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Circumcision (Male)

  

Male circumcision is the surgical removal of the foreskin


Circumcision

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

1 Prior Approval

Prior approval from the Integrated Care Board (ICB) will be required before any treatment proceeds in secondary care unless an alternative contract arrangement has been agreed with the ICB that does not necessitate the requirement of prior approval before treatment

2. Background

Penile circumcision is the removal of the foreskin from the penis. 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 policy is on the medical indications for penile circumcision

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

Most foreskin conditions can be managed with simple advice and reassurance. There are a range of treatment options available for foreskin conditions and it is 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

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 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 children with 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

NB: Circumcision refers to male circumcision only. Female circumcision is prohibited in law by the Female Genital Mutilation Act 2003 and is the subject of multi-agency guidelines from the Department of Health

3. Eligibility Criteria

Cosmetic, social, cultural and religious reasons – NOT funded

Male Circumcision under 16 years of age

This policy 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

Male Circumcision over 16 years of age

  • Male Circumcision for clinical indications funded with following clinical indications:
  • Pathological phimosis OR
  • Three documented episodes of balanoposthitis OR
  • Relative indications for circumcision or other foreskin surgery include the following:

o Prevention of urinary tract infection in patients with an abnormal urinary tract

o Recurrent paraphimosis

o Trauma (e.g. zipper injury)

o Tight foreskin causing pain on arousal/ interfering with sexual function

o Congenital abnormalities

Absolute indications for circumcision

  • Penile malignancy
  • Traumatic foreskin injury where it cannot be salvaged

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

For patients who DO NOT meet the eligibility criteria, the ICB will only consider funding the treatment if an Individual Funding Request (IFR) detailing the patient’s clinical presentation is submitted to the ICB.

4. Guidance/References

Penile circumcision – EBI (aomrc.org.uk)

Circumcision in boys – NHS (www.nhs.uk)

Circumcision in men – NHS (www.nhs.uk)

bma-non-therapeutic-male-circumcision-of-children-guidance-2019.pdf

Circumcision.pdf (baus.org.uk)

The Contrasting Evidence Concerning the Effect of Male Circumcision on Sexual Function, Sensation, and Pleasure: A Systematic Review – PubMed (nih.gov)

 

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