Diabetes Mellitus

Ok friend please copies artkel this is about Askep Diabetes Mellitus (Dm) complete, the student is important Akper essence of nursing, just deh to the point:

A. Definition

Diabetes Mellitus is a state of chronic hyperglycemia with various metabolic disorders due to hormonal disturbances that cause chronic complications of the eyes, kidneys, nerves, and blood vessels, accompanied by lesions in the basal vessels in the examination by electron microscopy. (Arif Mansyoer, 1997: 580)

Diabetes Mellitus is a chronic disease involving abnormalities in the complex metabolism of carbohydrates, protein and fat and the development of macrovascular complications, microvascular and neurological. Diabetes Mellitus is classified as an endocrine or hormonal disease because the picture of the production or use of insulin (Barbara C. Long, 1996:4)

Diabetes Mellitus is a syndrome caused by an imbalance between demand and supply of insulin. This syndrome is characterized by hyperglycemia and associated with abnormalities, metabolism of carbohydrates, fats and proteins. Abmormalitas metabolic leads to the development of specific forms of kidney complications, ocular, and cardiovascular neurogenic (Hotma Rumoharba, Skp, 1997).

Diabetes Mellitus is a disease hereditary (inherited) form of recession genetically caused metabolic disorders KH relative or absolute insulin deficiency that may arise at any age with symptoms of hyperglycemia, glycosuria, polyuria, polidipsi, general weakness and weight loss.

Aetiological classification DM American Diabetes Association (1997) as recommended by Society of Endocrinology Indonesia (PERKENI) are:

1. Diabetes type 1 (beta cell destruction, usually leading to absolute insulin deficiency):

a. Autoimmune

b. Idiopathic

2. Diabetes type 2 (varying from mainly predominant insulin resistance with relative insulin deficiency to a defect in insulin secretion, especially with insulin resistance).

3. Other types of diabetes

a. Genetic defects of beta-cell function:

1) Maturity Onset Diabetes of the Young (MODY) 1,2,3

2) mitochondrial DNA

b. Genetic defects of insulin

c. Exocrine pancreatic disease

1) Pancreatitis

2) Tumor / pankreatektomi

3) Pankreatopati fibrotakalkus

d. Endokrinopati: acromegaly, Cushing's syndrome, pheochromocytoma, and hipertiroidism.

e. Because the drugs / chemicals

1) Vacor, pentamidine, nicotinic acid

2) Glucocorticoids, thyroid hormone

3) thiazides, dilantin, interferona, etc..

f. Infections: Congenital rubella, cytomegalovirus

g. Causes of immunology yanng rare: antibody antiinsullin

h. Other genetic syndromes associated with DM yanng: down syndrome, kllinefelter syndrome, Turner syndrome, etc..

4. Gestational Diabetes Mellitus

B. Etiology

Insulin Dependent Diabetes Mellitus (IDDM) or Diabetes Mellitus Insulin Depends (DMTI) caused by the destruction of islet beta cells lengerhands due to an autoimmune process. While Non Insulin Dependent Diabetes Mellitus (NIDDM) or Not Dependent Diabetes Mellitus Insulin (DMTTI) due to the relative failure of beta cells and insulin resistance.

C. Pathophysiology

Because of the aging process, lifestyle, infection, heredity, obesity and pregnancy can cause insulin deficiency or insulin ineffective so so that permeability disturbances of glucose in the cell.

In addition it can also be caused due to acute excess thyroid hormone, prolactin and growth hormone can lead to increased levels of glucose darah.peningkatan hormone - hoormon in the long run, especially in regard diabetogenic growth hormone (causing diabetes). Hormone - the hormone insulin stimulates excessive spending by the islet beta cells lengerhans paankreas, so eventually decline innsulin cell response and an impaired liver in processing glukoosa into glycogen or glikogenesis process the blood sugar levels will increase.

And when it came glucosuria renal threshold through which menybebkan increased volume of urine, thirst and the simulated patient will drink water in large amounts (polidipsi) because glucose is lost with urine, then there ekhilangan calories and starvasi seeluler, kyak eat and people are often eating ( polifagi).

Hyperglycemia causes increased levels of sugar in the sweat, the sweat evaporates, sugars accumulate in the skin and cause irritation and itching - itching. Hyperglycemia due to a buildup of glucose in the cells that damage the capillaries and cause to be peningkaatan sarbitol menyebabkann endothelial dysfunction. Leakage sclerosis causes the disorder - disorder in the arteries and kepiler.

