Best Practice Guidance
Penile circumcision is the surgical removal of the foreskin. It is performed as a day case procedure and requires general anaesthetic. While penile circumcision may be undertaken for religious, cultural, or medical reasons, the focus of this guideline is on the medical indications for penile circumcision.
Most foreskin conditions can be managed with simple advice and reassurance. There are a range of treatment options available for foreskin conditions and it’s important that children and their parents are informed of these options prior to the decision to perform a penile circumcision, which cannot be reversed once performed.
While major morbidity and mortality following medical penile circumcision is very rare, these could be reduced and potentially avoided if surgical indications were more stringently applied.
Medical penile circumcision is rarely indicated as a primary treatment. Most children and young people presenting with penile problems require no intervention other than reassurance.
This guidance applies to children and young people under 16 years.
This guidance excludes children and young people with congenital penile conditions such as hypospadias.
Penile circumcision should only be performed for:
- Prevention of urinary tract infection (UTI) in patients with recurrent UTIs or at high
risk of UTI
- Pathological phimosis (balanitis xerotica obliterans /lichen sclerosus)
- For persistent phimosis in children approaching puberty, following an attempted
a trial of non-operative interventions e.g. a six-week course of high-dose topical
steroid. A prescription of this would not normally exceed three months and should
have achieved maximal therapeutic benefit within this time. A topical steroid such
as Betamethasone (0.025-0.1%) is commonly prescribed.
- Acquired trauma where reconstruction is not feasible, for example, following zipper
trauma or dorsal slit for paraphimosis
ALL patients must have a formally documented discussion of the risks and benefits of foreskin preserving surgery versus penile circumcision using a shared decision making framework.
Please note that this guidance is intended as a standard threshold for access. However, if you/ your patient falls outside of these criteria, the option to apply for an Individual Funding Request is still available to you.
Rationale for recommendation
The diagnostic code most often used for medical penile circumcision is phimosis. Phimosis is normal in babies and young children as the foreskin and glans of the penis are initially fused.
The percentage of children with full retraction of the foreskin increases with age. By the age of six years, approximately 8/100 cannot retract their foreskin at all, and 63/100 have adhesions which prevent the foreskin from being fully retracted. Since 99% of all childrenwith a penis have full retraction of the foreskin by age 17 years, this leaves only one in 100 requiring medical penile circumcision for phimosis by their 17th birthday.
The GIRFT Paediatric General Surgery and Urology National Report reviewed medical penile circumcisions performed in hospital trusts in England and found variation in volumes and activity:
- 17.5% of penile circumcisions are in children aged under five years old
- In some trusts, as many as 50% of children are under the age of five years at the
time of their procedure.
It is important to note that young children, especially those aged under five years are unable to give informed consent or assent and therefore it is especially important that surgeons and parents consider the evidence base and consider less radical options when making the decision to perform penile circumcision, which cannot be reversed once performed.
Penile circumcision is the removal of the foreskin from the penis. This guidance does not focus on religious or cultural reasons for penile circumcision. It refers only to the medical indications for penile circumcision in children and young people under 16 years of age. Phimosis (where the foreskin is too tight to be pulled back over the head of the penis) is normal in babies and young children. The percentage that can fully retract the foreskin increases with age.
Evidence shows that there is a wide variation in numbers of penile circumcision performed across the England. It is important to note that young children may be unable to give informed consent to penile circumcision, therefore clinicians should carefully consider the evidence-base and alternative options available.
The EBI programme proposes clear, evidence-based criteria for use across England.
We recommend using the BRAN principles (Benfits, Risks, Alternatives and do Nothing) when speaking with patients about this.
Further information on patient involvement in EBI can be found on the EBI for patients section.
