Poor wound care following traditional circumcision remains the largest cause of mortality and morbidity, and results from incompetence on the part of traditional attendants. Adequate wound care is of utmost importance to prevent infection and penile injury.
The two most common causes of local complications are impairment of the blood supply and bacterial infection of the circumcision wound. These two mechanisms are closely related. Impairment of the blood supply starves tissue of oxygen, which subsequently becomes more vulnerable to infection. Once infected, the tissues’ blood supply is further compromised by swelling and occlusion of blood vessels. This process leads to wet gangrene (infected dead tissue) if left untreated.
The size of the circumcision wound is an important factor to determine infection risk: large wounds become infected more easily. The average wound size following traditional circumcision is about 2cm (see left photo). Experienced traditional attendants will diminish the wound size by pulling the skin of the penile shaft towards the glans (the head of the penis), using a certain bandaging technique to hold it in place. This greatly reduces the infection risk.
The use of stitches in medical circumcision (see right photo) minimizes the size of the wound. Major advantages of this technique are the small infection risk and rapid wound healing.
Application of dressing
Herbs are applied directly onto the wound. A bandage is then applied by winding it around the penis from base to tip and back to the base, where it is tied to the thong around the waist.
Impairment of blood supply
Tight bandages compromise the blood supply of the penile skin, which leads to delayed wound healing and skin loss. Early signs of impaired blood supply are hardness, discolouration and swelling of the glans (see right photo). With tighter compression the deep blood vessels are occluded leading to varying degrees of gangrene (dead tissue).
Bandages are often tightly applied on purpose for a variety of reasons; for example to test endurance or as a form of punishment. Another common belief is that 'umlambo' should be prevented. As part of the normal healing process watery fluid may be draining from the wound during the first few days following circumcision. This fluid separates from the blood to bring necessary nutrients to aid wound healing. Traditional attendants refer to this as 'umlambo': a wound like a river. It is wrongly believed to impair wound healing. Many attendants therefore tighten penile bandages and restrict oral fluid intake. These practices are extremely dangerous.
The majority of infections are caused by poor hygiene practices, such as hands not being washed, re-use of dirty dressings, application of saliva to the under surface of the leaves, and rubbing leaves against the sole of the foot before application. All these practices introduce bacteria into the wound that may lead to infections.
Poor hygiene practices also allow for wound infections to spread from one boy to the other, especially if bandages are re-used on different initiates.
Spread of a wound infection into the blood stream can lead to blood poisoning, which is the most common cause of death in initiates.
The series of photos illustrate how wounds are often covered in 'traditional medicine', leading to highly unhygienic situations.
Loss of epithelium
The thin tissue that forms the outer layer of the glans is called ‘epithelium’. This layer is very vulnerable and dies relatively soon when the blood supply is compromised. It is therefore a clear indication that the traditional attendant has applied the bandage too tightly. This can be seen in the left photo, where it forms a superficial black layer that usually comes off after a few days. Health practitioners often confuse it with traditional medicine (muthi) that looks similar but is different in texture.
As said before, tissue starved of oxygen is more vulnerable to infection. A small wound in this epithelial layer will therefore rapidly lead to infection and subsequent further loss of tissue, which can be seen in the middle photo.
The right photo illustrates the remarkable potential of the epithelial layer to grow back, although sensation is often reduced afterwards.
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