution is injected. Local anaesthesia for adult males includes the use of a dorsal penile nerve block. The anaesthetic solution, Lidocaine, often mixed with Bupivacaine, is injected into the penile base into Buck's fascia, a point where the dorsal nerves sprout from the pubic bone and also as a ring block around the base of the penis to allow a pain-free procedure. Local anaesthetics with Adrenaline are NEVER USED for this purpose as that can cause gangrene of the penis!!!
Dr Okeke then removes the foreskin from the penis’ head using different surgical methods such as a Forceps guided, Dorsal slit or Gumco clamps. Plastibells are used for infants. Other circumcision techniques are Sleeve resection, Tara-Klamps or the use of other clamping devices. In some of these methods, bleeding blood vessels are tied off or cauterised with a diathermy machine, and an absorbable stitch is put in to keep the wound edges approximated for excellent healing and to prevent further bleeding.
Finally, the last stage of the procedure involves applying ointment and wrapping gauze around the penis. The entire procedure takes about twenty minutes to complete.
Recovery
You may experience some level of pain after the procedure. Dr Okeke will advise on post-operative care and follow-up dates which are part of the information leaflets handed to the patients or their caregivers in cases of minors.
In most cases, the primary wound healing is complete on the 7th-day follow-up visit post-circumcision. The stitches would fall off on their own and do not need to be removed.
Advice is given on when it is safe to return to school, work, and sports and when to resume intercourse. A baby undergoing the procedure will require close supervision until the area has healed entirely.
Regardless of age, the surgical area is given about 8-10 days to heal completely. It is normal to experience redness (inflammation) and swelling around the penis. In addition, a fine yellow film may develop at the penis' tip.
Care for a baby boy might be slightly different. As a result, you need to follow these post-operative guidelines:
- Change the diaper as often as they are soiled with urine or faeces
- During a diaper change, apply Vaseline
- Wash the site gently
- Take medication as prescribed and breastfeed regularly
In an infant boy, applying petroleum jelly to the penis' head is essential after every nappy change to prevent the scab from attaching to the nappy. It is also vital to avoid using surgical wipes to clean the penis. Instead, sprinkle water over it and use a soft towel to pat the area dry.
FAQ
A pre-circumcision consultation is needed with Dr Okeke, where the patient for a baseline clinical examination to determine fitness for circumcision, genital abnormalities, infection and chronic diseases that may need treatment before the procedure. Screening for HIV infection, Diabetes Mellitus, Hypertension, Bleeding disorders, Sexually Transmitted Infections (STIs) are also carried out.
If the patient has severe abnormalities in the Penis, foreskin or scrotum, such as undescended testes, Hypospadias, Epispadias, Inguinal hernias, Severe genital warts or genital ulcers, the patient is referred to a Urologist to address the problem.
Informed Consent for the procedure is obtained and signed after explaining the procedure, benefits and complications to the patient or the caregivers in cases of minors. Then the date of the procedure is agreed upon and set up.
When you neglect to follow post-operative care advice from the doctor, the following complications may occur:
- Bleeding
- Surgical infection
- Bad reaction to the anaesthetic used
- The opening of the penis can become inflamed (meatitis)
- Pain in the circumcision wound.
- Swelling of the head of the penis, especially if the penis is not held upwards with the dressing in the first few days after the procedure or if the dressing is tightly applied or if there is wound infection from poor hygiene.
Circumcision has several benefits, which include the following:
Circumcision reduces HIV transmission in men by about 60% and also reduces the risk of other Sexually Transmitted Infections (STIs)
Circumcision is linked to the reduction of the risks of Penile and Prostate cancers in males. Circumcision is associated with reducing the risks of transmission of the Human Papilloma Virus (HPV), which is linked to 100% of Cervical cancers in females. HPV is also linked to the incidence of 90% of Anal Cancers and 40% of Cancers of the Penis, Vulva Vagina.
Circumcision lowers the risks of Urinary Tract Infections (UTI) and balanoposthitis, a condition that irritates the foreskin and glans and phimosis and paraphimosis, which prevent retraction and return of retracted of the penis’ foreskin, respectively.
Dr Okeke performs circumcision all year round at all seasons as the reliance on cold weather to prevent bleeding is not necessary. Healthcare workers who are trained in performing circumcision use surgical means to stop bleeding blood vessels either by tying off the bleeding vessel or using diathermy cautery to stop the bleeding. Wound edges are also sutured to prevent bleeding from the skin edges or underlying tissues. Due to the inconvenience of pain and hygiene needs after circumcision, it is advisable that the procedure be performed when the child is on holiday for about at least a week or more or when a working adult is on leave from his usual work.
Most of the major Medical Aids would not require an authorisation for circumcision as it is performed as a day procedure outside the hospital. The procedure comes off the Medical Aid Savings or day-to-day benefits. Some medical Aids may require authorisation. Please cross-check with your Medical Aid if you need authorisation before booking the procedure.

ADDITIONAL SERVICES
Additional services available at Milestone’s Family Practice include:
Early antenatal care and sonars
Women's Health, pap smears, contraceptive pills, patches and implants, as well as intrauterine devices insertions and removals
Minor surgical procedures
Minor fracture and sprain management
Corporate and general medical checks
Intravenous fluid rehydration therapy, iron infusions, vitamin injections and jet fuel therapy
The family physician sees himself or herself as part of a community-wide
network of supportive and health-care agencies.
Prof. Ian McWhinney