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MANAGEMENT OF FORESKIN CONDITIONS
Statement from the British Association of Paediatric Urologists on behalf of the British
Association of Paediatric Surgeons and The Association of Paediatric Anaesthetists.
This statement refers to management of foreskin conditions and circumcision in male children
Female circumcision is prohibited by law
LASSL (2004)4: Female Genital Mutilation Act 2003, DoH, published 27.2.2004
Working Party Members
Consultant Paediatric Urologist, Sheffield, Chairperson
Consultant Paediatric Urologist, Sheffield
Consultant Paediatric Surgeon,Southampton
Consultant Paediatric Anaesthetist, London
Addresses for correspondence:
Statement from The Royal College of Paediatricians and Child Health:
This document addresses an important clinical area for which there are no existing guidelines or
practise statements. Whilst this statement is not evidence based on a consensus, it provides
information of relevance to paediatricians
Table of contents
2. Common conditions and diseases associated with the presence of a foreskin .8
3. Treatment of conditions of the foreskin .9
a. British Medical Association (BMA) Guidelines .10b. Anaesthesia and Analgesia for circumcision .11c. Complications of circumcision .13d. Governance issues .13
a. Comments by Doctors Opposing Circumcision .19b. Comment from NORM-UK .20c. Comments from a Muslim Male Religious Circumcision Practitioner.22d. Response from Association of Reform and Liberal Mohelim .25
The management of foreskin conditions varies amongst medical practitioners from observation tocircumcision. Therapeutic circumcision is performed in the U.K for specific indications. There is as yet nopolicy for non therapeutic or religious/cultural circumcision in the U.K. although a position statementwas issued by the British Association of Paediatric Surgeons (BAPS) in 200134.
1. The Natural history of the foreskin
Almost all boys have a non retractile foreskin at birth1. The inner foreskin is attached to the glans.
Foreskin adhesions break down and form smegma pearls ‘ white cysts under the foreskin’ which are then
extruded. The foreskin does not retract before the age of 2 years after which it ‘pouts like a flower’-
physiological phimosis. The process of retractility is spontaneous and does not require manipulation.
The majority of boys will have a retractile foreskin by 10 years of age and 95% by 16-17 years of age2-4.
2. Common foreskin conditions and diseases associated with presence of a foreskin
A. Common foreskin conditions
Balanoposthitis : inflammation of the glans and foreskin5,6.b.
Balanitis: inflammation of the glans that often spreads along the shaft and may occur in the cir-
Posthitis : inflammation restricted to the foreskin itself.d.
Balanitis Xerotica Obliterans (BXO) : a lesion akin to lichen sclerosus et atrophicus, is the cause of
true scarring of the foreskin- pathological phimosis - the shutter type foreskin with no pouting of the inner foreskin on gentle retraction8. It is rare before the age of 5 years9 and presents with discomfort on voiding and white firm scarring of the foreskin tip. The aetiology is unknown but may be of viral origin. This condition may also affect the glans and urethra.
Paraphimosis : results when the narrow tip of the foreskin is retracted behind the glans at the
coronal sulcus causing oedema of the glans and foreskin and inability to manipulate the foreskin back over the glans.
Hooded foreskin: is an abnormal dorsal hemiforeskin ( the penis is anatomically described in the
erect position ) which is deficient ventrally and is usually associated with hypospadias.
B. Diseases associated with presence of a foreskin
There is no current evidence to support an increased risk of penile cancer10-14, human
immunodeficiency virus infection15 or cervical cancer16,17 in uncircumcised males. Circumcision to
prevent urinary tract infection (UTI) is unproven except in boys with abnormal renal tracts18.
3. Treatment of conditions of the foreskin:
Inflammatory conditions: Balanoposthitis, Balanitis, Posthitis:
Simple bathing, topical steroids and antibiotics.
Non retractile healthy foreskin (physiological phimosis):
No intervention, topical steroids, preputioplasty- infrequently19-25.
Circumcision. There are no randomised trials that can ascertain the efficacy of other techniques and their long term outcome26-30.
Reduction with or without anaesthetic31,32.
Without hypospadias: no treatment, modified circumcision, foreskin reconstruction.
With hypospadias: no treatment, circumcision or foreskin reconstruction with hypospadias repair.
Male circumcision is the most common surgical procedure in the world. It may be performed for
clinical reasons or to comply with religious/cultural practice- the ‘non therapeutic circumcision’. Non
therapeutic circumcisions are not uniformly available on the NHS ( where they are performed by
medical practitioners and nurse practitioners ) and are also performed in the community by general
practitioners and non clinicians.
4a. British Medical Association guidelines:
Reproduced in part from the BMA document: The law
and ethics of male circumcision, London, 200635.
i) Ethics and the Law
Male circumcision is generally assumed to be lawful provided that:
- it is performed competently
- it is believed to be in the child’s best interests and
- there is valid consent.
ii) Consent and refusal
- Competent children may decide for themselves.
- The wishes that children express must be taken into account.
- If parents disagree, non-therapeutic circumcision must not be carried out without the leave of
- Consent should be confirmed in writing.
iii) Best interests
- Doctors must act in the best interests of the patient.
- The views that children express are important in determining what is in their best interests.
- Parental preference must be weighed in terms of the child’s interests.
- The child’s lifestyle and likely upbringing are relevant factors to take into account.
- Parents must explain and justify requests for circumcision, in terms of the child’s interests.
iv) Health issues
Parents seeking circumcision for their son for reasons of hygiene or health benefits must be fully
informed of the lack of consensus amongst the profession over such benefits.The BMA
considers there is insufficient evidence concerning health benefit from non-therapeutic
The General Medical Council advises that doctors must "have the necessary skills and
experience both to perform the operation and use appropriate measures, including
anaesthesia, to minimise pain and discomfort". There is no legal requirement for non
therapeutic circumcisions to be undertaken by registered health professionals.
