intact makes things harder for hospital patients

[USAmma]

I am very much against circ, but I'm also a student nurse about to graduate. I'm on a unit where several intact patients have needed catheters, and there are some hygiene issues also. It is very very difficult to cath an intact patient when there are neuro issues involved and the pt has no nerve function and there is atrophy. I don't know how else to put this delicately. It gets somewhat embedded. It's hard to find the urethra and causes pain and embarrassment for the patient, and difficulty for the nurses. There are also some hygiene issues involving incontinent male patients who wear the adult diapers- just very hard to clean all the skin layers.

I'm starting to understand why medical professionals, especially those who don't know that the foreskin has a purpose on healthy males, are so pro-circ. It's just easier and cleaner. We always think of our healthy baby boys growing into healthy men, but for the ones who are not healthy, the foreskin can honestly make them more prone to infection.

Please don't flame me-- in fact I'm looking for advice on how to care for these patients better and keep them cleaner and free of infection. If anyone has advice I'd love to hear it so I can make a difference with my patients.

[paquerette]

Can you search journals etc for writings by nurses in other countries? European nurses must deal with this a lot.

[Night_Nurse]

I've been a nurse for a long time. It has been a while since I worked with elderly men in both the hospital and home setting, but I never encountered a problem with foreskin issues. When I was a nurse's aide I bathed some intact men and don't recall any hygiene issues. The only one thing I can think of was when I was a young nurse I tried to cath an elderly intact man. He had a lot of loose foreskin and you know you have to grip the penis firmly w/ your non-dominant hand when inserting the cath. Well, all his loose skin made it difficult to "hold tight". I chalk it up to my inexperience at the time because I called in a more experienced nurse and she was able to cath 1st try, no problem. I've also never had a problem cathing one since (the other intact males I've cathed didn't seem to have so much skin as this one).

I have, however, had NUMEROUS experiences with elderly women who were incontinent and unable to open their legs for cleaning. Lots of folds to clean in that situation and I'd never advocate removing labia for that situation. It just took a few extra minutes of wiping to get the job done. No biggie.

The only advice I can give, and I'm sure you know this, but please make sure any co-workers know that if you retract a grown man to clean him that you do replace the foreskin forward. Not doing so could lead to a major situation! My sister once worked in a nursing home and said nobody at her work knew to do that!!!

[goinggreengirl]

I'd also suggest that US nurses/ doctors/ medical personnel look to outside of the US for information. There has to be information out there since most other countries do not routinely circ.

[eepster]

In an adult male, it is OK to retract.  The no retracting rule is for children who haven't fully developed yet.

[katelove]

Hi,

I am a registered nurse in Australia. I have looked after many circ'ed patients and I can honestly say it has never been an issue. From a cleaning point of view, I clean the outside of the penis first, using the index finger and thumb of one hand to make a ring around the base of the penis and stretching the skin gently to open any folds. Then retract and clean under the foreskin and, as a PP mentioned replace the foreskin afterwards.

For catheterisation I use the same ring technique but I use the ring to retract the foreskin by placing it on the head of the penis and sliding it to the base of the glans, taking the foreskin with me. I hold it firmly and wrap the rest of my fingers around the shaft of the penis. To overcome the embedding you mentioned you can use your little finger and the side of your hand to press into the flesh around the base of the penis which kind of pops it outwards a bit. It can be very tricky if the external part of the penis is very small but, if that's the case then the circ doesn't matter much either way to the degree of difficulty. If it's so small you can't grasp it then use the fingers of one hand on either side of the base to pop it out and grasp with the other hand.

I hope that makes sense. All the best with the rest of your course.

[Fyrestorm]

Do they suggest removing baby girls labia to make them easier to clean and cath in the event that they end up needing nursing care as an older adult? 

[Lauren82]

When I worked with the elderly, I never had a problem washing intact men. I just got in there and did it. No one was ever infected. Same with the women who were often overweight and much harder to get in all of the folds. I never felt as if someone needed to be circed to make my job easier.

[QueenOfTheMeadow]

Originally Posted by katelove 

Hi,

I am a registered nurse in Australia. I have looked after many circ'ed patients and I can honestly say it has never been an issue. From a cleaning point of view, I clean the outside of the penis first, using the index finger and thumb of one hand to make a ring around the base of the penis and stretching the skin gently to open any folds. Then retract and clean under the foreskin and, as a PP mentioned replace the foreskin afterwards.

For catheterisation I use the same ring technique but I use the ring to retract the foreskin by placing it on the head of the penis and sliding it to the base of the glans, taking the foreskin with me. I hold it firmly and wrap the rest of my fingers around the shaft of the penis. To overcome the embedding you mentioned you can use your little finger and the side of your hand to press into the flesh around the base of the penis which kind of pops it outwards a bit. It can be very tricky if the external part of the penis is very small but, if that's the case then the circ doesn't matter much either way to the degree of difficulty. If it's so small you can't grasp it then use the fingers of one hand on either side of the base to pop it out and grasp with the other hand.

