Circumcision in adult males

Contents:

Circumcision in adult males: what’s the procedure?

First, the doctor performing the circumcision will inform on the patient s general health and will check if there are no medical reasons to not do the circumcision. The doctor will also give information and answer potential questions.

Next, the patient will come to lie on the operating table, and the doctor will anesthetize the penis with a few injections of xylocaine 2% with adrenaline. The injections are painful, but will not take long. Before the procedure is started, the doctor will check if the penis is fully anesthetized. This is done by pinching the foreskin with a surgical clamp; the patient should not feel this. It is always possible to inject more anesthetic medicine if necessary.

When the doctor is convinced that the penis is fully anesthetized, he will start the procedure by removing the frenulum (the connecting bridge of tissue on the underside of the penis). Next, the foreskin will be pulled up and cut at the right height, after which the inner layer of the foreskin will be trimmed accordingly. Using electric surgical tweezers, the bleeding blood vessels will be burned closed. The doctor will suture the wound, and the penis will be covered with Vaseline-coated gauze and bandaged to prevent swelling. We advise wearing tight underwear for good support and to reduce the risk of swelling and bleeding. After that, the circumcision is done and the patient is discharged.

The anesthesia wears off after approx. 1 hour. The patient may experience some after-pain for 30 to 60 minutes, which is treatable with 1000mg Paracetamol and 600mg Ibuprofen. After-pain that follows is usually mild, and treatable with Paracetamol. The sutures will dissolve after 2-3 weeks, and do not need to be removed. See ?Aftercare adult male? for more information.

Reasons to do a circumcision

Reasons to do a circumcision are:

Phimosis: a narrowed foreskin, so much that it is unable to be pulled back. This could cause trouble with sexual contact, and makes thorough cleaning difficult, increasing risk of infection. Phimosis can also occur in older men;
Ejaculatio praecox: premature ejaculation. After circumcision it often takes longer to ejaculate and this is seen as a positive side-effect;
Hygienic or preventive reasons: i.e. lower risk of sexually transmitted infections (HIV), prevention of a narrowed foreskin and/or infections;
Religious obligation.

When is circumcision not an option?

The circumcision cannot be performed in the following cases:

When the patient has not read and signed the informed consent form;
When the patient is sick or feverish on the day of the procedure;
When the patient has a medical issue to such a degree that the doctor judges him unfit to be circumcised. In case the patient is on blood thinner medication, he should get in contact with one of our doctors beforehand to discuss whether these medications can be paused. The doctor may seek contact with the general practitioner or medical specialist having prescribed these medications;
When the patient wishes the circumcision to be performed in a way that the doctor cannot do.

Manner of circumcision

We perform circumcisions in adult males in one way: complete removal of the foreskin and inner skin layer, after which the wound is sutured closed. The frenulum is part of the foreskin and will be largely removed.

Besnijdenis Centrum Nederland (BCN) only performs complete circumcisions. Partial circumcision, where only a part of the foreskin is removed, causes scar tissue forming and may lead to narrowing of the remaining foreskin (phimosis) in a later stage.

There are a lot of myths circulating on the internet about different ?manners? of circumcisions (loose, tight, high, low, etc.). The reality is that there is only a small margin of removable foreskin available. A circumcision done too tight (too little remaining skin) may cause erectile issues, while a circumcision done too loose (too much remaining skin) may cause phimosis.

Informed consent

The patient needs to have read and signed the informed consent form before the circumcision. In it, he states that:

He has specifically requested the doctor to circumcise him;
He realizes that the circumcision is a medical operation, which in rare cases can lead to complications;
He has read and accepts the terms and conditions of the care and aftercare offered by BCN.

What is a normal healing process?

In most cases, the wound heals without any problems. After the anesthesia has worn off, the patient may experience some after-pain on the same day. In case of a ?normal? healing process, the wound is closed after 3 to 4 weeks.

Bathing and Vaseline
The patient must bathe daily, from 2 days after the circumcision onwards, rinsing the wound with clean, lukewarm water. He should dab the wound dry, cover it with Vaseline, and apply gauze to put it in the underwear. This should be done until the wound is healed.

Painkillers
Usually, Paracetamol is only needed on the day of the circumcision and the following night. If the patient is still experiencing pain in the following days, he may have more.

Blue discoloration of the skin
In some cases, the skin of the penis or scrotum may turn blue after the circumcision. This indicates a small, harmless hemorrhage, caused by the anesthetic injection. This will disappear after 1 or 2 weeks.

