Older Infants Children Adolescents Adults

Transcription

1 Older Infants Children Adolescents Adults

2 Gentle Procedures Clinic Champagne Centre - East Entrance 2 Champagne Drive Toronto, ON M3J 2C5 (416) (416) Dr. Sing, Cell (416)# (416) (not textable) info@gentleprocedurestoronto.ca Dr. Roland Sing: drsing@gentleprocedures.com Website:

3 Contents Welcome.. 1 About Gentle Procedure Clinic About Dr. Sing What is Circumcision What are the Potential Benefits of Circumcision. 2 What are the Risks of Circumcision. 3 Instructions before Circumcision Day of Circumcision. 4 Before you arrive After you arrive After the Surgery. 6 First 24 hours After 1 day After 2 days After 1-2 weeks The Healing Process. 8 What to Watch For. 9 Common Questions. 11

4 WELCOME Our goal at Gentle Procedures Clinic is to uphold the highest standards of patient care and surgical excellence. In keeping with this philosophy and to ensure that all patients are properly prepared before their circumcision, we have prepared this manual which you should read with care. About Gentle Procedures Clinic Gentle Procedures Clinic is the first circumcision clinic in the Toronto area that uses the Pollock Technique TM of circumcision. We have created private surgical rooms allowing convenient patient access to avoid long waits at local hospitals. We serve patients from all over Toronto. You can arrange a circumcision with us within just days or weeks. About Dr. Sing Dr. Roland Sing has been practicing urology since He is a member of the Royal College of Surgeons (Canada). He also holds a clinical fellowship in the subspecialty of Endourology. Dr. Sing is an assistant clinical professor in the Department of Surgery, McMaster University. Dr. Sing has made Circumcision a major focus of his medical clinic. He trained in this procedure under Dr. Neil Pollock who is a foremost authority on circumcision and developed the world-renowned Pollock Technique TM. Dr. Pollock resides in Vancouver, BC, where he is a Clinical Instructor at the University of British Columbia, Faculty of Medicine, and is an invited guest at many hospitals throughout the world. Dr. Sing provides the highest level of care while delivering surgical excellence. He is supported by a dedicated and highly qualified team who ensure the utmost comfort and superb care of patients in fully equipped procedure rooms. What is Circumcision? we apply the most extensive pain control methods available. newborns, but with the surgical expertise of Dr. Sing any pain or possible complications are minimized. -1-

5 What are the Potential Benefits of Circumcision? 1. Improved hygiene - It is well known that mircoorganisms accumulate under the foreskin, which fosters inflammation and can lead to conditions such as balanitis / balanoposthitis (inflammation of the head of the penis). The incidence of balanitis is twice as high in those who are uncircumcised. Smegma, which is a cheesy-like secretion, can also accumulate under the foreskin, combining with bacteria to produce an oଏensive odour. 2. Reduced risk of urinary tract and bladder infections - Because microorganisms can accumulate under and adhere to the foreskin, bacteria has a greater chance of migrating up the urethra causing urinary tract infections (UTI s), especially in infancy. Studies suggest an over 10-fold decrease in risk of urinary tract infection in circumcised infants. UTI s are a potentially painfull and dangerous condition, as they can result in kidney inflammation and scarring. Studies suggest that the protective eଏect of circumcision against UTI s, when done as a newborn, continues into adulthood. 3. Reduced risk of phimosis - Phimosis is a condition where the foreskin becomes so tight that it cannot be pulled back fully, resulting in UTI s, local skin infection, pain when passing urine, retention of urine, kidney stones, and sexual dysfunction. Circumcision eliminates the risk of phimosis, which aଏects 1 in 10 older boys and men. 4. Reduced risk of penile cancer - Studies have shown an over 20-fold reduction in the risk of invasive penile cancer which is thought to arise from adherence of high-risk human papillomavirus to the foreskin and smegma, causing chronic inflammation and recurrent infections resulting in phimosis. Invasive penile carcinoma is highly associated with a history of phimosis. 5. Reduced risk of prostate cancer - Uncircumcised men have a fold higher incidence of prostate cancer, which is thought to correspond with a higher chance of sexually transmitted infections resulting in a chronic state of inflammation. 6. Reduced risk of HIV/AIDS - Circumcision reduces the risk of getting HIV/AIDS by 3-fold during sex with an infected woman. This is because the HIV virus enters through the inner lining of the foreskin which is thin and vulnerable. Ulceration and tearing are also common in uncircumcised men, adding to the risk of HIV entry. 7. Reduced cervical cancer in women - Circumcision reduces cervical cancer risk of a man s female partner by 5.6 times as there is less risk of adherence and colonization of human papillomavirus.