Hyperglycemia due to accumulation and thickening of the basement membrane glycoprotein that impaired capillary perfusion that will menyebebkan disorder that affects the tissue down the kidneys, eyes, lower legs, nerves. (Elizabeth J. Corwin, 2001)

D. Clinical Manifestations

1. Polyuria

2. Polydipsia

3. Polyphagia

4. Weight loss

5. vulvular pruritus, fatigue, visual disturbances, sensitive excitatory and muscle cramps (electrolyte disturbances and the occurrence of complications of atherosclerosis).

Other symptoms complained yangmungkin in patients are tingling, itching, blurred eyes and impotaansi in men. (Mansjoer, 1999)

E. Chronic Symptoms

Chronic Symptoms of Diabetes Mellitus

Sometimes-kadng patients suffering from Diabetes Mellitus showed no symptoms of acute (sudden), but these patients showed gajala after a few months or a few months mengiap DM disease. This phenomenon is called chronic or chronic symptoms, while chronic symptoms that often arises is:

- Tingling

- Skin feels hot (medangen) or as terusuk needle

- Pain in the skin so thick that seeehingga berrjalan as on a pillow or mattress

- Cramps

- Easy mengntuk

- Accomplished

- Eyes blurred, replace the glass usually seeing eye

- Itching around the genitals, female pda terrutama

- Dental mudaah off shaky daaan mudaah

- Kemempuan decreased sexual or even impotent

- Terjaddi barriers to growth in children

(Tjokro Prawito, 1997)

The high-risk groups that facilitate the disease diabetes mellitus are:

- A group at high risk for diabetes mellitus

- Older adult age group (over 40 years)

- Obesity

- High blood pressure

- A family history of DM

- A history of diabetes in pregnancy

- History of pregnancy with weight 4 kg baby born

- A history of viral infectious diseases, such as viral morbili

- A long history of taking drugs or injections of corticosteroid group.

(Tjokro Prawito, 1997)

F. Examination Support

•  Blood Glucose: increased by 200 - 100 mg / dl, or more
•  plasma Acetone (ketone): a strikingly positive
•  Free fatty acids: increased levels of lipid and cholesterol
•  serum osmolality: menngkat but usually less than 330 m Osm / l
•  Sodium: may be normal, increased or decreased

Potassium: normal or elevated false (cell migration), will further decrease

Phosphorus: more often decreased.

•  glycosylated hemoglobin: menngkat levels 2-4 fold
•  Arterial blood gas: usually indicates a low pH and a decrease in HCO3 (metabolic acidosis) with compensated respiratory alkalosis.
•  Blood Platelets: Ht may increase (dehydration), leukocytosis, hemokonsentraasi a response to stress or infection.
•  U + / creatinine: may be elevated or normal (dehydration / renal impairment)
•  blood amylase: possible increased which indicates acute pancreatitis as the cause of Diaabetes mellitus (diabetic ketoacidosis)
•  ttiroid function tests: increased activity of thyroid hormones can menongkatkan blood glucose and insulin will need
• Urine: sugar and asetan positive, specific gravity and osmolality may increase.
•  Culture and sensitivity: the possibility saaluran urinary infections, respiratory infections, and wound infections.

G. Medical Management

The main purpose to regulate blood glucose and prevent acute and chronic complications. If the patient has successfully overcome the diabetes, he will avoid hyperglycemia and hypoglycemia.

Medical management in patients with diabetes mellitus depends on the accuracy of the interaction of three factors:

 Physical Activity

 diit

 pharmacological intervention with oral hypoglycemic agents or insulin preparations.

Planned interventions for diabetes should be individualized, must be based on objective, age, lifestyle, nutritional needs, maturation, activity level, occupation, type of diabetes patients and the ability to independently perform the skills required by the management plan.

