Foreskin, medical circumcision and other treatments
UK policy on the treatment of foreskin conditions
Providing choice for the treatment of foreskin conditions
In the past, foreskin conditions were commonly treated by medical circumcision. Although the procedure is still an important treatment option for some foreskin conditions, there are now more and more options available to all age groups – some of which don’t involve surgery.
In order to help make these alternative treatment options available around the UK, Alder Hey Consultant Paediatric Surgeon, Professor Simon Kenny OBE, convened a roundtable discussion with top surgeons and urologists from around the country.
The discussion is summarised in the below report, outlining the case for reducing medical circumcisions for the treatment of foreskin conditions and enabling patients to make an informed decision about their care – as well as bringing together recommendations for implementing change.
Recommendations
An online resource should be developed to support clinicians that provides clear definitions of foreskin conditions and the full range of treatment options for each. An online decision-making support tool would help less experienced clinicians select the most appropriate treatment options for their conditions.
This website and accompanying decision-support tool was developed as a result of this recommendation.
Training should be mandatory for clinicians across the pathway – in both private and public sectors and including sexual health clinic staff – in diagnosing foreskin conditions, the appropriate referral pathway, what treatments could be offered and how to perform alternative procedures.
GP referral forms should be introduced which ask for reasons behind the referral and justification for the decision to circumcise. This is preferable to limiting referrals as it allows for discretion and flexibility for second opinion.
The GIRFT report should be used as the basis of discussions for developing a formal pathway through which foreskin conditions are referred and treated, with a goal of reducing the variations identified.
There is a need for greater clinical leadership in educating and informing colleagues:
Experienced paediatric surgeons and urologists should consider publishing editorial articles in journals such as the British Medical Journal (BMJ) in an attempt to reach more clinicians.
BAPU, BAPS and the Royal Colleges should ensure the information they provide is balanced and sources are current, peer-reviewed and peer agreed.
Children’s Surgical Operational Delivery Networks (ODNs) should coordinate the patient pathway, support generalist providers and share expertise should be explored.
Integrated Care Systems should provide local oversight, including assuming accountability for ensuring that the recommendations of the GIRFT report are implemented in a timely manner, and should work with ODNs to achieve full, functional clinical pathways.
Personal, Social, Health and Economic (PSHE) forums in both primary and secondary schools should be encouraged to stimulate discussion around how penises range in appearance, the natural history of the penis and foreskin, penis hygiene and foreskin conditions as part of sexual health education.
The potential for sexual health clinics to play a role in hosting information about foreskin conditions and treatment options, and directing patients to accurate online sources of information, should be explored.
Children’s surgical ODNs should be supported to collect data on the use of circumcisions and alternative treatments locally and regionally. The database should be accessible to GPs so any side effects reported in the months and years following surgery can be collected; including sexual discomfort, reduced sensitivity/pleasure from sex or mental ill health.
Getting it Right First Time (GIRFT) programme national specialty report: Paediatric General Surgery and Urology
The Getting It Right First Time (GIRFT) programme has carried out a national review of paediatric general surgery and urology services, led by Professor Simon Kenny OBE. The review highlighted that services are under pressure from significant and increasing demand, poor infrastructure and a lack of data to benchmark services. A GIRFT national report is due for publication in 2021 and is expected to recommend reducing unnecessary surgical procedures – including non-infant medical circumcision – by applying evidence-based surgical decision-making.
This report is due to be published in 2021. You’ll be able to access the report here once it’s publicly available.
Clinical Commissioning Guidance
The British Association of Urological Surgeons (BAUS), British Association of Paediatric Surgeons (BAPS), British Association of Paediatric Urologists (BAPU) and Royal College of Surgeons published revised clinical commissioning guidance on foreskin conditions in 2016. The guidance suggests that children should not be referred for, or offered, circumcision for the treatment of physiological phimosis (non-retractile foreskin). It recommends that alternative treatment options should be explored first – such as the application of topical steroids or stretching.