Circumcision

Circumcision

Introduction

Male circumcision is the surgical removal of the foreskin (the hood of skin covering the end of the penis, which can be gently pulled back).

Circumcision may be carried out for:

  • religious reasons – circumcision is a common practice in the Jewish and Islamic faiths, and is also practised by many African communities as a tribal or ethnic tradition
  • medical reasons – although alternative treatments are usually preferred to circumcision

This topic focuses on the medical aspects of circumcision.

Routine circumcision

During the 19th century, many medical practitioners believed that being circumcised was more hygienic than not being circumcised.

As a result, the routine medical circumcision of all boys, regardless of religious faith, became a widespread practice in England. However, routine male circumcision gradually became less common as many members of the medical community began to argue that it had no real medical benefit in the majority of cases.

Routine circumcision may offer a number of potential benefits, such as reducing the risk of some types of bacterial or viral infections. However, most healthcare professionals now agree that the risks associated with routine circumcision, such as infection and excessive bleeding, outweigh any potential benefits.

Read more about the advantages and disadvantages of circumcision.

NHS availability

The majority of clinical commissioning groups (CCGs) don’t fund routine circumcision or circumcision carried out for religious reasons.

The NHS mainly funds circumcision used to treat a small number of medical conditions (see below). In such cases, it’s usually regarded as a “treatment of last resort”, when all other treatment options have failed.

It’s important to note that some CCGs in England do currently fund religious or ritual circumcision on the NHS. The decision is based on priorities relating to an area’s local population.

Read more about NHS authorities and trusts.

In rare cases, circumcision may be considered for the following health conditions:

  • paraphimosis – a condition where the foreskin gets trapped under the tip of the penis
  • balanitis xerotica obliterans – an uncommon condition that causes the tip of the penis to become hard and inflamed

However, these conditions are very rare in children and other treatments are usually preferred.

Circumcision may also sometimes be considered in severe cases of phimosis (a tight foreskin that can’t be retracted), or recurrent balanitis (inflammation of the tip of the penis and foreskin).

Read more about when circumcision may be necessary.

How circumcision is performed

Circumcision for medical reasons is usually carried out on a day-patient basis. This means that you won’t have to stay in hospital overnight.

Older children and adults who are circumcised are usually given a general anaesthetic, so that they’re unconscious during the procedure.

The circumcision procedure is relatively simple. The foreskin is removed with a scalpel, scissors or a surgical clamp. Any bleeding is either cauterised (closed using heat), or the remaining edges of skin are stitched together using dissolvable stitches.

After circumcision, there may be some pain and swelling, and the penis will be easily irritated until it heals. The healing process can take up to four to six weeks. Read more about recovering from circumcision.

Speak to your GP if there are signs of any bleeding or infection after a circumcision. Complications are rare when circumcision is carried out for medical reasons, but there are some risks of circumcision that should be considered.

Advantages and disadvantages of circumcision

There are several potential advantages and disadvantages associated with circumcising boys shortly after they’re born.

For example, circumcision may reduce the risk of:

However, there are much more effective and less invasive ways of preventing these conditions. For example, practising good hygiene to prevent UTIs, or using a condom to prevent STIs.

Read about when circumcision may be necessary.

Most healthcare professionals argue that the potential benefits of circumcision aren’t strong enough to justify routine childhood circumcision. They point out the disadvantages of circumcision such as:

  • reduced sensitivity – an uncircumcised penis is more sensitive than a circumcised penis, meaning that circumcised men may experience less pleasure during sex
  • potential complications of circumcision – these include excessive bleeding, post-operative infection and, in rare cases, injury to the urethra; these complications outweigh any potential benefits

Critics also argue that routinely circumcising baby boys on medical grounds violates the principle of consent to treatment. They say that circumcision should only be performed when a boy is old enough to make an informed decision about whether he wishes to be circumcised.

When circumcision may be necessary

Some conditions, such as paraphimosis, may benefit from circumcision. Others, such as balanitis xerotica obliterans, can only be cured with circumcision.

This section discusses the medical reasons why circumcision may be necessary. It’s outside the scope of this topic to discuss religious or cultural reasons for circumcision.

Conditions that may benefit from circumcision

Paraphimosis

Paraphimosis is a medical emergency. The foreskin is pulled back underneath the tip of the penis, becomes trapped and can’t be returned to its original position.

Paraphimosis sometimes occurs as a complication of a medical procedure that involves pushing back the foreskin for a prolonged period of time. Such procedures include:

  • an examination of the penis 
  • a cystoscopy – where a thin, flexible tube (catheter) with a camera on the end is inserted through the penis and up into the bladder so that the inside of the bladder can be examined
  • urinary catheterisation – where a catheter is inserted through the penis and up into the bladder to drain urine out of the bladder

Paraphimosis causes a band of swelling to develop around the penis, which can block the blood supply. If it isn’t treated, the lack of blood supply will cause the tissue of the penis to die.

In most cases, paraphimosis can be treated using medication to reduce the swelling, or minimally invasive surgery to return the foreskin to its original position.

Paraphimosis is very rare in children and other treatments are preferred. Circumcision is usually only required in adults in rare cases when medication and surgery aren’t effective. Occasionally, circumcision may be recommended if someone has repeated episodes of paraphimosis.

Balanitis

Balanitis is inflammation of the foreskin, usually caused by a bacterial infection.

Symptoms of balanitis include:

  • pain when urinating
  • a discharge of pus from the penis
  • inflammation of the head or shaft of the penis
  • itchiness
  • an unpleasant odour

Balanitis can usually be effectively treated with antibiotics, and most people don’t have further infections.