Doctors must ensure that the premises in which they are carrying out circumcision are suitable
for the purpose. In particular, if general anaesthesia is used, full resuscitation facilities must be
vii). Charging patients
Although non therapeutic circumcision is not a service which is provided free of charge, some
doctors and hospitals have been willing to provide non therapeutic circumcision without
charge rather than risk the procedure being carried out in unhygienic conditions. In such cases
doctors must still be able to justify any decision to circumcise a child based on the
viii). Conscientious objection
Health care professionals are under no obligation to comply with a request to circumcise a child.
Where the procedure is not therapeutic but a matter of patient or parental choice, there is no
ethical obligation to refer on.
4b. Anaesthesia and Analgesia for circumcision
There is an increased risk from general anaesthesia in the neonatal period36,37. According to
the Royal College of Anaesthetists handbook, any general anaesthetic should be administered
by an appropriately trained anaesthetist with ongoing relevant paediatric experience (38).
It is essential that adequate analgesia be provided when undertaking male circumcision. Dorsal
nerve block and ring block are equally effective45,70. Adequate time needs to elapse after the
block before surgery is started. Eutectic mixture of local anaesthetics (EMLA), contraindicated on
open wounds and mucous membranes, should be allowed 1 hour to take effect40. This can be
tested by picking up the foreskin in forceps before commencing the procedure. Non-
pharmacological methods ( non nutritive suckling, rocking, massaging, cuddling ) or systemic
analgesia with paracetamol are inadequate in isolation for analgesia49-59. Caudal analgesia is
effective in anaesthetised boys but has not been studied in neonatal awake circumcisions 62,64.
4c. Complications of circumcision
Bleeding (1.5%), local sepsis (8.5%), oozing (36%), discomfort > 7 days (26%), meatal scabbing or stenosis, removal of too much or too little skin, urethral injury ,amputation of the glans and inclusion cyst are recorded complications81-85.
There is conflicting evidence with respect to penile sensation, sexual function and satisfaction in adult men following circumcision86-89.
4d. Governance Issues
Clinical Governance applies to all professionals i.e. clinicians including medical and nurse practitioners90. Non clinical practitioners performing circumcisions in the community may apply similar governance principles.
A. Treatment of conditions of the foreskin
1. Inflammatory conditions: Balanoposthitis, Balanitis, Posthitis
Simple bathing, topical steroids and antibiotics.
2. Non retractile healthy foreskin ( physiological phimosis ):
No intervention, topical steroids, preputioplasty- infrequently.
CircumcisionThere are no randomised trials that can ascertain the efficacy of other techniques and their long term outcome.
Reduction with or without anaesthetic.
5. Hooded foreskin:
Without hypospadias: no treatment, modified circumcision, foreskin reconstruction.
With hypospadias: no treatment, circumcision or foreskin reconstruction with hypospadias repair.
1. Indications for circumcision
2. The operator
3. Standards of care
1. Indications for circumcision
i) Penile malignancy.
ii) Traumatic foreskin injury where it cannot be salvaged.
i) Balanitis Xerotica Obliterans.
ii) Severe recurrent attacks of balanoposthitis.
iii) Recurrent febrile UTI’s with an abnormal urinary tract.
(c) Non Therapeutic ‘Ritual’ circumcision
2. The Operator
The person performing the procedure should be experienced and competent to do so.
Written consent should be obtained from both parents.b)
The operator should be able to identify co morbidity and deal with it appropriately.c)
The operator should have a full understanding of the risks and complications of the
procedure and their management.d)
The operator should be familiar with various modes of analgesia for the procedure.e)
The operator should keep thorough records and regularly audit his/her practice.
3. Standards of Care
The operation should be undertaken in an environment capable of fulfilling guidelines for
surgical procedures in children.b)
Adequate analgesia is essential. This involves systemic (oral) paracetamol and an adequate
local anaesthetic. Sufficient time for the local infiltration to provide analgesia is crucial and
this should be tested prior to conducting the circumcision.c)
There should be close links with the community, GP and hospital services for ongoing care
and ease of referral if complications arise.d)
Regular audit of practice at individual level, trust level and in the community is essential.
1. THE NATURAL HISTORY OF THE FORESKIN
The fate of the foreskin has been well documented after the initial description by Gairdner in 19491.
There is developmental variability in the appearance of the normal foreskin throughout childhood andpuberty. The inner foreskin is attached to the glans. Foreskin adhesions break down and form smegmapearls ‘ white cysts under the foreskin’ which are then extruded.The foreskin does not retract before theage of 2 years. The process of retractility is spontaneous and does not require manipulation. Themajority of boys will have a retractile foreskin by 10 years of age and 95% by 16-17 years of age2-4. Since1996, there has been a decline in the number of children aged 0-14 treated by general surgeons withmore children being seen by paediatric surgeons and paediatric urologists. Figures from theDepartment of Health demonstrate a reduction in paediatric surgical procedures from 30,000 perannum to nearer 20,000 per annum over a period of 10 years ( Prof DFM Thomas- unpublished data ).
This may partly be secondary to a decrease in the number of circumcisions due to the recognition thatphysiological phimosis - a healthy non retractile foreskin which pouts like a flower on gentle retraction-is normal.
2. COMMON FORESKIN CONDITIONS AND DISEASES ASSOCIATED WITH PRESENCE OF A FORESKIN
Common foreskin conditions
( Balanos greek for acorn, posthos greek for foreskin ) is the term used for inflammationof both the glans and foreskin. It may present with dramatic swelling and erythema of the distal penisand foreskin associated with discharge, bleeding from the prepuce, dysuria, and occasionally urinaryretention. It occurs in about 4% of uncircumcised boys between 2-5 years of age5. The aetiology isunclear although infection, contact allergy and contact irritation have been described6. Althoughbalanoposthitis may be recurrent, the episodes decrease in frequency in older boys and reflect foreskinmaturation.
refers to inflammation of the glans that often spreads along the shaft and may occur in thecircumcised population7.
refers to inflammation restricted to the foreskin itself.
