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More often people here about circumcision as a religious rite among Jews and Muslims and less likely this procedure is discussed from a medical point of view. There is no consensus about its feasibility and even doctors can not determine whether this procedure needed or not. According to statistics, about 1/7 of the world male are circumcised and, in most cases it is for religious reasons. In Europe, male circumcision is not very popular, unlike the U.S., where more than 50% of boys are circumcised, mostly for reasons of hygiene (Rosen, 2010). There are vivid reasons for this procedure the same as effects which should be thought out thoroughly.

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The tradition of circumcision appeared in a primitive society, when the transition of boys into the group of adult men was accompanied by a rite of initiation. During the initiation, young men were not just receiving the traditions and intimate knowledge of the tribe, but also subjected to physical tests, among which the circumcision was perhaps not the most painful.

European and American part of the population is very ambivalent about this process. For example, in the early ’60s in Western countries there was the so-called “the boom of circumcision.” Through the process of cutting off the foreskin were going almost all male – adult and newborn babies. However, in the 70ies-80ies the “boom” finished and there was a time to sum up the results (it should be noted that according to statistics, nowadays about 80% of American men are circumcised) (Joseph, 2010).

In the modern world circumcision is made in some peoples of Australia, Oceania, and Africa. The most widespread, circumcision is in the religious rites of Judaism and Islam. So in some religions, circumcision is an obligatory ritual; for example Muslims circumcise children when they are 8-13 years old, while Jews do it already on the 8th day after the birth (Anwar, 2010).

Circumcision is a minor surgery aimed to remove the foreskin of the penis. The result of the complete removal of the foreskin is an open glans penis; as a result of partial removal of the foreskin, an opening of glans penis is achieved (Castellsague, 2002).

The question of circumcision is very discussible and has a lot of proponents and opponents.

Doctors have sounded positive and negative effects of circumcision. Discussing the positive effects, the most vivid are: the reduce of probability of occurrence the reproductive system malignant tumors; increased duration of coitus – due to the absence of the foreskin, the glans penis becomes less sensitive during the frictions that contributes to delay of ejaculation (though this point may not always be considered as positive); improvement in the appearance of the penis.

It is also proved that there is a connection between inflammation in the area of ​​the foreskin and urinary tract infection. Thus, while examining of 100 children with urinary tract infection in age from 5 days to 8 months, it was noticed that 95% of them were boys and all of them were not circumcised (Ginsberg CM, 1982). The survey of U.S. military showed that the incidence of urinary tract infections is 10-20 times higher in men who haven’t been circumcised (Wiswell TE, 1987).

One more positive medical effect of circumcision is that penile cancer is found only in men who previously did not have circumcision. Mortality in cases of penile cancer in the U.S. is 25% (Castellsague, 2002). Circumcision significantly reduces the likelihood of developing penile cancer in men. Also the connection between circumcision and sexually transmitted diseases is also acknowledged (Rosen, 2010). These diseases, which typically include the integrity of the epithelium, or ulcers (genetalny herpes, syphilis, AIDS) are more common in men who were not circumcised (Waldeck, 2003).

In addition, Australian researchers have found out that circumcised men are much less likely to get AIDS and other infectious diseases of the reproductive system. Scientists have discovered that immunodeficiency virus penetrates the foreskin much easier than other tissues of the male organism (Ferris, 2010). Also, a group of U.S. researchers, working in India under the leadership of Dr. Stephen Reynolds, made this conclusion, surveying more than 2 thousand men. The report of the Surgeon General is published in the medical journal Lancet (D’Arcy, 2011).

The article says that the risk of getting the deadly virus for circumcised men is six times less than for those who did not pass this procedure. However, scientists announce that from other sexually transmitted infections, circumcision does not protect. The reason may lie in specific cells of the foreskin, which are very susceptible to HIV (D’Arcy, 2011). 

