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Circumcision

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Introduction


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

Circumcision may be performed for:

  • religious reasons - circumcision is a common practice in the Jewish and Islamic faiths
  • medical reasons, although alternative treatments are usually preferred to circumcision

This article 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 vast majority of cases.

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

See Circumcision - Advantages and disadvantages for more information about the medical pros and cons of routine circumcision.

NHS availability

The NHS does not fund routine circumcision or circumcision that is carried out for religious reasons.

The NHS only funds circumcision that is used treat a small number of medical conditions (see below). In such cases, circumcision is usually regarded as a 'treatment of last resort' when all other treatment options have failed.

The health conditions where circumcision may be considered include:

  • paraphimosis - a condition where the foreskin gets trapped under the tip of the penis
  • balanoposthitis - an infection of the foreskin
  • balanitis xerotica obliterans - inflammation of the tip of the penis

See Circumcision - why it is necessary for more information about health conditions where treatment with circumcision may be considered.


Advantages and disadvantages of circumcision


There are a number of potential advantages associated with circumcising boys shortly after they are born. For example:

  • circumcision reduces the risk of developing a urinary tract infection (UTI), which include infections of any part of the urinary system, such as the bladder
  • circumcision reduces the risk of getting some types of sexually transmitted infections (STIs) such as HIV
  • circumcision reduces the risk of developing cancer of the penis (penile cancer)

See 'why it is necessary' for more details about the potential advantages of circumcision.

Most healthcare professionals maintain that the above potential benefits of circumcision are not strong enough to justify routine childhood circumcision. Critics of circumcision argue that it has disadvantages, 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 - such as excessive bleeding and post-operative infection - outweigh any potential benefits.

Critics have also argued 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.


How circumcision is performed


Circumcision that is performed for medical reasons is usually carried out on a day-patient basis. This means that you (or your child) will not have to stay overnight in hospital.

If a baby boy needs to be circumcised, he will usually be given a local anaesthetic because it is safer than a general anaesthetic.

Local anaesthetic is a numbing medicine, which can be injected into the shaft (base) of the penis, or applied as a cream. Older children and adults who are circumcised are usually given a full, general anaesthetic.

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


Why circumcision is necessary


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

Healthcare professionals use the term 'indication' when talking about the reasons for a treatment being necessary. There are two types of indication:

  • relative indications, where the treatment may offer some benefit and could be used in certain circumstances
  • absolute indications, where the treatment has to be used - for example, antibiotics would be an absolute indication for a serious bacterial infection.

See below for more information about relative and absolute indications for circumcision.

Relative indications for circumcision

Paraphimosis

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

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

  • a penile examination
  • a cystoscopy - a medical procedure where a thin, flexible tube (catheter) with a camera on the end is inserted through the urethra and up into the bladder (the urethra is the tube that runs from the penis to the bladder and through which urine passes out of the body)
  • urinary catheterisation - a procedure in which a catheter is inserted into the urethra 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. Left untreated, the lack of a blood supply will mean that the tissue of the penis will begin to die (gangrene).

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.

Circumcision is usually only required in rare cases when medication and surgery fail. Occasionally, circumcision may be recommended if someone has repeated episodes of paraphimosis.

Balanoposthitis

Balanoposthitis is an infection of the foreskin, usually by bacteria. It is a fairly common childhood infection that affects an estimated 1% of boys.

Symptoms of balanoposthitis include:

  • pain when urinating
  • a discharge of the pus from the penis
  • inflammation of the shaft of the penis

Balanoposthitis can be successfully treated using antibiotics. Most boys do not have further infections. Circumcision is usually recommended only if a boy has repeated infections.

Urinary tract infections

A urinary tract infection (UTI) is an infection of the urinary system. The urinary system is made up of the kidneys, the ureters (the tubes that carry urine from the kidneys to the bladder), the bladder and the urethra.

UTIs are a common infection in young boys. About 4% of boys have at least one UTI before they are 16.

Research has found that circumcised boys are 10-14 times less likely to catch 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 do not cause serious damage, so circumcision is usually only recommended when there is a pre-existing risk factor that increases the likelihood of the boy having 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.

Sexually transmitted infections

Circumcision is known to reduce the risk of catching three sexually transmitted infections. These are:

  • HIV
  • syphilis
  • chancroid - an uncommon type of STI in England that causes painful sores on the genitals.