Balanitis Xerotica Obliterans (BXO)
, a lesion akin to lichen sclerosus et atrophicus is the cause of truescarring of the foreskin i.e. pathological phimosis and the shutter type foreskin8 - no pouting of theinner foreskin on gentle retraction. It is rare before the age of 5 years9 and presents with discomfort onvoiding and a white firm scarring of the foreskin tip. The aetiology is unknown but may be of viralorigin. This condition may also affect the glans and urethra.
Whereas there is a strong association between BXO in adults and penile carcinoma, there is no suchevidence to link it as a precancerous condition in children because the majority of children with BXOhave historically undergone a circumcision.
results when the narrow tip of the foreskin is retracted behind the glans at the coronalsulcus causing oedema of the glans and foreskin and inability to manipulate the foreskin back over theglans.
A hooded foreskin
is an abnormal dorsal hemiforeskin ( the penis is anatomically described in the erectposition ) which is deficient ventrally and may or may not be be associated with hypospadias.
Diseases associated with presence of a foreskin
Cancer of the penis is extremely rare and was previously not documented in circumcised men. Several
recently reported cases question the protective effect of circumcision on the development of penile
cancer as an adult10-13.
Poor personal hygiene, smoking and exposure to wart virus (human papilloma virus) increase the risk
of developing penile cancer at least as much as being uncircumcised12-13.
Circumcised men are more at risk from penile warts than uncircumcised men14, and the risk of
developing penile cancer is now almost equal in the two groups. Routine circumcision in children
cannot be recommended to prevent penile cancer.
Human immunodeficiency virus (HIV) infection
The results from existing observational studies showed a strong epidemiological association between
male circumcision and prevention of HIV. These observational studies however were done in specific
high risk groups. Randomised controlled trials are currently under way and the results are awaited. A
Cochrane review15 found insufficient evidence to support an interventional effect of male circumcision
on HIV acquisition in heterosexual men.
Several studies have shown an association between an increased incidence of human papilloma virus
infection in heterosexual uncircumcised men with high risk activity (multiple sexual partners,
avoidance of condoms) and cervical cancer16-17. These studies are retrospective observational studies
from different geographical areas with a variable incidence of cervical cancer. The current evidence is
inadequate to recommend routine male circumcision as a preventive measure against cervical cancer.
Urinary tract infection (UTI)
Recent meta analysis18, data on 402,908 children were identified from 12 studies (one randomised
controlled trial, four cohort studies, and seven case-control studies). Circumcision was associated with
a significantly reduced risk of UTI for all three types of study design. This study concluded that
circumcision reduces the risk of UTI. Given a risk in normal boys of about 1%, the number-needed-to-
treat to prevent one UTI is 111. In boys with recurrent UTI or high grade vesicoureteric reflux, the risk of
UTI recurrence is 10% and 30% and the numbers-needed-to-treat are 11 and 4, respectively.
3. TREATMENT OF CONDITIONS OF THE FORESKIN
Inflammatory conditions: Balanitis, Balanoposthitis, Posthitis:
simple bathing, topical steroids and
antibiotics. Circumcision may very rarely be considered if recurrent severe episodes of inflammation
No intervention is necessary. Topical steroid application to the preputial ring
to treat ‘phimosis’ has reported success rates between 33% – 95% in various series19-24 but frequently
authors fail to define the difference between a healthy non retractile foreskin and true BXO. A
preputioplasty technique has been described with good results25 for the non-retractile foreskin
though the authors gave no significant reason for intervention.
Pathological phimosis (BXO):
Intralesional steroid injection26 , long term antibiotics27, carbon dioxide
laser therapy28, a radial preputioplasty alone29 or with intralesional injection of steroid30 have all been
described. There are no randomised trials to ascertain the efficacy and the long term outcome of these
Most paediatric urologists circumcise the foreskin for BXO. Once the range of treatment options are
presented, the surgeon should express his or her own preference. If a surgeon is faced with a parent
who refuses a conventional circumcision for BXO, but wishes for an alternative option, the surgeon is
at liberty to decline to treat.The surgeon then has a duty to offer a second opinion, although there is noobligation to find a colleague who is likely to advocate the alternative option.
Gentle compression with a saline soaked swab31 followed by reduction of the prepuce
over the glans is usually successful. Alternatives include multiple punctures in the oedematous
foreskin32 or injection of hyaluronidase31 prior to compression reduction. General anaesthesia may be
required. Paraphimosis is not an indication for circumcision as after reduction, the foreskin continues to
A hooded foreskin without hypospadias is a cosmetic abnormality. Any therapeutic
intervention should be undertaken after full discussion with both parents and may be a modified
circumcision or foreskin reconstruction. Hooded foreskin with hypospadias needs treatment with
correction of the hypospadias.
4. CIRCUMCISION: BACKGROUND
Circumcision is a surgical procedure that involves partial or complete removal of the foreskin (prepuce)of the penis. Circumcision may be performed for therapeutic or non therapeutic reasons and both areaccepted practises within the U.K. provided certain standards are met33,91. There is as yet no policy fornon therapeutic or religious circumcision in the U.K. although a position statement was published byBAPS in 200134.
4a. British Medical Association (BMA) Guidelines 2003
The BMA have set out guidelines with respect to both therapeutic and non therapeutic circumcision.