The initial goal for patients newly diagnosed with diabetes or patients with poor control of diabetes should be focused on the following:

 Elminasi ketosis, if there

 Achieving the desired body weight

 Prevention manifestation of hyperglycemia

 Maintenance of psychosocial well-being

 Maintenance of exercise tolerance

 Prevention of hypoglycemia

Management of Hypoglycemia:

a. Stadium beginning (realized):

 Provide pure sugar 30 grams (2 tablespoons) or syrup / candy gulamurni (not a sweetener instead of sugar or sugar diet / sugar diabetes) and carbohydrate foods bearer

 Stop hypoglycemic drugs while, check blood glucose during

b. Advanced (hypoglycemia commas):

 Handling should be fast

 Provide 40% dextrose solution as much as 2 flakon through every vein blood glucose within normal values ​​or above normal with blood glucose monitoring

 If hypoglycemia is not resolved, give anatagonis insulin such as adrenaline, high doses of cortisone, or glucagon 1 mg intravenous / intramuscular

 Monitoring of blood glucose levels.

I. Complication

a. Acute

 Comma hypoglycemia

 Ketoacidosis

 hyperosmolar coma nonketotik

b. Chronicle

 makroangiopati, menegnai large blood vessels, blood pembukluh heart, peripheral blood vessels, cerebral vascular

 microangiopathic, tiny blood mengenaipembuluh, retino diabetic, diabetic nephropathy

 Diabetic Neuropathy

 Vulnerable infections, such as pulmonary tuberculosis, gingivitas, and urinary tract infections

 Diabetic Foot.

CHAPTER II

NURSING CONCEPTS

A. Assessment

1. History

 General Information:

 Age

 Sex

 BB before and after illness

 TB

 If the client has been diagnosed

 The specific symptoms

 When gejalan appears

 diabetes medications: name, how long, how the injection of RX. Drug

 Type stressors: work, home or family, other penyaakit

 Type of monitoring: blood, urine

 Training Program: type

 health history and past

 Family history: diabetes, heart disease, stroke, obesity, history of lahhir death, birth, babies 9 months

 current health history:

 view double escape

 "Cramp" feet on the street and at rest when uncomfortable

 At the extremities feel: numbness, discoloration, cold, tingling, pain.

 If there is diarrhea: fekol incontinence, when the

 Is there a revenue problem

 Is there a revenue problem: urine left in vesicaurinaria cause a feeling of fullness that aba

 Concern clients and families: the hope and the need special

2. Physical examination

•  Level of consciousness → client orientation in response to stimulation
• Vital Signs: N, S, TD, P, breath odor of acetone
•  manifestations of complications: retinopathy signs → ophtamoncopic
•  skin temperature, weak pulse (posterior tibial and dorsalis pedia)
•  Sensation: blunt and sharp
•  Reflex

c. Psikososia

1.  description of her clients before the diagnosis and current perceptions.
2.  When the client's ability to perform the duties and functions
3.  Interaction with the client's other family members and people in work and school
4.  When Kien feel more stress
5.  Suport and service people around
6.  Depression feels loss of function, independence and control.

d. Laboratory

•  Serum electrolytes (K and Na)
•  Blood Glucose
•  BUN and serum cretinin
•  microalbuminuria
•  Glycosylated hemoglobin (HbA1c)
•  PH value and PCO2

B. Nursing Diagnosis

1. Lack of fluid volume

Can relate to: osmotic diuresis (from hyperglycemia), excessive loss of gastric, diarrhea, vomiting, limited input, nausea, mental mess.

Possible evidenced by: increasing the output of urine, urine dilute. Weakness, thirst, sudden weight loss, skin / dry mucous membranes, poor skin turgor, hypotension, tachycardia, slowed capillary refill.

Expected results /

Criteria for evaluation of patients will: Demonstrate adequate hydration evidenced by stable vital signs, peripheral pulses can be palpated, skin turgor and capillary refill is good, proper urine output individually, and electrolyte levels within normal limits.

Collaboration

•  Provide treatment in accordance with the indications:
•  Normal saline or half normal saline with or without dextrasa
•  Albumin, plasma or dextran.

R / - The type and amount of liquids depends on the degree of lack of fluids and individual patient response.

- Plasma Expanders (substitute sometimes needed if shortages threaten the life or blood pressure).

 Install or maintain urinary catheter left in place

R / Provide precise or accurate measurement to measurement of urine output, especially if the cause autonomic neuropathy bladder (urinary retention or incontinence).

 Provide potassium or other electrolytes intravenously or through appropriate indications.

R / Potassium should be added to the intravenous (soon to inadequate flow) to prevent hypokalemia.