I hope that makes sense. All the best with the rest of your course.

Thank you so much for the specific technique! It's nice to have a nurse from another country that deals with a lot more intact older patients. It sounds like the a lot of nurses and medical personal aren't taught to deal with intact patients. I think it's always good to remember that so many other countries do just fine with intact men than we do.

[Frootloop]

I understand and will actually agree that being intact may make it "harder" to clean and cath.. but that only means that it takes a bit more effort and maybe a few more steps to do what needs to be done. I worked for a very brief time in a nursing home while studying to become a CNA (I just wasn't cut out for it), and I have cleaned elderly womens' genitals and let me tell you, I can guarantee it would've been easier without all that labia in the way. Elderly women are prone to infections, as well, but no one would dare think to wish they'd had any part of genitals removed so that it would be easier on the worker.

As far as embarrassment goes.. both elderly men AND women can be embarrassed by someone needing to take over cleaning their genitals.. but perhaps elderly intact men will voice or show their embarrassment more than women because they realize the unfortunate situation that healthcare workers aren't used to dealing with intact foreskin (yet!!)? Or perhaps it's just because most elderly women have given birth and have already had a ton of doctors and nurses manhandling their bits throughout their lives and are therefore used to it? I just don't see this isn't an "intact" issue at all.. The elderly men that I worked with (both circ'd and intant) were definitely far more tense about me cleaning them up than the elderly women were. They apologized repeatedly. The vast majority of the women weren't concerned at all.. but as I said before, I believe it's just because they were used to being messed with down there. It's just part of being a woman.   

[Frootloop]

I have no idea why my previous post is all pushed to the side like that.. and for some reason, I'm unable to edit my post at all. Hmm.

[WildKingdom]

I think it is important to realize that an indwelling foley catheter is a major source of infection no matter what.  We see a ton of these infections in both inpatients and outpatients, and they are a major source of morbidity.  I don't have statistics off the top of my head, but the rate of infection is so high that I seriously doubt that there is a big difference between men who are circumcised and men who are intact.  Honestly, the most important thing is not to use these catheters unnecessarily.  They are often placed for the convenience of the caregivers, not the patient, because it's a lot easier to empty a foley bag then to constantly change pads and carefully maintain skin integrity or to constantly put a patient on a bedpan or assist out of bed to the commode.  However, unless the patient has some sort of outlet obstruction or you have to carefully monitor their urine output, a foley is usually not necessary.

[USAmma]

Thanks so much for the input! Perhaps I just don't have enough experience yet. I did take care of a couple of intact men at a nursing home no problem, but somehow the few in the hospital were just very challening. It was just so retracted into the body from neuro issues already and then on top of it the foreskin was hiding things. It was both an issue of them being really obese, and being neurologically impaired. Sorry don't mean to be so graphic-- just trying to describe the problem. I think too that the nurses I was trying to learn from were not that experienced either, with this type of patient.

Great idea to ask around on the internet with people from other countries!

I agree that taking care of some women is also challenging if they are large/obese and unable to help with positioning. At the hospital where I have done clinicals the main reason for foleys is to get an exact measurement of urine because of kidney failure, surgery etc. It is the policy to d/c ASAP and avoid the use of them. They would rather change the bed lines 10x a day rather than use the catheters, and actually they seem to really be on top of it so that people get cleaned up quickly. You rarely see the adult diapers either unless the client is trying to ambulate or personally asks for them. There is too much risk of skin breakdown.

[katelove]

Originally Posted by USAmma 

Thanks so much for the input! Perhaps I just don't have enough experience yet. I did take care of a couple of intact men at a nursing home no problem, but somehow the few in the hospital were just very challening. It was just so retracted into the body from neuro issues already and then on top of it the foreskin was hiding things. It was both an issue of them being really obese, and being neurologically impaired. Sorry don't mean to be so graphic-- just trying to describe the problem. I think too that the nurses I was trying to learn from were not that experienced either, with this type of patient.

Great idea to ask around on the internet with people from other countries!

I agree that taking care of some women is also challenging if they are large/obese and unable to help with positioning. At the hospital where I have done clinicals the main reason for foleys is to get an exact measurement of urine because of kidney failure, surgery etc. It is the policy to d/c ASAP and avoid the use of them. They would rather change the bed lines 10x a day rather than use the catheters, and actually they seem to really be on top of it so that people get cleaned up quickly. You rarely see the adult diapers either unless the client is trying to ambulate or personally asks for them. There is too much risk of skin breakdown.