These guidelines discuss the issues mentioned below
• Ethics and the law• Consent and refusal• Best interests• Health issues• Standards• Facilities• Charging patients• Conscientious objection
A full discussion of the guidelines is beyond the scope of this document. The 2003 guidelines (The law
and ethics of male circumcision - guidance for doctors)
can be obtained from the BMA website(www.bma.org.uk)
With respect to consent the working party point out that having both parents consent for a therapeutic
circumcision is not necessary. The legal purpose of consent is to provide the clinician with a defence
against negligence and battery, so a single consent is valid. In non therapeutic circumcision, the
purpose of the second consent is to protect the second parent from having a procedure performed on
their son of which they disapprove. At present case law is clear (Re J(child’s religious upbringing and
circumcision(COURT OF APPEAL (CIVIL DIVISION) 25 NOVEMBER 1999). Permission from both parents is
required for non-therapeutic circumcision. Currently, the only way for the clinician to show that they
have conformed to this is to get both parents to sign the consent form. However, legal advice has
suggested that this position is open to challenge. In discussion with the wider membership of BAPU
there was widespread support for the requirement for both parent’s signatures, but this was not
unanimous. Paediatric patient information documents for circumcision (ref PSO2) are available from
EIDO Healthcare at www.eidohealthcare.com
4b. Anaesthesia and Analgesia for circumcision
Modern general anaesthesia is extremely safe. However the risk of general anaesthesia will never
be zero and is increased in infants. In two large series36-37 the risk of complications was significantly
higher in infants than in children. Adequate analgesia must always be provided whether a general
anaesthetic is being administered or not.
There is an increased risk from general anaesthesia in the neonatal period. According to the Royal
College of Anaesthetists handbook38, any general anaesthetic should be administered by an
appropriately trained anaesthetist with ongoing relevant paediatric experience.
Adequate analgesia for male circumcision is required and is the subject of 2 Cochrane reviews39-40.
In unanaesthetised neonates who underwent circumcision a rise in adrenal corticoids41-42, skin
flushing, vomiting and cyanosis43,
pneumothorax46 have all been described. Increases in heart rate and respiratory rate withdecreases in oxygen saturation47 have been recorded with inadequate analgesia. Infants whoundergo circumcision show exaggerated pain behaviour to their routine immunisations duringthe ensuing six months when compared to uncircumcised control infants48 suggesting that theydevelop a ‘pain memory’ from an early age.
In neonates, rocking, massage, tucking and cuddling reduce pain responses to invasive
procedures49-51. Music and heartbeat sounds have been shown to modulate pain perception52.
None of these seem adequate as stand alone methods of providing analgesia for neonatal
circumcision and cannot be endorsed as such. These and similar methods may well have a role to
play as adjunctive therapies.
There are several trials comparing sugar solutions to water and or no treatment in neonatal
circumcisions without general anaesthesia53-59. Since a large range of concentrations (24-50%) and
volumes (1.5 – 10 ml) were used across these studies it is hard to draw any firm conclusions.
Heterogeneous outcome measures were used but, cry times and heart rate changes were not
significantly different in the treatment groups when compared to the controls in the context of
circumcision. This is not to say that non-nutritive suckling does not have a role to play as an
Paracetamol has been compared to placebo in two trials60-61. Macke61 found a benefit from
Paracetamol compared to placebo but Howard61 found no difference between placebo and
paracetamol as judged by a 20-point comfort score.
Parenteral opioids have been compared to caudal anaesthetics in older children having general
anaesthetics for circumcision. Intramuscular codeine62, fentanyl and paracetamol63, intramuscular
morphine64, intravenous diamorphine65 and intramuscular buprenorphine66 have all been
compared with caudal analgesia. In summary, parenteral opioids lead to a greater need for rescue
analgesia than caudals and result in a higher incidence of nausea and vomiting.
Post-procedural analgesia should always be provided. The paracetamol dose should not exceed
60mg/kg/24 hours for neonates and 90mg/kg/24 hours for older children.
Dorsal Penile Nerve Block (DPNB)
The results of DPNB when used against active treatment controls are shown in the table below. Penil
block is recommended as an effective means of providing analgesia. It should be noted that
performance of this block requires training, and that it is generally best performed in the anaesthetised
Comparison of active treatments versus DPNB in neonatal circumcision
2 ml 50% dextrose used, less cry time andlower heart rate.
Lower heart rate in DPNB when 10ml 50%
1% lidocaine to foreskin. 2 injections: serum
Cry time and heart rate not significantly
Although there are theoretical advantages to adding bicarbonate to the local anaesthetic solution in
any block in terms of decreasing the pain on injection and increasing the speed of onset of the block
Stang et al 56 showed no advantage in doing this as judged by any of the outcome measures of heart
rate, cry time, behavioural distress score or serum cortisol levels.
There are two trials comparing ring block to no treatment45,71 the latter showing significantly lower
heart rates in the treatment group and the former showing no difference in respiratory rate and
oxygen saturation. When compared to EMLA there was no advantage versus ring block as judged by
heart rate and cry time45.
A test of the adequacy of the block such as gently picking up the foreskin with forceps should always
be undertaken prior to surgery and the operator should be satisfied that there is no pain response to
Caudal Epidural Block
There is a reduced requirement for early post-operative rescue analgesia and less post-operative
nausea and vomiting if a caudal is used.
Urinary retention and leg weakness are known complications of caudal block. All studies (62,64)
comparing caudal block against other modes of analgesia for circumcision were in anaesthetised
Six studies compare EMLA (Eutectic Mixture of Local Anaesthetic) to placebo as cited in the Cochrane
review by Brady-Fryer and colleagues40. EMLA significantly reduced pain behaviour scores in most
Heart rate was significantly reduced in the EMLA groups whereas respiratory rate and blood pressure
There is risk of methaemoglobinaemia with the use of prilocaine (a constituent of EMLA) especially in
neonates. Indeed the BNF for children 2005 does not recommend its use in neonates. It has been safely
used for heel lancing in neonates on neonatal units. EMLA should not be used on open wounds or
mucous membranes. EMLA cream should be allowed adequate time to take effect and one hour is
regarded as the minimum.
Amethocaine (tetracaine 4%) gel
Like EMLA the BNF for children 2005 does not recommend the use of amethocaine gel in neonates
although it is commonly used in this population. Repeated applications should be avoided.
