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Penile circumcision

Penile circumcision

Best Practice Guidance

How up to date is this information?

Published January 2023 | Last reviewed September 2024

Using this guidance

The guidance set out here was reviewed extensively in the Autumn of 2024. There are no plans for any further reviews.

Medicine is constantly evolving and over time it is inevitable that the evidence base will change. Please use your own judgement and/or other sources of clinical guidance alongside the information set out here.

Please note this guidance is a recommendation and it should be used in the context of the overall care pathway and when all alternative interventions that may be available locally have been undertaken.

Summary

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.

Recommendation

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

OR

  • Pathological phimosis (balanitis xerotica obliterans /lichen sclerosus)

OR

  • 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.

OR

  • 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.

Patient information

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.

 

 

Make the most of your appointment using BRAN

2020

Coding

WHEN LEFT(Primary_Spell_Procedure,4) IN ('N303')
AND Any_Spell_Diagnosis LIKE '%N47%' 
AND (NOT( Any_Spell_Diagnosis LIKE '%N390%'
OR Any_Spell_Diagnosis LIKE '%N48[01]%'
OR Any_Spell_Diagnosis LIKE '%Q54[0123489]%'
OR Any_Spell_Diagnosis LIKE '%Q55[345689]%'
)
OR Any_Spell_Diagnosis IS NULL
)
-- Age between 0 and 15
AND (isnull(APCS.Age_At_Start_of_Spell_SUS,APCS.Der_Age_at_CDS_Activity_Date) between 0 AND 15
OR isnull(APCS.Age_At_Start_of_Spell_SUS,APCS.Der_Age_at_CDS_Activity_Date) BETWEEN 7001 AND 7007)
THEN '3J_Penile_Circumcision'
Exclusions
WHERE 1=1
-- Cancer Diagnosis Exclusion
AND (Any_Spell_Diagnosis not like '%C[0-9][0-9]%' 
AND Any_Spell_Diagnosis not like '%D0%' 
AND Any_Spell_Diagnosis not like '%D3[789]%' 
AND Any_Spell_Diagnosis not like '%D4[012345678]%' 
OR Any_Spell_Diagnosis IS NULL)
-- Private Appointment Exclusion
AND apcs.Administrative_Category<>'02'

References

  1. Royal College of surgeons. 2016. Foreskin Conditions – Commissioning Guide
  2. 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.
  3. Rickwood AM, Hemlatha V, Batcup G, Spitz L. (1980) Phimosis in boys. Br J Urol; 52:147-150
  4. 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
  5. Shankar KR, Rickwood AM. (1999) The incidence of phimosis in boys. BJU Int; 84:101-2
  6. 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
  7. Tekgul S, Riedmiller H, Gerharz E, Hoebeke P, Kocvara R, Nijman R, et al. Guidelines on Paediatric Urology. European Association of Urology. 2013
  8. 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
  9. 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
  10. 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
  11. 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
  12. GIRFT Programme National Specialty Report. 2021Paediatric General Surgery and Urology.
    (Pending formal approval)
  13. 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.
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