Actions / Interventions

•  Monitor TTV, note any changes in orthostatic blood pressure.
• R / Hypovolemia can be manifested by hypotension and tachycardia.
•  Temperature, skin color, or humidity.
• R / Although fever, chills, and diaphoresis are common in the infection process, fever with skin redness, dry perhaps as a reflection of dehydration.
• Assess the changes in mental / sensory
• R / mental changes may be associated with high glucose or low (hyperglycemia), electrolyte abnormalities, acidosis, decreased cerebral perfusion and the development of hypoxia.

2. Nutrition, changes: less than body requirements.

Can relate to: Insufficient insulin (decrease glucose uptake and utilization by the tissues resulting in increased metabolism of protein or fat).

Peenurunan oral input: anorexia, nausea, stomach full, abdominal pain, change in consciousness.

Hipermetabolisme Status: release of stress hormones (eg epinfrin, cortisol and growth hormone), infectious processes.

Possible evidenced by: Report input is inadequate, lack of interest in food. Weight loss, weakness, fatigue, poor muscle tone, diarrhea.

Expected results / criteria

Evaluation of patients will: Digesting the amount of calories or nutrients right shows the energy levels.

BB demonstrating stable or addition to the usual range / desired with normal laboratory values.

Collaboration

 Make checks blood sugar using a "finger stiek"

R / Analysis circumstances in bed for more accurate blood sugar (indicating the current state examination) than watching the sugar in the urine (reduced urine were not accurate enough to detect fluctuations in blood sugar levels.

 Provide glucose solution, such as dextrose and half normal saline.

R / glucose solution was added after insulin and blood sugar liquids carrying approximately 250 mg / dl.

 Perform diit expert consultation.

R / Very useful in the calculation and adjustment nitrisi diit to meet the needs of patients.

Actions / Interventions

 Determine the diet and diet program patients and compare it with foods that can be spent on patients.

R / Identify deficiencies and deviations from therapeutic needs.

 Auscultation bowel sounds, note the presence of abdominal pain / abdominal bloating, nausea, vomit food that has not had time to digest, maintain a state of fasting according to indications.

R / hyperglycemia and disorders of fluid and electrolyte balance may decrease mobility or function of the stomach (or Ilius paralytic distension) that will influence the choice of interventions.

 Identify the preferred or desired foods including ethnic or cultural needs.

R / If the food that the patient can be included in the digestion of food, this cooperation can be sought after home.

BB  Weigh every day or according to indications.

R / Assessing adequate food intake (including absorption and utilization).

3. Infection, High risk (Sepsis)

Risk factors include: high blood sugar, decreased leukocyte function, perrubahan in circulation, existing respiratory infections or UTI seebelumnya.

Possible proved by: (can not be applied: the tendaa-signs and symptoms - symptoms make actual diaknosa)

It is expected that / criteria

Evaluation of patients will: mengidentivikasi menceegah or interventions to reduce the risk of infection. Demonstrating techniques, lifestyle changes to prevent infeeksi.

Collaboration

 Perform tests in accordance with the culture and ssensitifitas indication

R / to identify organisms that can select / provide the best anti-biotic therapy.

 Provide appropriate antibiotics

R / initial treatment can help prevent the onset of sepsis.

4. Fatigue

Can be attributed to: a decrease in metabolic energy production, changes in blood chemistry: insulin insufficiency, increased energy demand: status hieper metabolic / infection.

Possible proved by: excessive lack of energy, inability to retain its usual routine, penutunan performance, a tendency to crash.

Results are expected to / criteria

Evaluation of patients will: reveal peeningkatan energy levels, indicating improved ability to participate in the desired activity.

Actions / Interventions

 Discuss with the patient the need for activity

R / education apat provide motivation for passien meninkatkan although activity levels may be very tired.

 Provide an alternative activity with periods of adequate rest / without bother.

R / prevent excessive fatigue.

 Monitor pulse, blood pressure and respiratory frequency before Atua after doing the activity.

R / indicates aktivitass level that can be tolerated physiologically.

 Increase the participation of patients in performing activities of daily living according to Degnan in tolerance

R / increased confidence / self-esteem in a positive corresponding to the level of activity in the patient's tolerance.

5. Less Knowledge (Needs Beljar) Know Your Disease, Proknosis and Treatment Needs.

Can be attributed to: lack of exposure / recall misinterpretation of information.

