Circumcision (adults and children) – Information for GPs
This commissioning policy is needed because male circumcision (defined as the surgical removal of all or part of the foreskin of the penis) may be done for certain medical reasons, but is often sought for cultural or religious reasons. Circumcision is not routinely commissioned by NHS Scarborough and Ryedale CCG unless medically necessary.
NB Circumcision refers to male circumcision only. Female circumcision is prohibited in law by the Female Genital Mutilation Act 2003 (ref 1) and is the subject of multi-agency guidelines from the Department of Health (ref 2).
NHS Scarborough and Ryedale CCG do not routinely commission Circumcision unless there is evidence of ONE of the following clinical indications:
- Balanitis Xerotica Obliterans (BXO) (chronic inflammation leading to a rigid fibrous foreskin) in males aged 9 years and over
- Potentially malignant lesions of the prepuce or those causing diagnostic uncertainty
Discrepancy between regional UK circumcision rates suggest a significant number of circumcisions are being unnecessarily performed and commissioning guidance is intended to provide the necessary information to identify and introduce conformity in the frequency of procedures undertaken though better understanding, and differentiation between disease and physiological change in the foreskin (3).
Funding will only be considered where there are exceptional clinical circumstances. The clinician needs to submit an application to the CCG’s Individual Funding Request Panel (IFR).Providing evidence of any of the following clinical indications:
- Congenital abnormalities
- Distal scarring of the preputial orifice
- Painful erections secondary to a tight foreskin
- Recurrent bouts of infection (balanitis/balanoposthitis
- Redundant prepuce, phimosis (inability to retract the foreskin due to a narrow prepucial ring) sufficient to cause ballooning of the foreskin on micturition; and paraphimosis (inability to pull forward a retracted foreskin).
- Pain on intercourse
- Traumatic injury
Summary of evidence / rationale
Nearly all boys are born with non-retractable foreskins as they are still in the process of developing and are often non-retractable up to the age of 3 years old. During normal development, the foreskin gradually becomes retractable without the need for any intervention. The majority of boys will have a retractable foreskin by 10 years of age and 95% by 16-17 years of age. Inability to retract the foreskin in boys up to at least the age of 16, in the absence of scarring, is, therefore, physiologically normal and does not require any intervention.
Paraphimosis (where the foreskin becomes trapped behind the glans and cannot go forward again) can usually be reduced under local anaesthetic and recurrence avoided by not forcibly retracting the foreskin. It should not be regarded as a routine indication for circumcision. There are several alternatives to treating retraction difficulties before circumcision is carried out. The BMA (ref 4) states that to circumcise for therapeutic reasons, where medical research has shown other techniques (such as topical steroids or manual stretching under local anaesthetic) to be at least as effective and less invasive, would be unethical and inappropriate.
Common risks of surgical circumcision include bleeding, local sepsis, oozing, discomfort >7 days, meatal scabbing or stenosis, removal of too much or too little skin, urethral injury, amputation of the glans and inclusion cyst (ref 5). Furthermore, long-term psychological trauma and possible decreased sexual pleasure have also been reported. There are claims that there may be health benefits associated with this procedure, for example a lower rate of penile cancer and a reduced chance of sexual transmitted diseases (including HIV among heterosexual men) (ref 6). However, the overall clinical and cost-effectiveness evidence is inconclusive. Condoms are far more effective (98% effective if used correctly) than circumcision for preventing STIs.
1. Female Genital Mutilation Act 2003
2. Female genital mutilation: multi-agency practice guidelines. Department of Health, April 2016
3. Royal College of Surgeons Commissioning guide: Foreskin conditions 2016 can be found here.
4. British Medical Association (2006), London. The law and ethics of male circumcision: guidance for doctors. J Med Ethics 2004; 30: 259–263. http://jme.bmj.com/content/30/3/259.full.pdf+html
5. British Association of Paediatric Surgeons, The Royal College of Nursing, The Royal College of Paediatrics and Child Health, The Royal College of Surgeons of England and The Royal College of Anaesthetists. (2001) “Statement on Male Circumcision”. http://www.rcseng.ac.uk/media/press-releases-new-system/2001/statement-on-male-circumcision
6. Siegfried N, Muller M, Deeks J, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database of Systematic Reviews 2009, Issue 2. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003362/pdf_fs.html
7. NHS Choices – Information on Circumcision and medical reasons why it may be necessary. http://www.nhs.uk/Conditions/Circumcision/Pages/Introduction.aspx