Dr. Reynolds says that circumcision can be a serious tool in the fight against AIDS – especially in developing countries, where condoms are not equally shared (D’Arcy, 2011). Previously, as noted at https://smashingessays.com/ scientists believed that circumcised men were less susceptible to AIDS due to the special patterns of sexual behavior – their upbringing did not permit to have casual sexual acts. However, it is clear now that the reason is just physiological and has nothing to do with ethics or religion (Brooks, 2010).

The effects of circumcision have not only positive points, but negative also. One of the main effects is a severe pain. Previously, infants were circumcised without anesthesia, which in turn led to a painful shock, but nowadays local anesthesia is used almost always during such procedures. One more strong negative effect is unnecessary intervention in human anatomy. There is nothing superfluous in humans; in fact the foreskin performs the same role for the glans penis as the eyelid to the eye. It protects the glans penis. The opponents of circumcision believe that it is far from inconsistency to ethical standards. Since the infant can not decide himself whether he needs circumcision or not, human rights advocates say that decisions made by parents, are inhuman.

Like most surgeries, the procedure of circumcision has a number of postoperative complications, the most common of which are the following: hematoma (bleeding in the tissue, or a bruise) and wound infection. To eliminate these negative effects, in most cases is possible through the most thorough dressing and postoperative area care. There are also possible such negative effects as contagious infection, the formation of excessive scar tissue, mechanical damage to the urethra during surgery, various strains of penis, swelling and inflammation of the urethra. Never the less such problems happen rather rare. A more serious consequence, requiring repeated surgical intervention is painful erections that are also considered as possible medical effects of circumcision.

It is important to mention that the presence of the foreskin makes the surface of the glans penis moist corresponding humidity of woman’s vagina and that physiological. Penis after circumcision does not have such natural advantages, and circumcised men often have to use special lubricants during sex. Medical practice shows that children whose foreskin was cut are affected by infectious disease of the penis during the first years of life five times more often then children who were not circumcised. This is explained by the fact that smegma contains lysozyme, which reduces the risk of urinary tract infection.

The infant is not asked whether he wants to have such surgery or not. Adults decide everything for him. However, any surgery is a trauma, the psychological consequences of which can persist for life. Americans, carefully, even reverently care about their mental health, combined into society under the slogan of opponents of circumcision: “Circumcision – mutilation and violence against child’s personality.” At the same time, the surgeons quite successfully develop techniques that allow pulling the skin of penis to form a new foreskin.

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Many people believe that circumcised foreskin impoverishes sexual feelings, and this view has the right for existence. Foreskin moves during the frictions, making the experience richer be the most natural way, without using any appliances from the store of intimate accessories. There is no doubt that circumcision is sometimes a necessary therapeutic measure during frequent inflammatory diseases of the foreskin, phimosis and paraphimosis. However, as a preventive operation, it is hardly justified, although not so long ago people practiced across-tonsillectomy as a preventive measure of angina, and cutting the appendix to avoid possible appendicitis.

Here’s what a well-known pediatrician, Dr. Hugh Jolly says: “There is no doubt that the best thing you can do with the foreskin of your infant son, is to leave it, you just need to give it time to separate itself from the glans, and it will easily pull back. It happens at the age of 4. It is best to try to move the foreskin during bathing. However, if the glans is exposed difficultly, do not hurry, there is no need… If you try to pull the foreskin before it happens naturally, you can damage skin and cause bleeding. The scar occurs at the place of injury. In cases where the foreskin is fused with the glans, circumcision can not be longer avoided” (Morris, 2010).

Until the natural separation of the foreskin, it protects the glans from infection. In infancy the cleansing of the glans penis in boys, as well as the clitoris in girls occurs itself, naturally. The irony is that it is after the cutoff there is an urgent need for careful care of the glans penis. Deepening and skin folds in the bridle and the corolla are ideal for bacterial growth.

