Revised Foreskin Conditions Commissioning Guide (2016)

By: Dr. Khan

Published: September 3, 2017

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:

  1. Show their practice is considered reasonable by peers (expert opinion).
  2. Demonstrate that the expert opinion can survive logical scrutiny in court.

Resource

Revised Foreskin Conditions Commissioning Guide (2016) – Royal College of Surgeons

Dr. A.R Khan

Paediatric Surgeon/Urologist

Bio

BSC, MBBS, FRCS, FEBPS, FRCS (PAEDS)
Dr. Khan is a highly experienced and respected paediatric surgeon and urologist with a distinguished career that spans over three decades. He has performed more than 7,000 circumcisions in the UK and is recognised for his expertise in treating foreskin problems, buried penis, and hypospadias. Dr. Khan is also pioneering new techniques in circumcisions for adults, children, and infants, ensuring the highest standards of care for his patients.
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