6 What are the Risks of Circumcision? 1. Bleeding - In 1 in 500 circumcisions there may be some bleeding that is usually stopped with pressure or less commonly with stitches. If there is a bleeding disorder such as hemophilia, we consult a hematologist prior to proceeding. 2. Infection - There is always a possibility that there could be a generalized infection requiring antibiotics after the surgery (1 in 4000). Serious infections are rare. (1 in 5000). 3. Concealed Penis - When there is a good amount of fat around the penis (pubic fat), the penis may retract inward and increase the chances that the penis gets partially buried and requires medical intervention (1 in 800). 4. Meatal stenosis - This is a narrowing of the urethra that may occur after the procedure, requiring medical intervention (1 in 1000). 5. Phimosis - This is a narrowing of the shaft skin opening over the head of the penis, requiring medical intervention (1 in 500). 6. Trauma or injury to the head of the penis (1 in 20,000). 7. Suboptimal cosmetic result (1 in 500). 8. More serious complications including death (highly rare). INSTRUCTIONS BEFORE CIRCUMCISION 7 days before circumcision DO NOT take or give your son any anti-inflammatory medications such as Advil / Ibuprofen, Naproxen or Aspirin. Appointments for patients who took Advil, Ibuprofen, Naproxen or Aspirin will be cancelled and rescheduled for another surgery date. -3-

7 Day of Circumcision : Before you arrive: Plan to be at the clinic for at least 1 hour to a maximum of 3 hours. This includes preparation time, surgery and recovery time to make sure that you are ready to travel home. Please arrive 15 30minutes before your appointment time. Late arrivals will be rescheduled for another date. Patients must have a good meal before leaving home. Avoid Being caffeinated well fed products like and well chocolate, hydrated nutella will improve and any the soft outcome drinks. of your Caffeine surgery. decreases the effect of the sedating medicine (if sedation is required for your child). Patients must wear comfortable, loose fitting pants or trousers such as pajamas or sweat pants. Think about bringing an athletic support or extra pair of underwear. Things to bring to the clinic to ensure comfort: -plenty of water or fruit juices -some snacks like crackers -Tylenol or Tempra (liquid Tylenol for children) -hand held game devices or tablets for entertainment ***Patients must take Tylenol, 1 hour before surgery according to the dosage based on the patient s weight. AVOID ADVIL / IBUPROFEN or NAPROXEN. Patients who received Advil / Ibuprofen or Naproxen or any other anti-inflammatory medicine will be cancelled and rescheduled for another surgery date. *** -4-

8 After you arrive : For parents with children: Liquid Tylenol Dosages by Weight Children 1-5 years old may be given Nozinan (levomepromazine), a sedating medication. Older children aged 6 years old and above may not require use of Nozinan. If your son received Nozinan, he must eat food every ½ hour until his surgery. If he is not a good eater a good alternative is fruit juices, crackers or potato chips. While under medication, keep your son under constant supervision. Do not let him wander into dangerous areas such as stairways without being held on to. Be careful and understand that children under Nozinan will be uncoordinated and have a tendency to lose their balance. Some children experience abnormal muscle movement or rigidity. Keep him in your sight the entire time and hold onto him whenever he moves. Your son cannot be left alone and do any activity without being supported. ***Nozinan Tylenol chewables should can not be be used given for together larger children. with any Adults other may medication use unless 650 mg (two cleared tablets) first approximately with Dr. Sing. one Nozinan hour before should the not procedure. be given if there It would is also a history help to of take irregular an additional heart rhythm dose of Tylenol in any member before going of your home. family. For teens Please and adults discuss consider any medical taking Tylenol problems every or 4-6 conditions hours for the with first Dr. 24 hours Sing post prior op. to surgery*** At the Clinic : We first apply a topical anesthetic cream to the penis to numb the skin. Next, Dr. Sing will give a dorsal penile block an injection through a tiny needle into the area that has already been numbed by the cream. After minutes, the penis will be frozen. Dr. Sing performs the circumcision. For children, when the circumcision is finished, Dr. Sing will apply surgical glue to the cut line in place of stiches. In teens and adults, fine absorbable cosmetic sutures and glue are used on the cut line to keep it together. (kids) -5-