The glans penis which is not circumcised has a smooth, slippery and wet surface. After the cutoff, it becomes matte and dry. The modern mentality often equates dryness and purity that is why from this point of view the untouched by the circumcision glans seen as dirty. That is a fallacy. Young people in the United States regularly go to the doctor for circumcision. Their decision, they often motivate by partner’s insistence, which is usually due to three factors: hygiene, aesthetics and traditions. The woman is afraid of dirt that can accumulate under a fold of skin, wrinkling her unpleasant appearance of the foreskin and, finally, she wants her partner looked like the rest men in her family.

The essence of the problem is that the excision of the foreskin causes severe pain. In most cases, operations are done without anesthesia, as it is commonly believed that in the first week of child’s life it is risky. It looks awful when a small, helpless creature is tied to a special table for cutting. The child lies on it; crucified and abandoned by all … He reacts with horror at the bright light of surgical lights, ringing metal tools, masks of doctors, shining knives and the terrible physical pain. None knows how long his continues continue. The psychological effects of such procedure are not studied yet, so none can tell how it affects a child.

Journalist Philip Baffle wrote in The New York Times: “Newborns experience pain. There is no need to explain it to parents; it’s not a mystery to many pediatricians. Unfortunately among doctors, who are operating babies without anesthetic or with minimal use, opposite opinion is dominated” (Gilliam, 2010).

Philip Baffle states that according to one of scientific researched, 77% of all infants who had surgery because of serious defects of the cardiovascular system in 1954-1983, were given only local anesthesia, and very rare with the interrupted supply of nitrous oxide (Gilliam, 2010). Meanwhile, really effective painkillers, which are suitable for children, have already passed into the category of available. Such a rare use of analgesics while operating newborn proves that medical practice is sometimes based on incomplete knowledge and false beliefs and that criticism contributes the truth.

The situation is changing. In most U.S. medical institutions doctors use painkillers during major surgery. However, some anesthesiologists stubbornly adhere to old beliefs and there are still surgical units where little children are operated without anesthesia in the case of simple operations, such as circumcision.

Considerations which make the routine practice of circumcision doubtful include pain and risk associated with small surgical interventions. Circumcision is a surgical procedure, and the pain that is brought to the baby is also real. Pain is manifested in grimace, cry, heart palpitations and lack of saturation blood with oxygen (Kaufman, 2001). Studies indicate that circumcision in the neonatal period is a stress, which causes behavioral and psychological pain reactions (Malnory, 2003). American Academy of Pediatrics (AAP) recognizes that there is a significant painful reaction during neonatal circumcision and recommends the use of analgesics (Gatrad, 2002). 

One of researchers believes that the most important argument against circumcision is a permanent violation of anatomy, histology and functions of the penis, which are fraught with potential complications (Atikeler, 2001). The same study reports about complications including bleeding, stenosis, incomplete circumcision, penile edema, damage of the glands, adhesion, hypospadias and damage of urethra (Atikeler, 2001). The overall incidence of complications of circumcision according to the medical literature is 1.6% (El-Bhnasawy, 2002).

Adhesion of the penis is the most preventable and non-binding complications of circumcision. Among all the complications, an adhesion is observed in 71% of cases (Kebaabetswe, 2003). After neonatal circumcision, the majority of adhesions resolve sponatanno (Kebaabetswe, 2003).

Another risk associated with circumcision, is the lack or excess of skin that can cause problems such as recurrent phimosis (Gatrad, 2002). Phimosis happens in approximately 2.9% of cases (Blalock, 2003). In the UK, the circumcision is not practiced routinely, as the procedure has limited medical benefits. As a result, circumcision is a medical event, which is paid by insurance only in case of medical necessity (Shah, 1999).

Summarizing everything that was written above, it is worth repeating that circumcision is a surgically removal of the foreskin. It is dome more due to cultural traditions, than medical prescriptions. Circumcision is a kind of intervention in the very intimate area associated with family and religious traditions. Typically, the feasibility of circumcision causes active debates. Modern parents, before deciding to cut off their son, must carefully think about pros and cons of this procedure and related to this operation danger. Circumcision causes medical and psychological effects on children and they are worth consideration while taking decision.