Amethocaine only takes 30 minutes to become clinically effective and is thus twice as fast in onset as
EMLA72. A common practice is to apply topical local anaesthetic such as amethocaine gel half an hour
before performing a deeper block such as DNPB or ring block thus helping to minimise the pain of
injection of the deeper block.
Three trials compare topical lidocaine to placebo73-75. Cry time is significantly reduced by lidocaine.
Oxygen saturations tend to be higher in the treatment groups but not statistically so.
It is essential to provide adequate analgesia when undertaking male circumcision. Dorsal nerve block
and ring block are easy to perform and are effective. Adequate time needs to elapse after the block
before surgery is started. Non-pharmacological methods and optimum treatment with systemic
analgesics should also be employed.
4c. Complications of circumcision
Numerous techniques have been described for circumcision. This is achieved either by the freehand or
sleeve technique76, using a clamp77,78 or a plastibell device79. Circumcisions performed in hospitals have
a statistically lower complication rate than those in the community80-82. These include bleeding, local
sepsis, meatal scabbing or stenosis, removal of too much skin or too little skin, urethral injury
,amputation of the glans and inclusion cyst. Engorgement of the glans as a result of failure of the
plastibell ring to fall off is well recognised83 and necessitates removal of the ring. An inappropriate
circumcision in the presence of a penile abnormality such as a hypospadias can lead to long term
morbidity. Griffiths et al84 in a prospective survey of hospital circumcision recorded the following
complications: oozing in 36%, discomfort >7 days 26%, infection needing antibiotics 8.5% and
haemorrhage in 1.5%. Kaplan85 noted the effect of the exposed glans to wet ‘diapers’ causing meatitis
and meatal ulcers.
There is conflicting evidence with respect to penile sensation, sexual function and satisfaction in adult
men following circumcision86-89.
4d. Governance Issues
In 1999 the Department of Health set out a white paper defining clinical governance in the NHS90. This
is maintained by regular audit, evidence based practice, Continuing Professional Development (CPD)
and Research, risk management and clinical effectiveness. All medically qualified practitioners fall
under this umbrella and are answerable to their peers.
The role of nurse practitioners in performing circumcision depends on their contractual position and
consultant supervision. It is anticipated that liability would be shared between the employing trust andthe operator, and only with the supervisor if it is ‘just and reasonable’ that they should share liability.
Non medical personnel performing circumcisions in the community must obtain valid consent andhave appropriate experience. There is a need for personal audit in these circumstances.
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Ng WT, Fan N, Wong CK, Leung SL, Yuen KS, Sze YS, Cheng PW. Treatment of childhood phimosis with a moderately
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Kiss A, Csontai A, Pirot L, Nyirady P, Merksz M, Kiraly L. The response of balanitis xerotica obliterans to local steroid
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Cuckow PM, Rix G, Mouriquand PD. Preputialplasty: a good alternative to circumcision. J Pediatr Surg 1994;29:561-563.
Poynter JH, Levy J. Balanitis xerotica obliterans:effective treatment with topical and sublesional corticosteroids. Br J
Shelley WB, Shelley ED, Grunenwald MA, Anders TJ, Ramnath A. Long term antibiotic therapy for balanitis xerotica
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Ratz JL. Carbon dioxide laser treatment of balanitis xerotica obliterans. J Am Acad Dermatol 1984;10:925-8.
Fischer KleinC, Rauchenwald M. Triple incision to treat phimosis in children: an alternative to circumcision. BJU Int
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conference, Estoril, Portugal, July 2002.
DeVries CR, Miller AK, Packer MG. Reduction of paraphimosis with hyaluronidase (see comments ). Urology
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College of Anaesthetists. 06 March 2001
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Van Der Walt J. Searching for the Holy Grail: measuring risk in paediatric anaesthesia. Paediatric Anaesthesia 2001; 11:
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Allan CY, Jacqueline PA, Shubhda JH. Caudal epidural block versus other methods of postoperative pain relief for
circumcision in boys. Cochrane Database Syst Rev. 2003;(2):CD003005.
Brady-Fryer B, Wiebe N, Lander JA. Pain relief for neonatal circumcision. Cochrane Database Syst Rev. 2004 ;
Gunnar MR, Fisch RO, Korsvik S, Donhove JM. The effects of circumcision on serum cortisol and behaviour.
Talbert LM, Kraybill EN, Potter HD. Adrenal cortical response to circumcision in the neonate. Obstet Gynecol
Poma PA. Painless neonatal circumcision. Int J Gynaecol Obstet. 1980;18(4):308-9.
Anders TF, Chalemian RJ. The effects of circumcision on sleep-wake states in human neonates. Psychosom Med
Lander J, Brady-Fryer B, Metcalfe JB, Nazarali S, Muttitt S. Comparison of ring block, dorsal penile nerve block, and
topical anesthesia for neonatal circumcision: a randomized controlled trial.
Auerbach MR, Scanlon JW. Recurrence of pneumothorax as a possible complication of elective circumcision. Am J
Obstet Gynecol. 1978 ;132(5):583
Rawlings DJ, Miller PA, Engel RR. The effect of circumcision on transcutaneous PO2 in term infants. Am J Dis Child
Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain response during subsequent routine
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Gray L, Watt L, Blass EM. Skin-to-skin contact is analgesic in healthy newborns. Pediatrics. 2000;105(1):e14.
Marchette L, Main R, Redick E, Bagg A, Leatherland J. Pain reduction interventions during neonatal circumcision. Nurs
Blass EM, Hoffmeyer LB. Sucrose as an analgesic for newborn infants. Pediatrics. 1991;87(2):215-8.
Kaufman GE, Cimo S, Miller LW, Blass EM. An evaluation of the effects of sucrose on neonatal pain with 2 commonly
used circumcision methods. Am J Obstet Gynecol. 2002;186(3):564-8.
Kass FC, Holman JR. Oral glucose solution for analgesia in infant circumcision. J Fam Pract. 2001 Sep;50(9):785-8.