9 After the surgery : Children aged 1 5 years old ( given Nozinan ) For After boys surgery, closer to your 1 year son old, should parents have can lots also to drink. review Try the to give Infant him Circumcision water every ½ Manual hour on our website, because there is a lot of overlap. For older/larger boys, we find or a glass of juice to eliminate the medication from his body. Your son may sleep for as that the biggest challenge is to relieve anxiety about the whole process. After the circumcision, long as 5-8 hours children after normally returning stay home about from 30 his minutes surgery. for This observation, is a common before occurrence. going home. Wake him A dose every of ½ Tylenol hour to after give him the procedure, some sweetened use of juice. an ice He pack, should and be distraction easily aroused with treats/use even during of his electronic post-operative devices sleep. is thoroughly In rare instances, encouraged. your son Once may at appear home, use pale of and regular feel dizzy. Tylenol, Should ice this and happen, distraction just lay works him down well. and At our give clinic, him sweetened try to avoid juice. the The use of prescription pain killers, because it tends to make things worse with altered levels symptoms should go away after a few minutes. If you have any concerns, please call of consciousness, confusion, nausea, and constipation. Dr. Sing at (416) Older children, adolescents and adults Again there is an observation period of 30 minutes before patients go home. An extra After surgery, you may feel a little bit of discomfort especially at the tip of the penis. dose of Tylenol, ice pack, food and drink help before leaving the clinic. For adults, drinking Take Tylenol caffeinated every 4-6 pop hours like for Coke pain or control. Pepsi seems In rare to instances, help. Adults some should patients not may drive themselves appear pale home. and feel Very dizzy rarely, or light-headed. patients who Should feel this perfectly happen, well just after lay surgery down and can drink pass out some 1 - sweetened 2 hours after juice. their The procedure. symptoms Please should disappear drive home in in a few the minutes. outside lane, so you can pull over if needed. FIRST 24 HOURS : Check the area for active bleeding every 1-2 hours. Keep the penis up, and wear 2 pairs of underwear. Slide ice pack in between the briefs, 10 min on/off. Make sure you are able to urinate, which you should be able to do within 8-12 hours after leaving the clinic. If you haven t urinated for more than 8 hours, please call Dr. Sing immediately at (416) Urinate sitting down, take your time, don't strain, because this can cause bleeding. For children: Give Tylenol every 4-6 hours with the dosage according to your son s age and weight. For older adolescents and adults: Take Tylenol every 4-6 hours. Do not take Advil or Ibuprofen. for the first 72 hours - you can take later because it is good for swelling. Keep the dressing as dry and intact as possible. Clean around the penis area with a soft cloth in lukewarm water. Do not take / give a full bath or shower until the follow up appointment with Dr. Sing. He will let you know when a full bath can be taken. -6-

10 AFTER 1 DAY : Some minimal swelling may develop. This is part of the normal healing process. Erections can occur in teens and adults. Consider taking Sudafed for this. Come A follow back up to appointment the clinic the will day be after scheduled. your surgery. Take/give / a give dose 1 dose of Tylenol of Tylenol 1 1 hour before your appointment. Some of the bandages may be removed at this time. You If the will bandages be given are packages removed, of sterile the penis gauze is and usually a tube re-wrapped of Vaseline a little to be less applied on the tightly. wound This from will the make 2nd it day easier of the to surgery. urinate, A but staff may member result in will more teach swelling you how to and/or bruising. Be prepared to use ice to settle the swelling. change the bandages at home. AFTER 2 DAYS : A full shower may be taken. Gently Please clean keep the the penis with dry lukewarm by wrapping water it to inmake plastic sure that wrap all dried or putting blood it and in a extra plastic glue bag. have Try been to keep washed the off. glue dry for a week. Change If the bandages the bandages become after wet taking with a urine shower. or water, Apply antibiotic change them. ointment It is (Polysporin) and okay Vaseline to apply on Polysporin the wound to using the cut a cotton line if bud you or wish. Q-tip. The Wrap penis with should the sterile be gauze covered we and have bandaged provided. for at least 7 days. Shower Continue and to change use ice the as needed bandages to daily help for control 7 days. swelling. If using Sudafed, take one tablet every 6 hours for 5 days. Don't take if you have hypertension or heart conditions. Older Children, teens and adults may start taking Advil / Ibuprofen 200 mg 1 tablet every 6 hours as needed to reduce swelling. Dr. Sing recommends that you can take these meds 72 hours after surgery. AFTER 1-2 WEEKS : Continue applying antibiotic ointment (Polysporin) until the wound is completely dry and healed. There may still be some glue and stitches present. Visit The the glue clinic will flake for an off, assessment and sometimes of the healing there may process. be some bleeding with this. Apply pressure for 5 minutes to stop. Stitches may take weeks to dissolve, but feel free to return to clinic to get them out if you want. You should wait about 2 weeks before doing this. -7- In some patients, there may still be swelling of the skin just under the head of the penis, usually at the bottom. All the swelling will go away completely, but in some it may take weeks - months. Sensitivity and redness of the penile head also occurs, and will take weeks - months to go away.