CASE STUDY: PENILE ADHESION

CASE STUDY: PENILE ADHESION

Charles R. Drew University of Medicine and Science

Mervyn M. Dymally School of Nursing

NUR 632 Primary care of women and children

Lara Sarkissian

March 25, 2021

Case # 6367694

Running head: CASE STUDY #3 1

CASE STUDY #2 10

CASE STUDY:  Penile Adhesion

PATIENT INFORMATION:  Patient is a 9 month old male, no acute distress.   

HISTORY OF PRESENT ILLNESS:  A 9-month- old male patient presents self to the clinic with mother at bedside. Patient was circumcised in the hospital after birth. According to the mother, patient’s penis skin would get stuck every month and primary doctor would apply Vaseline and was able to pull apart the skin. Now the patient’s mother is unable to do so and in clinic for evaluation.

ALLERGIES:  No known drug and food allergies

PAST MEDICAL HISTORY:  nka, ndka

SURGICAL HISTORY:  Patient’s mother denies any previous surgery.

FAMILY HISTORY:  Unremarkable

SOCIAL HISTORY:  Patient is 9 months old and is well nourished and playful.

REVIEW OF SYSTEMS:

Constitutional:  No fever, no weight loss, no weakness and fatigue, hypertensive, with complaint of left sided chest pain.

Skin:  No rash, itching, pruritus, nail, or hair changes.

Head:  No headache, dizziness, lightheadedness, or vertigo.

Eye:  No blurring of vision, double vision, no tearing.

Ears:  No pain, no hearing loss, no ringing in the ears.

Nose/Sinuses:  Patent, no sinus tenderness.

Mouth/Throat:  No dysphagia, sore throat, or hoarseness.

Cardiovascular:   Normal rate and rhythm, no distress

Respiratory:  No respiratory distress, no cough. 

Gastrointestinal:  No abdominal pain, nausea or vomiting, appetite remains the same.

Neurological:  No seizure, fainting, or weakness, normal speech, memory and motor coordination intact.

Hematologic:  No anemia, no bleeding disorders.

Psychiatric:  No depression, anxiety, mood and affect appropriate, no sleep disturbance 

Musculoskeletal:  No muscle aches, or pain, no weakness, or fatigue, no joint pain, or tenderness, remains active with no change in energy level. 

Endocrine:  Negative for thirst, cold or heat intolerance, no dysuria, nocturia, or frequency of micturation.

Allergies:  No seasonal allergies.

PHYSICAL EXAMINATION:

General: Patient is alert, awake and oriented, no acute distress.

Vital signs:  Ht. 29 in Wt. 20 lbs., BP is 89/57mmHg, HR is 110/min., RR  26/min. & Temp. of 98.7 F (oral), see more at nursing assignment help

Skin:  Normal in appearance, texture and temperature, nails pink without clubbing.

Head:  Scalp normal, no lesions, no mass, no tenderness, even hair distribution.

Eyes:  Pupils equally round, reactive to light and accommodation, sclera and conjunctiva normal. Red reflex present bilaterally, normal vessels without hemorrhage on fundoscopic examination.

Ears:  Outer ear without lesions, skin intact, same color as face, tympanic canals normal, eardrum flat, translucent and pearly gray in color.

Nose/Sinuses:  Midline nasal septum, nostrils patent bilaterally, no nasal discharge, no tenderness over frontal and maxillary sinuses.

Mouth/Throat:  Tongue & lips normal in color, moist, no lesions, no periodontal disease noted, tonsils pink, no exudate, no submandibular, or supraclavicular lymphadenopathy, thyroid   obviously not enlarged, trachea in midline. Learn more at essay help

Neck:  Supple, no JVP, carotid artery upstroke is normal bilaterally without bruits.