Possible proved by: a question or request information, express masalah.ketidakakuratan follow the instructions of complications that can be prevented.

Results are expected to / criteria

Evaluation of patients will: express understanding of the disease. Identify relationships signs or symptoms of the disease process dn Degnan linking symptoms with causes. Correctly perform necessary procedures and explain the rationale for the action. Make lifestyle changes and treatment programs in carrying beraprtisipassi.

Actions / Interventions

 Create an environment of mutual trust by listening attentively and always there for the patients.

R / notice and respond to needs to be created before the patient is willing to take part in the learning process.

 Working with patients in managing the expected learning goals

R / participation in carrying improve enthusiastic planning and working with patients with the principles learned.

 Discuss diit plans, as well as the use of high food and how to do meals outside the home.

R / awareness of the importance of kontrrol diit will assist patients in eating or obey emrancanakan program.

 Review the effect of smoking on insulin use, instruct the patient to stop smoking.

R / nicotine constricts small blood vessels in the slow passage and absorption of insulin for blood vessel constriction is experiencing.

 Identify sources - sources that exist in the community, if any.

R / support continuous ride biassanya important lifestyle changes and increased acceptance of yourself.

REFERENCES

1. Practical Management of Type 2 Diabetes Mellsitus. PB Perkeni, 2002.

2. Diabetes Mellitus classification, diagnosis, and therapy. Askandar Tjokroprawito. PT Scholastic Press, 1989.

3. Medical Surgical Nursing Care Plans. Barbara engram. EGC Medical Book Publishers, 1994.

Bleeding Nose Or Epistaxis (Nosebleed)

Definition
Epistaxis or nose bleeding reportedly occur in 60% of the general population. The peak incidence of epistaxis obtained in the form of two peaks (bimodal) at age <10> 50 years.
Epistaksia nose is bleeding that can occur due to local causes or common causes (systemic disorders). Epistaxis is not a disease, but a symptom of a disorder.

Anatomy And Physiology Nose
The nose consists of outer nose or nasal pyramid and nasal cavity. Nasal pyramid consists of:
1. bridge of the nose (bridge)
2. dorsum nasi (dorsum = back)

3. nasal peak
4. ala nasi (Alae = wing)
The function of the nose is to:
1. airway
2. regulator air conditions (temperature and humidity set)
3. air filter
4. the sense of smelling (olfactory)
5. for air resonance
6. assist the process of talking
7. nasal reflex
Epistaxis is divided into two, namely the anterior (front) and posterior (back). Anterior epistaxis cases mainly from the front of the nose to the origin of the hemorrhage is kiesselbach plexus. Generally comes from Epistaxis posterior nasal cavity through the posterior branch a.sfenopalatina.
Anterior Epistaxis obvious clinical symptoms such as bleeding from the nostrils. Posterior epistaxis often show symptoms that are not too clear as nausea, vomiting blood, coughing up blood, anemia and posterior epistaxis usually involve large blood vessels so that more severe bleeding. Epistaxis (nosebleeds) in children generally come from little's area / kiesselbach plexus located on the front wall of the nasal septum.