11 THE HEALING PROCESS 5 DAYS TO 2-3 WEEKS: You will see a yellow/green, slimy discharge on the glans, it is normal - it is serous fluid (same as in a blister) mixed with Vaseline and is not an infection. The tissues are thicker on the underside, so the swelling tends to be greater here. ridge glans gulley shaft The swollen, red collar temporarily obscures the back of the glans, but will soften in colour and flatten out over the next 1-2 weeks. There is often a patch of yellow/green here as well. This is a scab made up of serum, called granulation tissue. Just like a red scab, which is made up of whole blood, this will fall oଏ when the underlying tissues have healed. If the healing foreskin seems to be stuck to the glans, don t panic. Most often this is a mucosal adhesion A which will usually unstick itself after a week or so just with the normal friction of movement, bathing, or changing. These adhesions separate easily by gently peeling the edges apart, which Dr. Sing will do at a follow-up visit, if required. A Mucosal Adhesion Dr. Sing will gently move the skin oଏ the glans Less commonly, though, you may have a skin bridge B where new skin grows across the gulley attaching the shaft skin to the head of the penis. These can be more difficult to separate if left too long, so it is best to bring these to Dr. Sing s attention immediately so he can separate them as soon as possible. B Skin bridge Skin bridge released -8-

12 **Parents often comment on the deep, ruby red colour of the glans ---this is the normal colour of the glans while it is inside the foreskin. After several weeks of being exposed to the outside, it will become lighter in colour. After the cut foreskin stops bleeding, it will continue to ooze plasma for about a week or so, and when it dries and mixes with Vaseline, it takes on that slimy, yellow appearance. ** If you have any concerns regarding the appearance of the penis, book an appointment with the office for re-examination by Dr. Sing. DR. SING S emergency cell phone number is: (416) WHAT TO WATCH FOR Please watch carefully for the following possible complications: Fever If the patient (yourself or your son) feels warm or has a temperature greater than 37.9 degrees Celsius, please let Dr. Sing know immediately. Infection - If you notice redness, pus, or foul smell coming from the surgical area, call Dr. Sing immediately. The most common time for infection to present itself is in the first week after surgery. Bleeding - Having a few drops of blood on the gauze, the size of a loonie, is normal. Blood dripping off the penis is NOT normal. If you see this, hold pressure on the bleeding area for two minutes and call Dr. Sing immediately. Peeing / urination The patient (yourself or your son) may not urinate for a few hours after surgery. It is nothing to worry about as it is not uncommon after surgery due to discomfort, anxiety and effects of sedating medication. However, if the patient (yourself or your son) has not urinated at all after 8 hours, call Dr. Sing. If there has been no urination by 12 hours you need to see Dr. Sing immediately. -9- Dr. Sing's Emergency Phone Number is (416)

13 Concealed Penis - When the length of the penile shaft is no greater than the diameter, or when there is a good amount of pubic fat, the penis may retract inward. This is normal. If your son fits this profile, you can reduce the chance of a concealed penis by applying a thin layer of Vaseline to the entire glans once a day, until the glans takes on a healed appearance (about 1-2 months). To expose the glans that has retracted inward, place gentle downward pressure on either side of the base of the penis. Consult with Dr. Sing if the head of the penis cannot be fully exposed or if any connecting bridges form between the shaft skin and the head of the penis. Dr. Sing s emergency cell phone number is : Dr. Sing's Emergency Phone Number is (416)

14 Common Questions: How will I / my son feel after the circumcision? It is not unusual to sleep 6-8 hours after the procedure and to miss a meal. Will it hurt when urinating? It may sting a little bit for the first 24 hours, after that it should not be painful. To urinate sitting down on the toilet. It is best How often should Tylenol be taken? Every 4-6 hours on the first day with the dosage based on age and weight, then as needed. Ice is also very helpful for the first and next days if required. When to take a bath? No shower until Dr. Sing tells you it is ok to have a shower or a full bath. You can have, or give your son a sponge bath and gently clean around the penis area with a soft cloth in lukewarm water. Usually 2 days after the procedure, Dr. Sing will allow the patient to have a shower. -11-

15 Supplies to Get Gel Packs- small skinny ones work the best. Available at Dollar Store or any pharmacy. Polysporin-there is a Kid's version too. Available at any pharmacy. Gauze-3 inch by 3 inch. Can unravel into a thin shape. Available at any pharmacy. Sudafed. Get the plain version or the version with Tylenol mixed with it. Do not get the version with ibuprofen. Available at any pharmacy. Self adherent wrap. One inch width is best. Can be cut thinner for children. Available at Dollar Store or any pharmacy.