Heart:  Regular rate and rhythm, S1 and S2 normal, no murmurs, no gallops, or rubs, no abnormal pulsation.

Thorax and Back:  Symmetrical lung expansion, spine no deformity or tenderness.

Lungs:  Symmetric expansion on inspection, respiratory effort even and unlabored without use of accessory muscles, on palpation tactile fremitus equal bilaterally, normal resonant on percussion, clear breath sounds, no wheezes, crackles, rhonchi or rales noted.

Abdomen:  Flat contour, no visible lesions or abnormality on inspection, non- distended, soft, no tenderness on palpation, no hepatojugular reflux, normoactive bowel sounds in all four quadrants.

Extremities:  Moves all, no discoloration, or cyanosis, no clubbing or edema, good pulses with regular rhythm.

Neurological:  Patient is alert and normal appearance with no distress, motor, strength, and sensory examination of the upper and lower extremities is normal, symmetrical and normal reflexes bilaterally in both extremities, crawling normal.

Genitalia:  Normal penis, no scrotal masses, or swelling noted, penis skin adhesion

Primary Diagnosis:  The patient presents with mother with a penile adhesion. The chief complaint of penile adhesion located on penis, has no pain that the mother can report. Patient had a circumcision during his first day of life in the hospital where he was born, with no other complications. After the first month, the penis adhesion would get worse over time, and worrisome for mother. The patient’s mother is unable to treat patient on her own and has presented the patient into the clinic for an evaluation and for possible referral for a Urologist to see what her options are with the circumcision. Penile Adhesion can occur when the penis skin is attached to the head or the glands of the penis. In this particular case, the penis skin is attached to the head of the penis. According to the Pediatric Surgical Associates, the adhesion is common with circumcised penis’, and is usually benign and causes no discomfort (2020). There are different causes for this to occur, which include excess foreskin following a circumcision, and fat in the pubis that can cause a fat pad which ultimately leads to a buried penis. According to the Pediatric Surgical Associates, the penile adhesion should have no symptoms and should be resolved fairly easily. There are other complications that may occur such as redness and irritation around the skin which can cause a smegma (2020).

Pathophysiology:

Penile Adhesion occurs in circumcised infant boys. This takes place when the shaft of the skin sticks to the gland of the penis. There are three different types of adhesions that can occur with infant boys after their circumcision; glandular adhesions, penile skin bridges, and lastly the cicatrix. When the infant develops more fat than usual around the pubis area, this then causes the penis to burry inside of the fat pad, and hence cause more skin to overlap the entire penis. The penis skin needs to be pulled downwards at each diaper change, and if this isn’t completed each time, then the skin can become attached (Children’s Hospital of Philadelphia, 2020). Glanular adhesions occur when the coronal margins are covered and stuck to the skin. The penile skin bridge occurs when there is a thicker and more permanent attachment, and will eventually separate on its own. The cicatrix occurs after the circumcision occurs and the penis falls back into the fat pad and traps the penis (Children’s Hospital of Philadelphia, 2020).

The primary goal for any primary care provider is to detach the penis from the skin on the shaft before it becomes too permanent. The primary care provider and the parent can make a decision based on the situation and stages of the adhesion, along with whether or not the parent is comfortable with completing the task of separating the skin on its own, at home.

DIFFERENTIAL DIAGNOSIS;

1. Phimosis – According to the UCSF Department of Urology, Phimosis is the inability to retract the skin that covers the head of the penis. This may be a tight ring more of a rubber band over the foreskin of the tip of the penis, that can prevent the full retraction. Phimosis is separated into two different categories which are physiologic and pathologic (2019). For a physiological process, the infant is born with the skin of the penis, and will eventually separate over time. However, the pathological phimosis is different, and occurs during an infection or an inflammation on the penis. IF the skin is forcefully retracted, this can lead to bleeding, scaring, infection, and inflammation.