That certainly sounds like a particularly challenging set of issues. I'm not sure I've ever looked after anyone with all those issues combined but, hopefully, the techniques I described should make it possible, if not easy.

Do you ever use uridomes/condom catheters? Not for females obviously but they can be a useful alternative for males in some circumstances. I've seen used primarily overnight so that the person's sleep doesn't have to be interrupted to change a wet bed and it keeps urine away from fragile skin.

[JulianneW]

Originally Posted by USAmma 

I am very much against circ, but I'm also a student nurse about to graduate. I'm on a unit where several intact patients have needed catheters, and there are some hygiene issues also. It is very very difficult to cath an intact patient when there are neuro issues involved and the pt has no nerve function and there is atrophy. I don't know how else to put this delicately. It gets somewhat embedded. It's hard to find the urethra and causes pain and embarrassment for the patient, and difficulty for the nurses. There are also some hygiene issues involving incontinent male patients who wear the adult diapers- just very hard to clean all the skin layers.

I'm starting to understand why medical professionals, especially those who don't know that the foreskin has a purpose on healthy males, are so pro-circ. It's just easier and cleaner. We always think of our healthy baby boys growing into healthy men, but for the ones who are not healthy, the foreskin can honestly make them more prone to infection.

Please don't flame me-- in fact I'm looking for advice on how to care for these patients better and keep them cleaner and free of infection. If anyone has advice I'd love to hear it so I can make a difference with my patients.

I don't have a problem with your post. If someone viewed foreskin as a useless piece of skin that made their job more difficult I can see why someone could be for circumcision.  

 If I were in your position I would research the foreskins immunology and antibacterial protection.

After much research and some experience I personally think that it is easier to keep a natural man clean and infection free.

Why do I think this? 

 The inner foreskin is made up of a mucosa membrane much like that found in the mouth or eye lid. This mucosa membrane maintains optimal pH balance and cleanliness. Plasma cells in the mucosa lining secrete immunoglobulins which are antibodies that defend against infection. The foreskin also produces antibacterial and antiviral proteins such as lysozyme. Lysozyme is also found in tears. The foreskin also produces specialized Langerhans cells. That being said the foreskin should also protect the urethra from getting fecal matter or harmful bacteria in it.

 Improper care such as over washing or washing the glans and inner foreskin with soap, destroys the beneficial bacteria flora and pH balance that protect the penis from harmful germs and can lead to irritation and infection. Just as you would not douche with soap you should not wash a mans internal sex organ (head and inner foreskin) with soap. 

In order to avoid over washing think of it as you would a healthy man, when an intact man goes to the bathroom he wipes it like a finger and then eventually rinses it in the shower. Much like the vagina gets rinsed in the tub. I think the most important thing to understand is that the inner foreskin is NOT DIRTY, it has its own cleaning system. An un retractable man stays healthy and clean simply by peeing. The pee flushes out any bad bacteria and the amazing inner mucosa takes care of the rest.

For me personally wiping an intact penis like a finger is easier than wiping a circumcised penis because I don't have to make sure the head is clean (I know it is because its covered). Occasionally retracting and rinsing is no big deal.

I have however, never cared for someone with the issues you mentioned. I hope this information can be of some use to you :)

[QueenOfTheMeadow]

Originally Posted by JulianneW 

I don't have a problem with your post. If someone viewed foreskin as a useless piece of skin that made their job more difficult I can see why someone could be for circumcision.  

 If I were in your position I would research the foreskins immunology and antibacterial protection.

After much research and some experience I personally think that it is easier to keep a natural man clean and infection free.

Why do I think this? 

 The inner foreskin is made up of a mucosa membrane much like that found in the mouth or eye lid. This mucosa membrane maintains optimal pH balance and cleanliness. Plasma cells in the mucosa lining secrete immunoglobulins which are antibodies that defend against infection. The foreskin also produces antibacterial and antiviral proteins such as lysozyme. Lysozyme is also found in tears. The foreskin also produces specialized Langerhans cells. That being said the foreskin should also protect the urethra from getting fecal matter or harmful bacteria in it.

 Improper care such as over washing or washing the glans and inner foreskin with soap, destroys the beneficial bacteria flora and pH balance that protect the penis from harmful germs and can lead to irritation and infection. Just as you would not douche with soap you should not wash a mans internal sex organ (head and inner foreskin) with soap. 

In order to avoid over washing think of it as you would a healthy man, when an intact man goes to the bathroom he wipes it like a finger and then eventually rinses it in the shower. Much like the vagina gets rinsed in the tub. I think the most important thing to understand is that the inner foreskin is NOT DIRTY, it has its own cleaning system. An un retractable man stays healthy and clean simply by peeing. The pee flushes out any bad bacteria and the amazing inner mucosa takes care of the rest.

