Child circumcision in Birmingham: medical reasons, alternatives and NHS funding

In young boys the foreskin is attached to the glans and separates gradually. The NHS says this can take until puberty. The Academy of Medical Royal Colleges gives figures: by age six about 8 in 100 boys cannot retract the foreskin at all and 63 in 100 have adhesions that prevent full retraction, yet 99% of boys have full retraction by age 17. Ballooning of the foreskin while peeing is common as separation begins and should stop by itself, although the NHS says that if it does not it can signal a tight foreskin.

A tight foreskin is not usually a problem unless it causes symptoms. The NHS lists swelling and tenderness, pain when peeing or a weak flow, blood in the urine, frequent urinary tract infections, bleeding or a thick discharge from under the foreskin, an unpleasant smell and, in older boys, painful erections. These are reasons to see a GP rather than to wait.

The Academy of Medical Royal Colleges evidence-based interventions guidance, which applies under the age of 16, sets out four situations in which medical circumcision should be performed. It also requires a documented discussion of the risks and benefits of foreskin-preserving surgery versus circumcision, using a shared decision-making approach.

• The guidance excludes children with congenital penile conditions such as hypospadias, who are managed through a different pathway.

• It notes that betamethasone at 0.025 to 0.1% is commonly prescribed as the topical steroid; dose and duration are for the prescriber to decide.

The NHS says that treatments for a tight foreskin include steroid creams or gels to soften it, antibiotics if the foreskin or glans is infected, and surgery, either removal of the foreskin or a procedure where small cuts are made in the tip of the foreskin so it can be pulled back more easily, which it says is usually only suitable for children. BAUS describes a related procedure to free preputial adhesions with a probe, done under anaesthetic, and notes that adhesions can come back and that a small proportion need circumcision later.

The Alder Hey 4skin Health programme describes a UK push to widen choice for foreskin conditions beyond circumcision, citing 2016 clinical commissioning guidance from BAUS, BAPS, BAPU and the Royal College of Surgeons that children should not be referred for or offered circumcision for physiological phimosis, and that steroid cream or stretching should be tried first. Ask the clinician whether these options have been considered and, if not, why.

The first step is a GP, who can examine the child, treat infection, prescribe steroid cream where suitable and refer to paediatric surgery or urology if needed. The Birmingham and Solihull ICB policy funds circumcision for pathological phimosis and for three documented episodes of balanoposthitis, and lists related indications including recurrent paraphimosis, injury, prevention of urinary infection in a child with an abnormal urinary tract, a tight foreskin that interferes with function and congenital abnormalities. It says the clinician caring for the patient can support an individual funding request in cases of exceptional clinical need, and that circumcision for cultural, social or religious reasons is not commissioned.

The policy is written in the language of the former clinical commissioning groups, so current criteria should be checked with a GP. No local waiting time was found in a published source and none is stated here.

The BMA says that when a child is able to express a view, it matters even if the child cannot give consent alone, and that it cannot envisage a situation in which it is ethically acceptable to circumcise a child who refuses. For non-therapeutic circumcision it recommends consent from both parents with parental responsibility. The Academy of Medical Royal Colleges notes that young children cannot give informed consent or assent, which is why alternatives need careful consideration. A medical circumcision for a clear clinical reason is generally carried out in hospital, and the Birmingham and Solihull leaflet says that for an older boy it is not advisable to have circumcision outside a hospital setting.

If a family chooses private care, the same checks apply as for any procedure: a GMC-registered doctor, a provider registered with the Care Quality Commission, a written quote including anaesthesia and aftercare, and clear out-of-hours arrangements. The Academy guidance says medical circumcision is a day-case operation that requires a general anaesthetic.

The NHS says the operation is the same in adults and children and takes about 30 minutes, with dissolvable stitches that should dissolve after 2 to 6 weeks. Children usually go home the same day. Swelling, bruising and minor bleeding are normal for 1 to 2 weeks, and the head of the penis is very sensitive at first. Painkillers such as paracetamol or ibuprofen can be given as the leaflet directs, but not aspirin to under-16s. Loose clothing, gentle washing, patting dry, a week off school, and no swimming, cycling, sport or heavy lifting for at least 2 weeks are the NHS recommendations.

Always call NHS 111 for a child under 5. For older children, the NHS says to ask for an urgent GP appointment or call 111 for bleeding that does not stop, a red or warm wound, high temperature, great difficulty peeing, blood in the urine, or severe pain. Call 999 or go to A&E if he cannot pass urine at all. See a GP if stitches remain after 6 weeks, if there is pus or a smell, or if the wound re-opens.