WHEN LEFT(der.Spell_Dominant_Procedure,4) IN ('N303’) AND APCS.Der_Diagnosis_All LIKE '%N47%’ AND (NOT( APCS.Der_Diagnosis_All LIKE '%N390%’ OR APCS.Der_Diagnosis_All LIKE '%N48%’ OR APCS.Der_Diagnosis_All LIKE '%Q54%’ OR APCS.Der_Diagnosis_All LIKE '%Q55%' ) OR APCS.Der_Diagnosis_All IS NULL ) THEN '3J_Penile_Circumcision'
Procedure codes (OPCS)
Diagnosis codes (ICD)
N47X Redundant prepuce, phimosis and paraphimosis
N390 Urinary tract infection, site not specified (current infection – only added unspecified site code as most likely)
Z874 Personal history of diseases of the genitourinary system (history of infection – not specific to UTI)
N480 Leukoplakia of penis
Q540 Hypospadias, balanic
Q541 Hypospadias, penile
Q542 Hypospadias, penoscrotal
Q543 Hypospadias, perineal
Q544 Congenital chordee
Q548 Other hypospadias
Q549 Hypospadias, unspecified
Q553 Atresia of vas deferens
Q554 Other congenital malformations of vas deferens, epididymis, seminal vesicles and prostate
Q555 Congenital absence and aplasia of penis
Q556 Other congenital malformations of penis
Q558 Other specified congenital malformations of male genital organs
Q559 Congenital malformation of male genital organ, unspecified
apcs.der_diagnosis_all not like '%C[0-9][0-9]%' and apcs.der_diagnosis_all not like '%D0%' and apcs.der_diagnosis_all not like '%D3%' and apcs.der_diagnosis_all not like '%D4%’
This code captures code in the ranges C00-C99, D00-D09 and D37-D48.
Age range: the codes use the following age ranges 0-18 for children and 19-120
— Private Appointment Exclusion
- Royal College of surgeons. 2016. Foreskin Conditions – Commissioning Guide
- British Association of Paediatric Urologists on behalf of the British Association of Paediatric Surgeons and the Association of Paediatric Anaesthetists. 2007. Management of foreskin conditions.
- Rickwood AM, Hemlatha V, Batcup G, Spitz L. (1980) Phimosis in boys. Br J Urol; 52:147-150
- Rickwood AM, Walker J. (1989) Is phimosis over diagnosed in boys and are too many circumcisions performed in consequence? Ann R Coll Surg Engl; 71:275-7
- Shankar KR, Rickwood AM. (1999) The incidence of phimosis in boys. BJU Int; 84:101-2
- Yang C, Liu X, Wei GH. (2009) Foreskin development in 10 421 Chinese boys aged 0-18
years. World J Pediatr. Nov; 5(4):312-5
- Tekgul S, Riedmiller H, Gerharz E, Hoebeke P, Kocvara R, Nijman R, et al. Guidelines on Paediatric Urology. European Association of Urology. 2013
- Kayaba, H., Tamura, H., Kitajima, S., Fujiwara, Y., Kato, T. and Kato, T. (1996). Analysis of Shape and Retractability of the Prepuce in 603 Japanese Boys. Journal of Urology, 156(5), pp.1813–1815
- Oster, J. (1968). Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Archives of Disease in Childhood, 43(228), pp.200–203
- Spilsbury, K., Semmens, J.B., Holman, C.D.J. and Wisniewski, Z.S. (2003). Circumcision for phimosis and other medical indications in Western Australian boys. Medical Journal of Australia, 178(4), pp.155–158
- Green PA, Bethell GS, Wilkinson DJ, Kenny SE, Corbett HJ. (2019 ) Surgical management of genitourinary lichen sclerosus et atrophicus in boys in England: A 10-year review of practices and outcomes. J Pediatr Urol. Feb;15(1):45.e1-45.e5 https://doi.org/10.1016/j.jpurol.2018.02.027
- GIRFT Programme National Specialty Report. 2021Paediatric General Surgery and Urology.
(Pending formal approval)
- Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Arch Dis Child, 2005; 90:853–858.
How up to date is this information?
Last revised - December 2023
December 2023 - Coding updated