For me personally wiping an intact penis like a finger is easier than wiping a circumcised penis because I don't have to make sure the head is clean (I know it is because its covered). Occasionally retracting and rinsing is no big deal.

I have however, never cared for someone with the issues you mentioned. I hope this information can be of some use to you :)

I am sure that USAmma is aware of these things, although there are many people in the health care profesion who are not. She is an active poster in TCAC and has given a presentation to her other nursing students regarding the issues that can be caused by circ and the correct care of an intact penis. I think she was just coming here for support and information regarding what she was experiencing at work in regards to having catheterize older intact patients with numerous issues. And it looks like she got some wonderful advice!

I really hope this helps with some of the problems you are dealing iwth at work! If it does, it might be something you could pass on to your fellow nurses!

[jessjgh1]

NOCIRC has a general pamphlet on intact care for hospital workers  (http://nocirc.org/publish/).

[PlainandTall]

While I understand the spirit behind the original post, the tile had a slant that is biased against the natural human form.

I am reminded of a quote about surgery- but I'm sorry I don't remember it exactly- it goes something like... "The greatest obstacle to the surgeon is the life of the patient." While this concept may seem shocking and confusing- after all- we are trained to believe that the life of the patient is the thing the surgeon aims to preserve- the gritty fact is- the life of the patient is the thing that makes it hard for the surgeon to do their job.  If it wasn't for all that messy business of sustaining life- a surgeon could approach their task much more directly and with many fewer things in their way.  If all they had to do was tackle a tumor- without worrying about bloodflow or impaired function- well- that would be as simple as carving a turkey!

Well- the same goes for nursing, your patient is not just a check mark on a  "to do list" of blood pressure cuffs and butt wipings... they are a person... and the nature of people is that they have a lot of human baggage that comes in the way of you simply getting the job done.  Things like human dignity, feelings of anxiety or pain, pride, denial etc.  They have pecular habits that are not accomidated by hospitalization, they are out of their element.  They may have a large concerned family that nit-picks your every move... or they may have no family at all- leaving them unsupported and dependant on you to help them emotionally not despair.    I am sure that you make an effort as a nurse to make a human connection with your patients- to call them by their name, or to make some small talk to break the ice before jabbing them with a needle... you know that making that effort is not just a nicety- but is an integral part of your job as a nurse.  Embracing the humanbeingness of your patients has got to be a major pain and adds tremendously to your job- but if it was not for that- you would not be a nurse, you'd be a butt-wipe technician (and I don't mean that to be an insult- I mean that to show you that I know and respect the true value and work of nurses!!!)

So- what I'm getting at- is, humanbeingness makes things harder for hospital patients.  If we could just strip people of all the stuff that makes us unique and valueable people and just make them bodies in beds that the technicians could monitor and medicate- that would  make things a lot easier on hospital staff... but we wouldn't dream of wishing that on our human souls- and I doubt that you would find working in such an institution very rewarding. 

Just as you must learn to love all the human quirks that make your patients individuals- and not just cases by number, you- and all medical professionals- need to accept the entire male body and all that goes along with caring for it even in old age or illness- just as you unquestioningly accept the issues that go along with female patients.  If you catch wind of attitudes that do not respect the whole emboddied patient- you should make an effort to confront and correct them.  I hope that there is information available to you and your peers about how best to manage the natural male body in these special circumstances.

There is a blog post here written by a nurse:

http://mannursediaries.blogspot.com/2010/03/circumcision-males-perspective.html 

[Papai]

Originally Posted by USAmma 

Thanks so much for the input! Perhaps I just don't have enough experience yet. I did take care of a couple of intact men at a nursing home no problem, but somehow the few in the hospital were just very challening. It was just so retracted into the body from neuro issues already and then on top of it the foreskin was hiding things. It was both an issue of them being really obese, and being neurologically impaired. Sorry don't mean to be so graphic-- just trying to describe the problem. I think too that the nurses I was trying to learn from were not that experienced either, with this type of patient.

Great idea to ask around on the internet with people from other countries!

I agree that taking care of some women is also challenging if they are large/obese and unable to help with positioning. At the hospital where I have done clinicals the main reason for foleys is to get an exact measurement of urine because of kidney failure, surgery etc. It is the policy to d/c ASAP and avoid the use of them. They would rather change the bed lines 10x a day rather than use the catheters, and actually they seem to really be on top of it so that people get cleaned up quickly. You rarely see the adult diapers either unless the client is trying to ambulate or personally asks for them. There is too much risk of skin breakdown.

Sounds like the obesity played more of a factor in any difficulties you had than the presence of a foreskin, as the fat pad of the pelvis overwhelming the penis made getting to the penis difficult.

As an intact male, I've been cathed with no problem. In normal healthy intact males, retraction is not an issue.