Possible complications after the circumcision

Because of our vast experience with circumcisions, complications rarely occur. Of course, there is always a risk of complications, which may impede the healing process. The following things may occur:

Bleeding, less than 2 days after the circumcision
This occurs on the same or following day of the circumcision. A little red spot on the bandage is normal, but it should not noticeably grow. If the bleeding will not stop after 5 to 10 minutes of applying pressure on the wound, the patient should call our doctor on duty, available day and night within the first 48 hours. The doctor may decide to see the patient back in our clinic to stop the bleeding. Bleedings occur rarely in our clinics (<1%), but, of course, the risk is always there. Bleeding, more than 2 days after the circumcision
In some cases, the wound may start to bleed a bit after a few days. This is caused by erections (which put stress on the wound) and is totally harmless. To stop this, we advise the patient to rinse off all the blood in a bath or shower, dab the wound dry, cover it with Vaseline, and apply an elastic bandage around the penis. The bleeding should stop.

Signs of infection, without pain
A mild infection may occur after the circumcision, meaning the penis will become red and swollen with some yellow discharge. Touching the wound should not be painful. By bathing twice a day, these signs should disappear. Medication is rarely needed.

Signs of infection, with pain
In case the skin of the penis turns red and swollen after a few days, and there is pain present, the infection should be treated with antibiotics. The patient should get in contact with a doctor, be it their own general practitioner, or a doctor of our clinic.

Opening wound
A stitch may become untied, causing the wound to open. This is usually caused by erections and is totally harmless. Although it may take some more time, the wound edges will grow towards each other and heal. It is important to bathe daily, and see a doctor in case the pain worsens.

The wound looks bad
The penis may be swollen, red, and ?crooked? shortly after the circumcision. If the patient is not experiencing any pain and there are no signs of infection, this is okay. The swelling and redness will disappear, and the final results will be reached after 4 weeks. In case the penis still looks bad after 4 weeks, the patient may book a check-up appointment with our head doctor. Due to our years of experience, we know that in most cases the wound will heal properly and the end results will be good.

Severe complications
Severe complications could occur after circumcision in very rare cases, such as severe bleeding, extensive infection of the penis and scrotum (Fournier gangrene), narrowing of the urethral opening, damage of the glans, and development of an abnormal passage between urethra and skin (fistula).
Due to our vast experience, the risk of these kinds of complications is minimal, but never zero. In case there is a complication, we will do a check-up to examine the patient and give advice on further treatment. If needed, we can refer the patient to a medical specialist.

Aftercare

The head doctor will be on duty for 48 hours after the circumcision, which means the patient is able to call in case of a bleeding etc. The patient will receive the aftercare form including the telephone number after the circumcision. After the initial 48 hours, acute issues will not occur anymore (note: infections develop over time). We will be reachable then on weekdays between 9 AM and 5 PM.

Telephone interview on end results and satisfaction
A few weeks after the circumcision, we reach out to our patients to get informed on the healing process, and whether the end results and our service were satisfactory. If needed, we can make a check-up appointment. The results of these interviews are good: the number of complications (i.e. bleeding, infection) is very low, and the mean satisfaction rate is high (8.9/10).

Costs and reimbursement

The total cost of a circumcision of an adult male over 16 years is 495,- EUR. In case the circumcision has a religious or cultural reason, this will not be reimbursed by health insurance. In case of a medical reason, this may (partially) be reimbursed, depending on the insurance company.

Complaints and disputes

Complaints and disputes policy of Besnijdenis Centrum Nederland 2018
Complaints on the procedure or treatment may be filed with the performing doctor or the board of BCN. One of our board members will then speak with the complainant on the case and will try to get to a solution. If a solution is not found, our complaints officer will be brought in to mediate between the complainant and board member. In case this proves insufficient, the complainant will put his complaint on paper. Our complaints officer might help if needed. Our complaints officer will then reflect on the case and will hear the perspectives of the involving doctor and other health care providers. There will be a fair hearing during this process. After the case is settled, the complainant will receive a letter from the involving doctor with his/her point of view on the case and, if applicable, taken measures. If needed, our complaints officer may help writing this letter.

If the complaint involves multiple care providers, our complaints officer may include the other care providers in the process. This way, the complainant will not have to tell his/her story multiple times, and will not need to file the same complaint with different institutions.

Regional complaints committee
If the case cannot be solved with our complaints officer, the complainant may turn to the regional complaints committee with which BCN is affiliated. If our mediation is not wanted, we could get you directly in contact with the committee.