Stang HJ, Snellman LW, Condon LM, Conroy MM, Liebo R, Brodersen L, Gunnar MR. Beyond dorsal penile nerve block: a
more humane circumcision. Pediatrics. 1997;100(2):E3.
Herschel M, Khoshnood B, Ellman C, Maydew N, Mittendorf R. Neonatal circumcision. Randomized trial of a sucrose
pacifier for pain control. Arch Pediatr Adolesc Med. 1998 ;152(3):279-84. Erratum in: Arch Pediatr Adolesc 1998 ;152(5):448.
Maichuk GT, Zahorodny W, Marshall R. Use of positioning to reduce the severity of neonatal narcotic withdrawal
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Zahorodny W, Rom C, Whitney W, Giddens S, Samuel M, Maichuk G, Marshall R. The neonatal withdrawal inventory: a
simplified score of newborn withdrawal. J Dev Behav Pediatr. 1998 ;19(2):89-93.
Macke JK. Analgesia for circumcision: effects on newborn behavior and mother/infant interaction. J Obstet Gynecol
Neonatal Nurs. 2001;30(5):507-14.
Howard CR, Howard FM, Weitzman ML. Acetaminophen analgesia in neonatal circumcision: the effect on pain.
Bramwell RG, Bullen C, Radford P. Caudal block for postoperative analgesia in children. Anaesthesia. 1982;37(10):1024-8.
Concha M, Gonzalez A, Gonzalez J, Vergara R. Postoperative analgesia for ambulatory surgery in children: a
comparison of 2 techniques Cah Anesthesiol. 1994;42(3):339-42.
Lunn JN. Postoperative analgesia after circumcision. A randomized comparison between caudal analgesia and
intramuscular morphine in boys. Anaesthesia. 1979;34(6):552-4.
Martin LV. Postoperative analgesia after circumcision in children. Br J Anaesth. 1982;54(12):1263-6.
May AE, Wandless J, James RH. Analgesia for circumcision in children. A comparison of caudal bupivacaine and
intramuscular buprenorphine. Acta Anaesthesiol Scand. 1982;26(4):331-3.
Butler-O’Hara M, LeMoine C, Guillet R. Analgesia for neonatal circumcision: a randomized controlled trial of EMLA
cream versus dorsal penile nerve block. Pediatrics 1998;101(4):E5.
Howard CR, Howard FM, Fortune K, Generelli P, Zolnoun D, tenHoopen C, deBlieck E. A randomized controlled trial of a
eutectic mixture of local anesthetic cream ( lidocaine and prilocaine) versus penile nerve block for pain relief during
circumcision. Am J Obstet Gynecol 1999;181(6):1506-11.
Herschel M, Khoshnood B, Elman C, Maydew N, Mittendorf R. Neonatal circumcision. Randomized trial of a sucrose
pacifier for pain control. Arch Pediatr Adolesc Med 1998;152(3):279-84.
Masciello AL. Anesthesia for neonatal circumcision: local anesthesia is better than dorsal penile nerve block. Obstet
Hardwick-Smith S, Mastrobattista JM, Wallace PA, Ritchey ML. Ring block for neonatal circumcision. Obstet Gynecol.
Murat I, Gall O, Tournaire B 2003 Procedural pain in children: evidence based best practice and guidelines. Reg Anesth
Pain Med 28: 561-72).
Woodman PJ. Topical lidocaine-prilocaine versus lidocaine for neonatal circumcision: a randomized controlled trial.
Obstet Gynecol. 1999;93(5 Pt 1):775-9.
Weatherstone KB, Rasmussen LB, Erenberg A, Jackson EM, Claflin KS, Leff RD. Safety and efficacy of a topical anesthetic
for neonatal circumcision. Pediatrics. 1993 ;92(5):710-4.
Mudge D, Younger JB. The effects of topical lidocaine on infant response to circumcision. J Nurse Midwifery.
Cuckow PM, Nyirady P. Male genital Abnormalities- The foreskin. IN Pediatric Urology. Gearhart JP, Rink R, Mouriquand
P eds. WB Saunders, Philadelphia 2001, pp 705-712.
Wiswell TE, Smith FR, Bass JW. Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics
Kaweblum YA, Press S, Kogan L. Circumcision using the Mogen clamp. Clin Pediatr 1984;23:679-82.
Fraser IA, Allen MJ, Bagshaw PF, Johnstone M. A randomized trial to assess childhood circumcision with the Plastibell
device compared to a conventional dissection technique. Br J Surg 1981;68:593-595.
Ozdemir E. Significantly increased complication risks with mass circumcisions. Br J Urol. 1997 Jul;80(1):136-9.
Atikeler MK, Gecit I, Yuzgec V, Yalcin O. Complications of Circumcision Performed within and Outside the Hospital. Int
Urol Nephrol. 2005 ;37(1):97-99.
Gatrad AR, Khan A, Shafi S, Sheikh A. Promoting safer male circumcisions for British Muslims. Diversity in Health and
Social Care 2005;2:37-40.
Owen ER, Kitson JL. Plastibell circumcision. Br J Clin Pract. 1990 Dec;44(12):661.
Griffiths MD, Atwell JD, Freeman NV. A Prospective Survey of the Indications and Morbidity of Circumcision in
Children. Eur.Urol 1985;11: 184-187.
Kaplan GW. Complications of Circumcisions Urol clin North Am 1983 ; 10: 543-549.
Bleustein CB, Fogarty JD, Eckholdt H, Arezzo JC, Melman A. Effect of neonatal circumcision on penile neurologic
Casella R. Effects of circumcision on male sexual function: debunking a myth? J Urol. 2002 ;167(5):2111-2.
Senkul T, IserI C, sen B, KarademIr K, Saracoglu F, Erden D. Circumcision in adults: effect on sexual function. Urology.
Fink KS, Carson CC, DeVellis RF. Adult circumcision outcomes study: Effect on erectile function, penile sensitivity, sexual
activity and satisfaction. J Urol 2002;167(5):2113-6.