Classification
Nosebleed Front (Anterior)
If the wound is blood vessels in the nasal cavity the front, it is called 'bleed front' (= anterior epistaxis). More than 90% of this type of bleeding is bleeding. Nosebleed forward more often about the children, because at this age selapun nasal mucus and blood vessels has not been too strong.
Nosebleeds usually marked by the release of future blood through the nostrils, either through one or both nostrils. Rarely bleeding out through the back of the head to the throat, unless the victim on his back or looked up.
On examination of the nose, can be found bleeding source location. Usually in the nasal septum, but sometimes also on the side wall of the nasal cavity.
Anterior nosebleeds due to:
1. Prying nose
2. Prolonged inhalation of air dried, for example at altitude or air-conditioned room
3. Prolonged exposure to sunlight
4. Colds or sinusitis
5. Blowing your nose too strong
Usually relatively harmless. Bleeding arising lightweight and can stop itself in 3-5 minutes, although it is sometimes necessary actions such as pressing and nose with a cold compress.
Some steps to tackle next nosebleed:
1. The patient sits in a chair or stand, head bowed slightly forward. In the sitting or standing position, a bloody nose higher than the heart. This action is useful to reduce the rate of bleeding. Head inclined forward so that blood flow through the nostrils, do not fall into the throat, which, when entered into the stomach causing nausea and vomiting, and if it enters into the lungs can cause respiratory failure and death.
2. Press around the nostrils, just above the nostrils and under the nose. Keep this act for 10 minutes. Try not stop pressing until the 10 minutes has elapsed. Patients were asked to breathe through the mouth.
3. Give cold compress on the area around the nose. Cold compresses blood vessels to help wrinkles, so bleeding is reduced.
4. After the bleeding stopped, should not be digging the nose and exhale through your nose too strong should be at least within 3 hours.
5. If the first treatment does not work, the victim should be taken to the hospital, because it may take the tent (rolled gauze) into the nasal cavity or the act of cauterization. During the trip, the patient should remain seated with bow slightly forward position.
2. Rear nosebleed
Nosebleed back (= posterior epistaxis) occurred due to injury to the blood vessels of the nasal cavity rear. Nosebleed rear rare, but relatively harmless. Nosebleed behind most of the adults, although it did not rule out also the children.
Behind the bleeding is usually more severe because the injury was suffered considerable blood vessels. Being situated at the back, the blood tends to fall into the throat and then swallowed into the stomach, causing nausea and vomiting of blood. In some cases, there was no blood coming out through the nostrils.
Some causes of nosebleeds behind:
1. Hypertension
2. Scarlet fever
3. Nasal or nasopharyngeal malignant tumors
4. Blood diseases such as leukemia, hemophilia, thalassemia, etc..
5. Lack of vitamin C and K.
6. Etc.
Behind the bleeding is more difficult to overcome. Therefore, the patient should be immediately taken to a clinic or hospital. Usually medics do the tent behind. How, a catheter is inserted through the nostril through the rear cavity mouth (pharynx), then pulled out through the mouth. In the end it comes out through the mouth and gauze mounted balloon. Only the tip of the catheter was pulled nostril, then the gauze and the balloon became interested and clog up the back of the nasal cavity. It is expected the bleeding stops. If this action fails, the medical officer would probably do the cauterization. Another step you might consider is surgery to find blood vessels cause bleeding and then tied. This action is called ligation.

CIRCUMCISION, NOW AND LATER.

What is circumcision?

The procedure is commonly performed shortly after birth or around puberty.

Circumcision is a surgical procedure that involves partial or complete removal of the foreskin (prepuce).

How common is circumcision?

About one-fifth of men worldwide have been circumcised, mostly for religious and cultural reasons when the procedure is commonly performed shortly after birth or around puberty.

Although adults are occasionally circumcised as an act of religious dedication, adult circumcision is most commonly performed for medical reasons.

Non-retractable foreskin in children

Contrary to common belief, the foreskin cannot be pulled back (retracted) in almost all newborn babies.

About 50 per cent of one-year-old boys will have a non-retractable foreskin, 30 per cent of two-year-olds, about 10 per cent of four-year-olds and about 5 per cent of 10-year-olds.

It's not necessary to try cleaning under the foreskin until it has become fully retractable of its own accord because attempts to pull back a non-retractable foreskin can result in pain and possibly injury.

The small percentage of adults who have a persistently non-retractable foreskin have a slightly increased chance of developing phimosis (see below). But this persistence is not a reason for circumcision.

A non-retractile foreskin does not of its own accord require circumcision unless it's causing symptoms.

Why circumcise?

Reasons for circumcision fall into three broad groups:

• for an medical indication
• to prevent future disease
• as an act of religious dedication.

Circumcision for a medical reason

Medical reasons for Circumcision include phimosis, acute balanoposthitis or paraphimosis.

Phimosis

In phimosis the opening of the foreskin is narrowed, preventing retraction. Occasionally, the edge of the foreskin has a white, scarred, inelastic appearance and will not pucker open as it is retracted.

Between 1 and 1.5 per cent of boys will develop this condition by the time they are 17 years old.

Symptoms can include:

• irritation or bleeding from the edge of the foreskin, particularly during sexual intercourse or masturbation
• stinging or pain on passing urine (dysuria)
• inability to pass urine if the foreskin is very tight.

The changes in the prepuce are due to a condition known as balanitis xerotica obliterans. Circumcision is advisable in most cases.

