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Revised Foreskin Conditions Commissioning Guide-republished 2016

Royal college of Surgeon, England has published following documents for doctors and surgeons for commissioning foreskin conditions. 

In the financial year 2013/2014, activity and cost rates for Foreskin Conditions procedures in patients aged 18 years and below in England were as follows:


  • Circumcision
  • Frenuloplasty
  • Prepucioplasty
  • Freeing of adhesions of prepuce,
  • Dorsal slit on prepuce, stretching of prepuce,
  • Other procedures Activity

In children <18 years, pathological phimosis must be distinguished from physiological adherence of the foreskin to the glans, which is normal.

In the adult population there is a wide differential diagnosis including STDs and skin diseases such as eczema, psoriasis, lichen planus, Zoons 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 and posthitis refers to inflammation of the inner layer of the foreskin/prepuce. Balanoposthitis refers to inflammation of both
Balanoposthitis can be and often is chronic, not just acute.

In children up to and including 18 years of age, pathological phimosis (non-retraction) must be distinguished from physiological adherence of the foreskin to the glans, which is normal.

Non-retractile ballooning of the foreskin and spraying of urine do not routinely need to be referred for circumcision although not all ballooning is related to physiological phimosis and spraying can be due to lichen sclerosus.

The proportion of partially or fully retractable foreskin by age is:

  • 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.

Referrals from primary care for physiological phimosis account for a significant clinical workload in consultation time that could be avoided.

Conservative management of the non-retractile foreskin is under-recognised and practiced in some regions. This is of particular importance in the paediatric population where too many circumcisions are undertaken for physiological phimosis thereby incurring avoidable morbidity.

Currently, paediatric surgeons, paediatric urologists, adult general surgeons or urologists with a dedicated paediatric practice, paediatricians or specially trained clinical nurse specialists see outpatient referrals to regional centres.

Only a minority of children will have pathology and be subsequently listed for circumcision.

Indications for circumcision

  • Pathological phimosis: The commonest cause is lichen sclerosus, balanitis xerotica obliterans BXO is an old fashioned descriptive term (BXO)
  • Recurrent episodes of balanoposthitis
    Relative indications for circumcision or other foreskin surgery
  • Prevention of urinary tract infection in patients with an abnormal urinary tract
  • Recurrent paraphimosis
  • Traumatic (e.g. zipper injury)
  • Tight foreskin causing pain on arousal/ interfering with sexual function
  • Congenital abnormalities

Non-therapeutic circumcision is not within the scope of this document although doctors or others who undertake circumcisions for non-medical indications (in hospitals or the community) are scrutinised in the normal way, as per any aspect of medical practice. If their practice is criticised, they can defend themselves against litigation providing they are able (i) to show that their practice is considered reasonable by their peers (in the form of an expert opinion) and (ii) that the expert opinion is viewed by a court as being able to survive logical scrutiny. 

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