2. Smegma- Smegma is known as the collection of the skin cells from the penis glans. There is also collection of the skin cells in the inner foreskin, which is usually seen when the parent retracts the foreskin. This is a natural process that takes place while shedding process takes place in infants. Smegma can be seen as white pearls underneath the penis. Smegma is a non-threatening condition for the infant. For uncircumcised male infants, the Smegma usually resolves on its own, within a few months after it appear (UCSF Department of Urology, 2019).

PLAN:

Diagnostics:  

There are no diagnostic tests for a penile adhesion. The best diagnostics that are done are with the primary care provider, and the actual parent. During the routine visits, the primary care provider will check on the male penis and see the adhesion by examination. The parent is also able to check the adhesion, during regular diaper changes and physical examinations at the pediatrician. Once diagnosed, it is up to the primary care provider to decide the best treatment plan for the safety of the infant.

Medical treatment:

1. Betamethasone 0.05%- apply the corticosteroid on the penile adhesion twice a day, for approximately 4 weeks until the skin is able to thin, and the parent or physician is able to retract the skin, without any complications or severe bleeding.

2. Vaseline- Apply Vaseline to the adhesion daily and during every diaper change, meanwhile trying to separate the adhesion on the penis.

3. Lidocaine- If all measures are not able to resolve the adhesion, then lidocaine is applied to the adhesion then the physician is able to separate the adhesion at the clinic. However, a possible surgical correction can be recommended by the urologist.

MANAGEMENT:

Management for the penile adhesion is simply if the patient’s caregivers or parents are persistent enough with every diaper change to pull the foreskin back and retract the skin in order to avoid the skin sticking together. The parents can also apply a Polyporin topical cream to the separation in order to avoid any infection due to the skin being pulled apart. During this processes it is crucial to have the presents avoid any type of infection and avoid any unnecessary dirty hands touching the new torn skin (Children’s Hospital of Los Angeles, 2020). There is a chance that the penile adhesion can get stuck one more even after any surgical process, however the outcome is typically the same. After the fat pad has disappeared in the infant, approximately around the age of 2, there should no longer be an issue regarding the adhesion.

Follow up care/Referral:

Advising the patient’s parents for a follow up with the primary physician is important. The infant should be seen every 3 months, for a check on developmental milestones and to check on the penile adhesion. Referral to a Urologist can be necessary in cases where the pediatrician is unable to pull apart the foreskin that is stuck to the penis shaft. The Urologist is able to perform the procedures and even surgery if there is a necessary for it, in the clinic due to their profession.

EDUCATION:

Patient education is key in this category. Parental education is necessary for each visit, because one must be vigilant with the process of separating the foreskin and applying the necessary creams in order to have the circumcised penis heal without any adhesions. According to the Pediatric Surgical Associates, having the Vaseline topical cream applied during every diaper change is necessary in order to avoid any more adhesions or even unnecessary infections for the infant (2020). Education for the parents should be given during every pediatric visit. Education regarding redness and swelling in the penile adhesion, should be a concern that the physician should be notified. Education regarding every diaper change to apply the cream and jelly provided. Education for the parent regarding to complete every diaper change with clean hands to avoid any infection. The primary should be notified if there is any sort of new redness or irritation and possible swelling regarding the penile adhesion.

References

Children’s Hospital of Los Angeles. (2020, January 27). Penile adhesion. Growing Healthy Together. https://ghtkids.com/holistic-care/penile-adhesion/

Children’s Hospital of Philadelphia. (2020). Penile adhesions. https://www.chop.edu/conditions-diseases/penile-adhesions

Pediatric Surgical Associated. (2020). Penile Adhesions. Pediatric Surgical Associates, Ltd. https://www.pediatricsurgical.com/wp-content/uploads/2019/02/Penile-Adhesions.pdf

UCSF Department of Urology. (2019). Phimosis. Department of Urology. https://urology.ucsf.edu/patient-care/children/phimosis#:~:text=Phimosis%20is%20defined%20as%20the,the%20penis%2C%20preventing%20full%20retraction

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