Circumcision

What is the evidence base for this information?

This leaflet includes advice from consensus panels, the British Association of Urological Surgeons, the Department of Health and evidence based sources; it is, therefore, a reflection of best practice in the UK. It is intended to supplement any advice you may already have been given by your urologist or nurse specialist as well as the surgical team at Addenbrooke’s. Alternative management options are outlined below and can be discussed in more detail with your urologist or specialist nurse.

What does the procedure involve?

This is the surgical removal of the foreskin and is only indicated for disease or tightness of the foreskin itself.

What are the alternatives to this procedure?

Conservative management (observation), topical cream to relieve inflammation.

What should I expect before the procedure?

You will usually be admitted on the same day as your surgery. You will normally undergo pre-assessment on the day of your clinic or an appointment for pre-assessment will be made from clinic, to assess your general fitness, to screen for the carriage of MRSA and to perform some baseline investigations. After admission, you will be seen by members of the medical team which may include the consultant, junior urology doctors and your named nurse.

You will be asked not to eat or drink for six hours before surgery and, immediately before the operation, you may be given a pre-medication by the anaesthetist which will make you dry-mouthed and pleasantly sleepy.

Please be sure to inform your urologist in advance of your surgery if you have any of the following:

• an artificial heart valve
• a coronary artery stent
• a heart pacemaker or defibrillator
• an artificial joint
• an artificial blood vessel graft
• a neurosurgical shunt
• any other implanted foreign body
• a prescription for warfarin, aspirin, rivaroxaban, dabigatran, apixaban, edoxaban or clopidogrel, ticagrelor or blood thinning medication
• a previous or current MRSA infection high risk of variant CJD (if you have received a corneal transplant, a neurosurgical dural transplant or previous injections of human derived growth hormone)

What happens during the procedure?

A full general anaesthetic (where you will be asleep throughout the procedure), a spinal anaesthetic (where you are awake but unable to feel anything from the waist down) or a local anaesthetic injection around the penis may be used. All methods minimise pain; your anaesthetist will explain the pros and cons of each type of anaesthetic to you.

Local anaesthetic is also injected into the base of the penis to aid pain control after the operation; this can be used as the sole form of anaesthesia in some patients. All methods minimise post-operative pain.

The tight part of the foreskin will be removed using an incision just behind the head of the penis. This leaves the head of the penis exposed with no redundant skin.

What happens immediately after the procedure?

You may experience discomfort for a few days after the procedure, but painkillers will be given to you to take home. Absorbable stitches are normally used which do not require removal.

Vaseline should be applied to the tip of the penis and around the stitch line to prevent the penis from adhering to your underclothes and it is advisable to wear light clothing for two to three days. Passing urine will be painless and will not be affected by the operation.

The average hospital stay is less than one day.

Are there any side effects?

Most procedures have a potential for side effects. You should be reassured that, although all these complications are well recognised, the majority of patients do not suffer any problems after a urological procedure.

Please use the check boxes to tick off individual items when you are happy that they have been discussed to your satisfaction:

Common (greater than one in 10)

☐ Swelling of the penis lasting several days

Occasional (between one in 10 and one in 50)

☐ Bleeding of the wound occasionally needing a further procedure

☐ Infection of the incision requiring further treatment and/or casualty visit

☐ Permanent altered or reduced sensation in the head of the penis

☐ Persistence of the absorbable stitches after three to four weeks, requiring removal

Rare (less than one in 50)

☐ Scar tenderness

☐ Failure to be completely satisfied with the cosmetic result

☐ Occasional need for removal of excessive skin at a later date

☐ Permission for biopsy of abnormal area on the head of the penis if malignancy is a concern

What should I expect when I get home?

When you leave hospital, you will be given a discharge summary of your admission. This holds important information about your inpatient stay and your operation. If, in the first few weeks after your discharge, you need to call your GP for any reason or to attend another hospital, please take this summary with you to allow the doctors to see details of your treatment. This is particularly important if you need to consult another doctor within a few days of your discharge.

It will be at least 10 days before healing occurs and you may return to work when you are comfortable enough and your GP is satisfied with your progress.

Most people require at least a week off work.

You should refrain from sexual intercourse for a minimum of four weeks.

What else should I look out for?

There will be marked swelling of the penis after a few days. This will last three to four days and will then subside but do not be alarmed because this is expected.

However, if you develop a temperature, increased redness, throbbing or drainage at the site of the operation, please contact your GP.

Are there any other important points?

You will not normally be given a follow up outpatient appointment after circumcision unless this is felt necessary by your consultant.

Driving after surgery

It is your responsibility to ensure that you are fit to drive following your surgery.

You do not normally need to notify the DVLA unless you have a medical condition that will last for longer than three months after your surgery and may affect your ability to drive. You should, however, check with your insurance company before returning to driving. Your doctors will be happy to provide you with advice on request.

Privacy & dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high tech equipment and/or specialist one to one care is required.

Hair removal before an operation

For most operations, you do not need to have the hair around the site of the operation removed. However, sometimes the healthcare team need to see or reach your skin and if this is necessary they will use an electric hair clipper with a single-use disposable head, on the day of the surgery. Please do not shave the hair yourself or use a razor to remove hair, as this can increase the risk of infection. Your healthcare team will be happy to discuss this with you.

References

NICE clinical guideline No 74: Surgical site infection (October 2008); Department of Health: High Impact Intervention No 4: Care bundle to preventing surgical site infection (August

2007)

Is there any research being carried out in this field at Addenbrooke’s Hospital?

There is no specific research in this area at the moment but all operative procedures performed in the department are subject to rigorous audit at a monthly audit and clinical governance meeting.

Who can I contact for more help or information?

Oncology nurses

Uro-oncology nurse specialist
01223 586748

Bladder cancer nurse practitioner (haematuria, chemotherapy and BCG)
01223 274608

Prostate cancer nurse practitioner
01223 274608 or 01223 216897

Surgical care practitioner
01223 348590 or 01223 256157

Non-oncology nurses

Urology nurse practitioner (incontinence, urodynamics, catheter patients)
01223 274608

Urology nurse practitioner (stoma care)
01223 349800

Urology nurse practitioner (stone disease)
07860 781828

Patient advice and liaison service (PALS)

Telephone: 01223 216756
PatientLine: *801 (from patient bedside telephones only)
Email PALS

Mail: PALS, Box No 53
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

Chaplaincy and multi faith community

Telephone: 01223 217769
Email the chaplaincy

Mail: The Chaplaincy, Box No 105
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

MINICOM System ("type" system for the hard of hearing)

Telephone: 01223 217589

Access office (travel, parking and security information)

Telephone: 01223 596060

What should I do with this leaflet?

Thank you for taking the trouble to read this patient information leaflet. If you wish to sign it and retain a copy for your own records, please do so below.

If you would like a copy of this leaflet to be filed in your hospital records for future reference, please let your urologist or specialist nurse know. If you do, however, decide to proceed with the scheduled procedure, you will be asked to sign a separate consent form which will be filed in your hospital notes and you will, in addition, be provided with a copy of the form if you wish.

I have read this patient information leaflet and I accept the information it provides.

Signature……………………………….……………Date…………….………………….