The Royal College of Surgeons, England has published the following documents for doctors and surgeons regarding the commissioning of foreskin conditions.
In the financial year 2013/2014, activity and cost rates for foreskin condition procedures in patients aged 18 years and below in England were as follows:
Procedures
- Circumcision
- Frenuloplasty
- Preputioplasty
- Freeing of adhesions of prepuce
- Dorsal slit on prepuce, stretching of prepuce
- Other procedures
Key Notes
- In children under 18 years, pathological phimosis must be distinguished from physiological adherence of the foreskin to the glans, which is normal.
- In adults, the differential diagnosis includes STDs and skin diseases such as eczema, psoriasis, lichen planus, Zoon’s balanitis, carcinoma in situ (CIS), and frank squamous carcinoma.
- Circumcision in an adult may also be undertaken for premalignant conditions, CIS, and for biopsy where disease other than lichen sclerosus cannot be excluded.
- Balanitis refers to inflammation of the glans penis, posthitis to inflammation of the inner foreskin/prepuce, and balanoposthitis to inflammation of both. Balanoposthitis can often be chronic, not just acute.
- Non-retractile ballooning of the foreskin and spraying of urine do not routinely require circumcision, although some cases may be due to lichen sclerosus.
Foreskin Retractability by Age
- Birth: 4%
- 6 months: 20%
- 1 year: 50%
- 3–11 years: 90%
- 12–13 years: 95%
- 14+ years: 99%
Parents and patients should be made aware of the risks and benefits of circumcision.
Clinical Workload and Referrals
- Referrals from primary care for physiological phimosis account for significant consultation time that could be avoided.
- Conservative management of the non-retractile foreskin is under-recognised in some regions.
- This is especially important in the paediatric population, where too many circumcisions are undertaken for physiological phimosis, leading to avoidable morbidity.
- Outpatient referrals are seen by paediatric surgeons, paediatric urologists, adult general surgeons or urologists with paediatric practice, paediatricians, or specially trained clinical nurse specialists.
- Only a minority of children will have pathology and be subsequently listed for circumcision.
Indications for Circumcision
- Pathological phimosis (commonly caused by lichen sclerosus; BXO is an outdated term)
- Recurrent episodes of balanoposthitis
Relative Indications for Circumcision or Foreskin Surgery
- Prevention of urinary tract infection in patients with an abnormal urinary tract
- Recurrent paraphimosis
- Traumatic injury (e.g. zipper injury)
- Tight foreskin causing pain on arousal or interfering with sexual function
- Congenital abnormalities
Non-therapeutic circumcision is not within the scope of this document. However, doctors or others who undertake circumcisions for non-medical indications (in hospitals or the community) are scrutinised like any aspect of medical practice.
If their practice is criticised, they can defend themselves against litigation provided they can:
- Show their practice is considered reasonable by peers (expert opinion).
- Demonstrate that the expert opinion can survive logical scrutiny in court.
Resource
Revised Foreskin Conditions Commissioning Guide (2016) – Royal College of Surgeons