HSC 1998/113: A first class service consultation document on quality in the new NHS. Department of Health. Published
General Medical Council, Guidance for Doctors asked to circumcise male children: (procedure must take place in
‘hygienic’ conditions), September 1997.
Comment by Doctors Opposing Circumcision
This statement, Management of Foreskin Conditions, is a progressive move to reform the treatment offoreskin conditions. The statement favours conservative treatment over radical circumcision and shoulddo much to promote genital integrity. We urge its speedy adoption.
The lawfulness of non-therapeutic male circumcision is questionable under British law.
Law professors Fox and Thomson recently argued that non-therapeutic male circumcision is unlawful
under the Offences Against the Person Act 1861 after the House of Lords decision of R v Brown
(1993)1. Fox and Thomson argue that consent cannot excuse the practice of non-therapeutic
circumcision because no one can consent to a criminal act.1 No court has ruled on this matter so this
question remains unsettled.
Death is a possible outcome of male circumcision2.
Natural history and development of retractile foreskin.
This section provides newer and more
accurate data. These data should greatly reduce the incidence of erroneous diagnosis of pathological
phimosis in boys and adolescents.
Diagnosis and Treatment of Inflammation (Balanitis, Posthitis, and Balanoposthitis.)
We would like to see greater emphasis placed on the importance of careful diagnosis, since these
conditions have varied etiology, which require varied treatment3. Careful diagnosis is necessary to
find the cause and select the appropriate treatment. The British Guidelines provide excellent
information4. Diagnosis may include a patient history, physical examination, swab and culture, and
biopsy3,4. The presence of infection with Candida Albicans should cause suspicion of diabetes
mellitus3. Recurrent mycotic infection may indicate a compromised immune system and dictate
Fox M, Thomson M. A covenant with the status quo? Male circumcision and the new BMA guidance
to doctors. J Med Ethics 2005;31:463-9.
Williams N, Kapila L. Complications of circumcision. Brit J Surg 1993;80:1231-6.
Edwards S. Balanitis and balanoposthitis: a review. Genitourin Med 1996;72(3):155-9.
Edwards S. (for the Clinical Effectiveness Group) National guideline on the management of balanitis.
Association for Genitourinary Medicine (U.K.)
and the Medical Society for the Study of Venereal
Diseases (U.K.). (2001) Available at: http://www.bashh.org/guidelines/2002/balanitis_0901b.pdf
Mayser P. Mycotic infections of the penis. Andrologia
1999;31 Suppl 1:13-6.
Doctors Opposing Circumcision
Comment On Baps Statement On Management Of Foreskin Conditions 2006 From Norm-UK
On the whole NORM-UK do not consider that this is a balanced view of the management of foreskinconditions, since they are looking at circumcision rather than the management of foreskin conditions.
It is pleasing to see that conservative management is stressed in the cases ofbalanitis/balanoposthitis, non-retractile foreskin and paraphimosis. With regard to circumcision, arealistic view of complication rates is mentioned. We also welcome your sensible, up to date view ofthe natural history of the foreskin.
It is also pleasing that the authors of report are not impressed by supposed prevention of penilecancer by circumcision. It is interesting however that they note increased risk of penile warts incircumcised men as compared with intact.
With regard to BXO, we would urge you to state that this is lichen sclerosus, rather than merely beingakin to lichen sclerosus. We also believe that there is RCT evidence to support the efficacy of topicalsteroids for the treatment of lichen sclerosus. Lindhagen presented a prospective, randomised,double-blind study, although it is admittedly unclear as to whether those who were effectivelytreated actually had lichen sclerosus1. Kiss and colleagues also presented a randomised, placebocontrolled double blind study to show the effective treatment of "BXO" histopathology bymometasone furoate2. At the very least this would seem to merit a recommendation for furtherresearch.
It is also pleasing that they are not impressed by claims that circumcision prevents cervical cancer infemale partners. Unfortunately in this connection they have not questioned the ethics of performingsurgery on a healthy child with a view to preventing disease in a third party at some distant time inthe future on the assumption that the individual will go on to have a partner of the opposite sex.
Setting aside that this is outside the scope of managing actual disease of the foreskin, it is surely anexample of where a choice for circumcision could be made by a consenting adult rather than beingimposed on an un-consenting child?
In the case of prevention of UTI the fact that it is necessary to operate on 111 infants to prevent onecase of UTI is pretty clear evidence that circumcision should not be undertaken for this reason,particularly in view of the complication rates, which they report. However, they haven't pressed thatconclusion clearly enough. It is also noteworthy that the one RCT to examine circumcision for theprevention of UTI in boys found that circumcision was not effective at reducing recurrences of UTI3.
While this was a study solely of boys having anti-reflux surgery for VUR, this is to the best of ourknowledge the only published RCT to consider circumcision for prevention of UTI. It seemsdisingenuous to recommend circumcision in boys with VUR when the only RCT to have consideredthe matter shows that it doesn't work.
Lindhagen T. Topical clobetasol propionate compared with placebo in the treatment of the
unretractable foreskin. Eur J Surg. 1996; 162:969.2.
Kiss A, Csontai A, Pirot L, Nyirady P, Merksz M, Kiraly L. The response of balanitis xerotica obliterans
to local steroid application compared with placebo in children. J Urol. 2001; 165(1):219-20.3.
Kwak C, Oh SJ, Lee A, Choi H. Effect of circumcision on urinary tract infection after successful
antireflux surgery. BJU Int. 2004; 94(4):627-9.
We note that in their discussion of the management of Hooded Foreskin, a congenital defect ofcosmetic but not functional significance, the authors do not propose a course of management ofwaiting for the patient to be mature enough to express an opinion as to whether he wants surgicalcorrection or not, which might be a suitable plan in some cases. We consider this to be an illustrationof the wider question as to why male circumcision should be construed as a matter of personalchoice as opposed a choice to be made by the individual affected when he is of sufficient age andmaturity to make the choice for himself. We urge you to bear this in mind when you go on toconsider religious circumcision.
