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, that subsequently becomes more vulnerable to infection. Once infected, the tissues’ blood supply is further compromised by swelling and occlusion of blood vessels. This process can lead to wet gangrene (infected dead tissue – rotting) if left untreated.
The size of the circumcision wound determines a part of the 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), and then use a certain bandaging technique to hold it in place. This greatly reduces the infection risk.
In medical circumcision (see right photo) stitches are used to minimize the wound size. Big advantages of this technique are a minimal infection risk and rapid wound healing.
Application of dressing
The traditional attendant applies herbs onto the wound after reducing the size of it. A bandage is then applied by winding it tightly around the penis from base to tip and then back to the base again, where it is tied to a thong that is around the initiate’s waist.
Impairment of blood supply
Tight bandages compromise the blood supply of the skin, which leads to delayed wound healing and skin loss. Early signs of impaired blood supply are hardness, discoloration, and swelling of the glans (see right photo). With tighter compression the deep blood vessels are occluded leading to varying degrees of tissue death (gangrene). This dead tissue amputates spontaneously after some time.
Bandages are often intentionally tightly applied for a variety of reasons. Some attendants do it to test endurance, others to ‘punish’ initiates. A common belief is that the circumcision wound should be dry and that so-called ‘umlambo’ should be prevented.
As part of a 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. This is referred to as ‘umlambo’ by traditional attendants: a wound like a river. It is wrongly believed to impair wound healing. Many attendants therefore tighten penile bandages (some even aim for swelling of the glans) and restrict oral fluid intake. These practices are extremely dangerous.
The majority of infections are caused by poor hygiene practices, such as not washing hands, re-use of dirty dressings, applying 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 which 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 photo’s illustrate how wounds are often covered in ‘traditional medicine’, causing highly unhygienic situations.
Loss of epithelium
More details on possible complications are described in the training manual, which can be found under ‘downloads’. One very common early complication is discussed here. The loss of epithelium of the glans is a clear indication that the traditional attendant has applied the bandage too tightly.
The thin tissue that forms the outer layer of the glans is called ‘epithelium’. This layer is very vulnerable and dies relatively rapid when the blood supply is compromised. This can be seen in the left photo, where it forms a superficial black layer that usually falls off after a few days. Health practitioners often confuse it with traditional medicine (muthi), which 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 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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