Circumcision is usually only recommended in adults in rare cases where someone has repeated infections (recurrent balanitis).

Urinary tract infections

A urinary tract infection (UTI) is an infection of the urinary system. It’s estimated that one in 50 boys develop a UTI between their first and second birthdays. Around 1 in 2,000 men develop a UTI every year.

Research suggests that circumcised boys are around 10 times less likely to develop a UTI than uncircumcised boys. This is because many UTIs are thought to be caused by bacteria that gather inside the foreskin before spreading to the urinary system.

However, most UTIs are mild and don’t cause serious damage. Circumcision is usually only recommended if a boy has a risk factor that increases the likelihood of repeated UTIs. Repeated UTIs can cause kidney damage.

An example of a pre-existing risk factor is a birth defect that causes urine to leak back up into the kidney. This carries the risk of bacteria spreading from the foreskin, through the urine, and infecting the kidney. In such circumstances, circumcision may be recommended.

Read more about urinary tract infections in children and urinary tract infections in adults.

Sexually transmitted infections

Circumcision is thought to reduce the risk of catching some types of sexually transmitted infections (STIs). These are:

Circumcision has also been shown to reduce the chance of certain conditions occurring in female partners, including:

Research carried out in Africa found that heterosexual circumcised men are 38-66% less likely to contract HIV than uncircumcised men.

It’s thought that the foreskin contains special cells that attract the cells of the HIV virus. This means that uncircumcised men who have vaginal sex with an HIV positive woman are more likely to develop the infection.

However, it’s still unclear whether circumcision has the same protective effect for men who have unprotected anal sex with men.

Circumcision is thought to reduce the risk of a man getting syphilis and chancroid because the foreskin:

  • may provide a warm, moist environment that allows syphilis and chancroid bacteria to grow and multiply
  • can sustain tiny cuts (micro-abrasions) during sexual intercourse, which allow the bacteria to pass into the bloodstream

It’s estimated that uncircumcised men are twice as likely to get syphilis and 10 times as likely to get chancroid than circumcised men. 

However, circumcision is nowhere near as effective as condoms in preventing STIs. If used correctly, male condoms are 98% effective in preventing STIs.

Cancer of the penis

Research has shown that men who are circumcised in childhood are three to four times less likely to develop penile cancer than uncircumcised men. This is because many cases of penile cancer develop in the foreskin.

However, cancer of the penis is very rare. On average, 550 new cases are diagnosed each year in the UK. It would therefore be very difficult to justify routine circumcision as a method of preventing penile cancer.

In some rare cases, a person may have an increased risk of developing penile cancer – for example, if they have a family history of the condition or a weakened immune system. In such cases, circumcision is often recommended as a preventative measure.

Conditions that require circumcision

Balanitis xerotica obliterans (BXO) is a skin condition that can only be cured with circumcision. It’s rare in young children and tends to only affect children over nine years of age and adults.

BXO can cause hardening and inflammation of the penis, usually affecting the foreskin and tip of the penis. It causes symptoms such as:

  • difficulty passing urine
  • pain when passing urine
  • itchiness and soreness of the penis

In cases of BXO that primarily affect the foreskin, circumcision is usually the most effective treatment, and often results in a complete cure. In some cases, BXO can affect the urethra and treatment to widen the urethra may be necessary (a meatotomy).

Recovering from circumcision

In babies who are circumcised, the foreskin usually takes about seven to 10 days to heal. In older boys and men, the healing process can take up to four to six weeks.

Self care advice

Circumcision is a painful procedure so painkillers, such as paracetamol or ibuprofen, will need to be taken for at least the first three days after the operation. Children aged 16 or younger shouldn’t take aspirin.

Circumcision exposes the sensitive skin at the tip of the penis (glans). In babies, nappies can rub against the glans, making it sore. Therefore, tuck your baby’s penis down before securing the nappy. You may be advised to apply an antibacterial cream for up to a week.

After circumcision, the penis will be red and swollen for a few days. You or your child may find it more comfortable to wear loose clothing for a while. Putting petroleum ointment directly on to the area can also reduce irritation.

Boys who’ve been circumcised shouldn’t t ride a bike or use other sit-on toys until the swelling has completely gone down. Your child should be able to return to school about a week after being circumcised. However, you should let his teacher know that he’s had the operation.

It’s important to practise good hygiene and ensure that your child’s nappies are frequently changed after a circumcision. Don’t use scented products in the shower or bath and leave the penis to dry naturally.

For adults, the surgeon will also give advice about sexual activity. Sex should usually be avoided until the wound has healed to avoid it reopening.

When to seek medical advice

After your child has been circumcised, speak to your GP if:

  • there’s bleeding from his penis
  • his penis remains swollen after two weeks
  • he still finds passing urine painful a few days after the operation

Older boys and men should also see their GP if they have any problems after circumcision.

Risks of circumcision

As with all types of surgery, circumcision has some risks. However, complications from circumcisions carried out for medical reasons are rare in England.

Bleeding and infection are the most common problems associated with circumcision.

Other complications can include:

  • a decrease in sensation in the penis, particularly during sex
  • damage to the tube that carries urine inside the penis (urethra), causing it to narrow and making it difficult to pass urine
  • removal of too much of the foreskin
  • accidental amputation of the head of the penis, which is very rare
  • a blood infection or blood poisoning (septicaemia)

Problems with circumcisions carried out for religious or cultural reasons may go unreported.

Circumcision isn’t carried out on boys born with a specific birth defect of the penis that affects where the opening of the urethra (urinary tube) is found. This is because the foreskin is used to reconstruct the urethra.