Adult circumcision in Birmingham: NHS criteria, procedure, recovery and private options

Circumcision removes the foreskin, the layer of skin that covers the glans (the head of the penis). In adults it is nearly always carried out to treat a problem rather than as a routine procedure. The NHS says it is usually only offered when other treatments have not worked or when it is the only option.

The reasons the NHS lists include a swollen, itchy or sore foreskin or head of the penis that keeps coming back, a tight foreskin (phimosis) that causes painful erections or difficulty passing urine, a foreskin that cannot be pulled back, and scarring or tightness from conditions such as lichen sclerosus. It may also be recommended as part of treatment for penile cancer, which the NHS describes as rare. BAUS adds skin disease on the foreskin and glans, large warty lesions, and cancerous or pre-cancerous lesions to its list of reasons.

Some adults ask for circumcision for religious, cultural or personal reasons without a medical problem. That is a legitimate personal decision for a consenting adult, but it follows a different funding route from medical circumcision, which is covered further down.

Because circumcision cannot be undone, UK urology guidance expects the options that keep the foreskin to be considered. The BAUS patient leaflet sets out four alternatives. For a tight foreskin, topical steroid creams and washes can reduce inflammation and ease tightness, although BAUS notes that symptoms often return when treatment stops and that circumcision is usually necessary if they fail. The NHS lists steroid creams, antibiotics for infection, and surgery as treatments for a tight foreskin.

The usual starting point is a GP, who examines the problem, may treat infection or skin disease first, and refers to urology or another surgical service if circumcision looks appropriate. Which patients are funded is decided locally by the NHS commissioning body for the area, which is why access can differ between parts of England.

In Birmingham and Solihull, the ICB publishes a male circumcision policy on its website. It says the local NHS will fund circumcision where the foreskin is trapped behind the head of the penis (pathological phimosis) or where there have been three documented episodes of balanoposthitis, which is inflammation of the head of the penis. Related indications it lists include recurrent paraphimosis, injury such as a zip injury, a tight foreskin that causes pain on arousal or interferes with sexual function, preventing urinary infection in someone with an abnormal urinary tract, and abnormalities present from birth.

The same page says the ICB does not commission male circumcision for cultural, social and religious reasons. For someone who falls outside the criteria, it describes an individual funding request, which must come from the treating clinician and show exceptional clinical need. Two cautions apply: the page and the policy document still use wording from the former clinical commissioning groups, and policies are reviewed, so the current position should be confirmed with a GP or the ICB. This guide does not state local waiting times because none were found in a published source.

Some adults pay for circumcision because they do not meet NHS criteria or prefer a different timescale. The sources read for this guide do not give private prices, and costs vary between providers, so the useful step is to ask for a written quote and check what it covers.

• The operating surgeon should be a doctor registered with the General Medical Council, and the clinic or hospital should be registered with the Care Quality Commission (the Birmingham and Solihull ICB leaflet points to both checks, and the BMA says doctors who carry out non-therapeutic circumcision in England must be registered with the CQC).

• Ask which anaesthetic is planned. BAUS says circumcision is usually done under general anaesthetic, with local or spinal anaesthetic used instead in some cases, and the NHS lists the same options.

• Ask what happens if there is bleeding or infection after you leave, who to speak to out of hours, and whether treating a complication is included in the quote.

• Ask whether the quote covers the consultation, the procedure, anaesthetist and facility fees, dressings, medication and any follow-up appointment.

• Ask how many circumcisions the surgeon performs, and whether foreskin-conserving options were discussed before surgery was proposed.

• You should receive written information about risks and a consent form to read before the day, not on arrival.

The NHS says the operation takes about 30 minutes. The surgeon makes a circular cut around the foreskin just below the head of the penis, removes the foreskin, and attaches the skin to the shaft with dissolvable stitches. BAUS says these usually disappear within two to six weeks. Nerve blocks are used for pain relief whichever anaesthetic is chosen. After a general anaesthetic the NHS advises that someone takes you home, that you do not drive for at least 24 hours and that someone stays with you overnight.

The head of the penis is usually very sensitive at first. BAUS says this often lasts two to three weeks and that applying a little petroleum jelly can help if the exposed skin dries or scabs. Some tightness or discomfort during erections is expected for a few months as scar tissue stretches, and the NHS notes it can occasionally cause bleeding.

BAUS gives approximate figures for adults. Infection needing antibiotics or drainage and bleeding that occasionally needs a further procedure are each put at between 1 in 50 and 1 in 100. Dissatisfaction with the cosmetic result and swelling of leftover skin that needs more surgery are each put at between 1 in 50 and 1 in 250. The NHS adds that rarely the urethra (the tube that carries urine) can narrow or be damaged, which can make passing urine difficult and may need surgery.

On sex, BAUS and the NHS say the head of the penis is usually less sensitive afterwards, that the skin moves differently without a foreskin, and that this can change how sex and masturbation feel. BAUS says the procedure has no effect on ejaculation or fertility and suggests a hypoallergenic silicone-based lubricant in the early weeks.

The NHS advises seeing a GP if stitches have not dissolved after 6 weeks, if there is pus, discharge or a smell, if the wound re-opens, or if the tip of the penis seems narrower or urine comes out slowly. It advises an urgent GP appointment or NHS 111 for bleeding that does not stop, a red or warm wound, a high temperature, very difficult urination, blood in the urine, or severe or worsening pain. It says to call 999 or go to A&E if you cannot pass urine at all.

• Which diagnosis is the operation for, and has it been confirmed by examination or a skin biopsy where relevant?

• Have steroid cream, a dorsal slit, frenuloplasty or preputioplasty been tried or ruled out, and why?

• If a skin condition such as lichen sclerosus is suspected, who will review the skin afterwards?

• What anaesthetic is planned, and what is the plan for pain relief at home?

• What are the stitches and dressing arrangements, and when is a check-up due?

• How long should I plan to be off work, avoid driving and avoid sex?