Acute balanoposthitis

This condition involves redness and swelling of the foreskin, together with a discharge of pus from the space between the foreskin and the glans.

Sometimes the whole penis may be swollen and inflamed. Between 3 and 10 per cent of boys will develop this condition, depending on how the condition is defined.

Balanoposthitis is very occasionally the first sign of diabetes. If there is no underlying cause, simple hygiene measures, mild painkillers and the avoidance of tugging the foreskin are the only necessary treatments. Most cases will recover without further intervention.

Circumcision is only done for recurrent and troublesome cases.

Paraphimosis

This condition is caused by pulling back the foreskin behind the coronal ridge of the glans or head of the penis, without its subsequent replacement to its normal position.

The foreskin then forms a tight tourniquet around the glans, causing severe pain. The condition can sometimes be treated by firmly but gently squeezing the trapped glans until the foreskin can slip over it again.

If this is not possible, the paraphimosis needs to be reduced under a general anaesthetic.

Circumcision is not usually performed at this stage because of the associated inflammation, but may be required later if the foreskin remains tight.

Circumcision to prevent future disease

Prevention of disease is the second most commonly given reason for circumcision after religious reasons, although the evidence that it has any beneficial effect on future health is very poor.

The practice is, more likely, rooted in cultural traditions, although western societies may find this an uncomfortable conclusion.

Penile cancer

Cancer of the penis is an extremely rare disease and, in the early part of the last century, was almost unheard of in circumcised men.

However, there is some evidence that circumcision may only offer protection from penile cancer if done in childhood, and adult surgery may not offer any protection.

Poor personal hygiene, smoking and exposure to wart virus (human papilloma virus) increase the risk of developing penile cancer at least as much as being uncircumcised.

Circumcised men are more at risk from penile warts than uncircumcised men, and the risk of developing penile cancer is now almost equal in the two groups.

Therefore, routine circumcision cannot be recommended to prevent penile cancer.

Sexually transmitted diseases

Sexually transmitted diseases that cause ulcers on the genitals (syphilis, chancroid, herpes simplex) are more common in uncircumcised men.

However, urethritis or inflammation of the tube that carries urine through the penis (caused by gonorrhoea and non-gonococcal urethritis) is more common in circumcised men, as are penile warts.

Yeast infection (caused by candida or thrush) is equally common in circumcised and uncircumcised men, although circumcised men are less likely to have symptoms with this infection so they are more likely to unknowingly pass on thrush to their sexual partners.

Far more effective and reliable methods than circumcision exist to reduce the risk of contracting sexually transmitted diseases, such as the use of condoms and adoption of safer sexual practices. Thus circumcision cannot be recommended to prevent these infections.

Human immunodeficiency virus (HIV) infection

Views conflict on whether circumcision can prevent HIV infection.

A recent review in the British Journal of Urology concluded that there is no link between having an intact foreskin and HIV infection, whereas another paper in the British Medical Journal takes exactly the opposite view.

Circumcision may be appropriate as a routine preventive measure only in regions that have a high rate of HIV infection, such as sub-Saharan Africa. The existing evidence is inadequate to recommend circumcision as an HIV-preventive measure in the UK.

Cervical cancer

A study in 1947 reported that Jewish women rarely developed cervical cancerand the author attributed this finding to the fact that their sexual partners were circumcised.

Further studies over the past 50 years have had contradictory conclusions, with experts enthusiastically championing the case for and against circumcision. The evidence is inadequate to recommend it as a preventive measure against cervical cancer.

Urinary tract infection (UTI)

Since 1987, several studies have suggested that uncircumcised male infants are up to 10 times more likely to contract a urinary tract infection (UTI). One in 100 uncircumcised infants will develop a UTI, compared with 1 in 1000 circumcised infants.

A UTI is not usually a great risk to health, so it does not seem reasonable to perform a surgical procedure on 100 infants to reduce the risk of one developing UTI.

Circumcision as an act of religious dedication

The circumcision of male children is a central feature of both Judaism and Islam. It is also important in many African and New World cultures.

An increasing number of committed Jewish and Muslim people reject circumcision on ethical grounds, although they are certainly the minority at present.

Attitudes to circumcision may provoke fierce hostility within families and among communities. In the past, wars have been fought, and thousands have died, to preserve the right to circumcise when rulers from other cultures forbade it.