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

It is 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 a HIV positive woman are more likely to develop the infection.

However, it is still unclear whether circumcision has the same protective effect for homosexual men who have unprotected anal sex. There also seems to be no protective benefits for the female sexual partners of heterosexual circumcised men.

Circumcision is known to reduce the risk of a man getting syphilis and chancroid. This is thought to be due to two reasons:

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

It is estimated that uncircumcised men are twice as likely to get syphilis, and 10 times as likely to get chancroid.

However, it should be stressed that circumcision is nowhere near as effective as condoms in preventing STIs. If used correctly, condoms are 98% effective in preventing STIs.

Cancer of the penis

Research has shown the men who are circumcised during childhood are 3-4 times less likely to develop cancer of the penis (penile cancer) than men who are uncircumcised. This is because many cases of penile cancer develop in the foreskin.

Cancer of the penis is a very rare cancer. On average, 400 new cases are diagnosed each year in the UK. It would therefore be very difficult to justify routine circumcision as a preventative method for penile cancer.

However, there may be some rare cases where a person has multiple risk factors, such as a family history of penile cancer and a weakened immune system. In such cases, circumcision is recommended as a preventative measure.

Absolute indications for circumcision

The only absolute indication for circumcision is an uncommon skin condition called balanitis xerotica obliterans (BXO).

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

  • difficulties 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.

Bacteria
Bacteria are tiny, single-celled organisms that live in the body. Some can cause illness and disease and some are good for you.
Blood
Blood supplies oxygen to the body and removes carbon dioxide. It's pumped around the body by the heart.
Circumcision
Circumcision is a simple operation in which the foreskin is cut from the penis. This is done for religious reasons or because the foreskin is too tight to pull back.
Congenital
Congenital means a condition that's present at birth - the condition could be hereditary or develop during pregnancy.
Pain
Pain is an unpleasant physical or emotional feeling that your body produces as a warning sign that it's been damaged.
Swelling
Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

Recovering from circumcision


In babies, who are circumcised, the foreskin usually takes about 7-10 days to heal. However, in older boys and in men, the healing process can take up to three weeks.

Self-care advice

As circumcision is a painful procedure, painkillers such as paracetamol or ibuprofen will need to be taken for at least the first three days after the operation. Children who are 16 years old or younger should not take aspirin.

Circumcision exposes the sensitive skin of the glans (the tip of the penis). In babies, nappies can rub against the glans, making it sore. Therefore, make sure that you tuck down your baby's penis before putting the nappy in place.

Following 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. Petroleum ointment put directly on to the area can also reduce irritation.

After your son has been circumcised, make sure that he does not ride a bike or use other sit-on toys until the swelling has completely gone down. If your son is of school age, he should be able to return to school about a week after being circumcised. However, let his teacher know that he has had the operation.

When to seek medical advice

Following circumcision, consult your GP if:

  • there is bleeding from your child's penis
  • your child's penis remains swollen after two weeks
  • your child 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 having a circumcision.

Circumcision
Circumcision is a simple operation in which the foreskin is cut from the penis. This is done for religious reasons or because the foreskin is too tight to pull back.
Painkillers
Analgesics are medicines that relieve pain. For example paracetamol, aspirin and ibuprofen.
Swelling
Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

Risks of circumcision


As with all types of surgical procedure, circumcision has some associated 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 (feeling) in the penis, particularly during sex
  • damage to the urethra (the tube that carries urine inside the penis) causing it to narrow and making it hard to pass urine
  • accidental amputation of the glans (head of the penis), which is very rare
  • a blood infection or blood poisoning (septicaemia)

Problems with religious or cultural circumcisions may go unreported.

Blood
Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.
Circumcision
Circumcision is a simple operation in which the foreskin is cut from the penis. This is done for religious reasons or because the foreskin is too tight to pull back.
Urethra
The urethra is a tube that carries urine from the bladder to the outside of the body.

The materials in this website are provided by Medicine Chest and NHS Choices.  Neither Co-operative Group Limited or Co-operative Healthcare Limited (trading as The Co-operative Pharmacy or otherwise) shall be in any way responsible or liable for its content.

The materials in this website are in no way intended to replace the professional medical care, advice, diagnosis or treatment of a doctor.  The website does not have answers to all problems and answers to specific problems may not apply to everyone.  If you notice medical symptoms or feel unwell, you should consult your doctor.  For further information, consult the terms and conditions.


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