Judaism

In the book of Genesis (17: 10-14), circumcision represents the covenant made by God with Abraham and his descendants.

Traditional religious circumcision is performed by a mohel (pronounced mo-hell in Hebrew or moyle in Yiddish). It is usually carried out on the eighth day after birth, unless there is a danger to the child's health, in which case it should be delayed until that danger has passed. In the UK, mohelim attend 40 to 50 circumcisions and have to pass practical and theoretical examinations during their training before performing circumcision alone.

Islam

The divine law or sharia defines every aspect of Muslim life. It is based upon the Holy Koran, the hadith (the sayings of the Prophet Mohammed) and the sunnah (Prophet's tradition).

All Muslims agree that these are the three sources of Islamic law, but different groups interpret their application in different ways. Circumcision is not mentioned in the Koran, but has the status of sunnah. Only the Shafiite school of law regards circumcision as obligatory (wajib), while the Hanafite, Jafarite, Malikite, Hanbalite and Zaidite regard it as only recommended, because it is sunnah.

Even those who consider circumcision an obligatory duty for themselves do not see it as an essential requirement for others to become a Muslim. However, the procedure is very commonly practised and is certainly seen as an important external symbol of submission to God's will.

Should we avoid circumcision?

The foreskin is not simply a useless piece of skin, to be disposed of without careful thought. It forms the covering of the head (glans) of the penis in men and the clitoris in women. It is very rich in nerves responsible for touch and the movement of the foreskin backwards and forwards over the glans provides some of the pleasurable sensation experienced during sex.

Adult males that were circumcised as infants do not usually report sexual problems linked with their circumcision, perhaps because they have never experienced sexual sensation with a foreskin.

However, men circumcised as sexually active adults quite frequently complain of sexual problems arising from either reduced or altered penile sensation.

How is circumcision performed?

Circumcision is usually performed as a day case procedure under a general anaesthetic.

There are many different techniques to achieve the same effect, which is to remove the foreskin and suture the skin on the shaft of the penis to the remaining mucosal lining beneath the head of the penis. The sutures used are absorbable and do not need removal.

Complications of circumcision

Happily, complications of circumcision are relatively rare, although they may be under-reported following religious or cultural circumcision.

For this reason, figures on the rate of complications may not be reliable.

Complications include:

• swelling of the penis which may last a few days (common)
• bleeding, infection, reduced penile sensation (less common)
• tenderness in the scar, poor cosmetic outcome (rare).

Can circumcision be reversed?

Attempts have been made to restore the foreskin following circumcision since ancient times. Unfortunately, no procedure had satisfactory results.

Modern surgical procedures may have more success, but they are still experimental and the long-term results are unknown. If foreskin restoration is being considered, a urologist should be consulted.

Female circumcision is not required by any religious group and is a traditional practice prevalent in Africa, Southeast Asia and South America.

Example image circumcision with clamp tehnic:

The foreskin is a sleeve of tissue which covers the penis. At birth the foreskin is tightly attached. By mid-childhood it can be pulled over the penis when the penis is flaccid, or retracted back over the shaft of the penis during urination or erection.

The common indication for circumcision is cultural or religious desire for circumcision. Other indications (rare):

• treatment for inability to pull back the foreskin completely (phimosis)
• infection of the penis (balanitis)

Circumcision of a newborn boy is usually done before he leaves the hospital. A numbing medication (local anesthesia such as Xylocaine) is injected into the penis to reduce pain. Ring-type clamps are placed around the foreskin, tightened like a tourniquet to reduce bleeding, and the foreskin is removed below the clamp. Sometimes a plastic clamp is used (Plastibell). The Plastibell will fall off in 5 to 8 days, after the surgical site has healed.

For both newborns and older children, circumcision is considered a very safe procedure with complete healing expected. Healing time for newborns usually takes about 1 week. Apply petroleum jelly after diaper changes to protect the healing incision. Some initial swelling and yellow crust formation around the incision is normal. Healing time for older children and adolescents may take up to 3 weeks. In most instances, the child will be discharged from the hospital on the day of the surgery.

It's far more disfiguring, disabling and potentially dangerous than male circumcision so cannot be viewed in the same light. The original author fully supports the World Health Organisation's policy that this procedure should cease throughout the world.