Dr J Warren
Management of Foreskin Conditions: Statement from the British Association of Paediatric
Urologists--Comments from a Muslim Male Religious Circumcision Practitioner
In my capacity as a General Practitioner who also serves my community with such a service, mycomments will only concern ‘non-therapeutic ritual/religious’ circumcision.
I would like to make mention, again, that I do NOT ascribe to the view that a child should becircumcised simply to ‘look like his dad’- the main reason for circumcision in the States andelsewhere! I think this is a deplorable state of affairs! I have had to turn many parents away who cometo me to have it done ‘because his dad is circumcised’! Circumcision been an irreversible procedurewith attendant surgical/anaesthetic risks.
Specifically I would like to raise certain pertinent points under the headings Non Therapeutic
and Standards of Care
of the associations draft statement.
‘The operator should have a full understanding of the risks and complications of the procedure
and their management’
I assume this means the operator must be aware of the different
management decision making processes when he / she encounters complications, as opposed to
actually been able, skilled, and qualified to deal / handle any complications that may arise. Whereas
some us may at the very least be ‘trained’ to perform circumcisions, most us are necessarily not
trained to handle the more than simple, albeit uncommon, complications of circumcisions e.g.,
significant bleeder, significant infection, concealed penis,denuded penis, meatal stenosis, revision of
circumcisions, urethrocutaneous fistula, etc. There was a G.M.C. case recently where it was felt that it
was inappropropriate and beyond the professionalism of the G.P. to manage a post-operative bleeder.
The child should have been referred to hospital instead. This is in keeping with the very useful and
almost pragmatic B.A.P.S guidelines and G.M.C guidelines on offering "appropriate after care" A lot of
us who seek support or training have been either turned down (no PCT funding etc) or have had
very "unsupportive" letters back. There is a lot of noise about protecting children and the welfare of
children being paramount, but in reality, training/support is never forthcoming for those G.P.s who
want to offer a circumcision service for the children amongst the 3,000,000 Muslims who live in the
Even if help is offered, the conditions under which one will be trained would be that of a motionless,unconscious child with a low blood pressure: ie general anaesthetic. One should not underestimatethe singular advantage this gives the operator. Community practitioners are faced with the singularhurdle of operating on a person with local anaesthesia with all its limitations, including a moving,slippery target. A lot of Paediatric surgeons/urologists have stated how difficult it is to operate on amoving target, and that they view with disbelief and awe how we manage to perform circumcisionunder L.A-(personal e-mail communications with >10 paediatric surgeons, including a professor ofpaediatric surgery).It would therefore not be unreasonable to form an opinion that communitypractitioners would legitimately have intra-/post operative outcomes not as favorable as thoseperformed in hospitals.
Who then decides what an acceptable outcome in the community setting is? Throw in certainconfounding variables: assent NOT consent, unlicensed usage of local anaethesia, operators not beensurgeons NOR trained properly, a contentious surgical technique, suboptimal anaesthetic conditionse.g. the child been awake! In medical malpractice litigation the standard of care is that degree of carewhich a reasonably prudent person in similar circumstances would be expected to exercise1-2. In viewof the recent statement on Medical Expert Witness from the Academy of Medical Royal Colleges, itwould be very difficult for a hospital paediatric surgeon to claim to pronounce on a case carried outby a community practitioner3. There being a difference between, reasonable, acceptable practice and
the Gold standard, as explained by Bolam and Bolitho. In terms of drawing up guidelines aroundreligious circumcision it is unclear what benefit can be derived from such publications when such aposition does not reflect the diversity of opinion and practice in the profession itself4.
‘The operation should be undertaken in an environment capable of fulfilling guidelines for
surgical procedures in children’.
At a single stroke you will stop all qualified Jewish doctors, who are
also Mohels, from performing home ceremonial religious circumcision on babies! It has been shown
time and again that Jewish religious neonatal male circumcision can be carried out under aseptic
technique, with minimal morbidity and mortality and primary healing5-7. The singular advantage of
neonatal circumcision is the reduced infective and technical burden. I am somewhat embarrassed to
say the Muslim community, as far as I am aware, has no such internal system of training and
accreditation and hence benchmarking.
There is ample work done to show that paediatric circumcision is a safe office procedure and
notrequiring an "environment capable of fulfilling guidelines for surgical procedure in children" This isneither necessary nor cost-effective. The bare minimum appears to be it must take place underhygienic conditions.8 –17
There is not much good research published to determine complications rates, especially when thosedone in the community are not often reported - BMJ Best Treatment.
A commonly quoted range is 2-10%18. Looking at the international experience, complications rates are indeed quite high19 . But acasual review indicates that the operators are mainly non medics with no ideas of surgical techniqueor infection control
The procedure itself is relatively straightforward,20: when this is done in hospital and so under generalanaesthetic
.To help prevent complications four principal factors have to be adhered to attention toaseptic conditions, adequate but not excessive excision of inner and outer preputial layers,meticulous haemostasis, and protection of glans and urethra21.
Brian Hurwitz. How does evidence based guidelines influence determinations of medical
negligence? BMJ 2004;329:1024-1028
American Academy of Pediatrics, Policy Statement, Committee on Medical Liability: Guidelines for
Expert Witness Testimony in Medical Malpractice Litigation Pediatrics 2002;109:974-979
3. Medical Expert Witnesses, Guidance from the Academy of Medical Royal Colleges, July 2005.
R Mussell- Ethics department B.M.A.The development of professional guidelines on the law and
ethics of male circumcision. Journal of Medical Ethics, 2004; 30:254-25.
Dr J Spitzer, The Surgery of Bris Milah. Published under the auspices of The Initation Society,
Ben-Chaim-Jacob et al. The Israel Medical Association Journal, June 2005;7:368-70
Samuel Menahem. Complications arising from ritual circumcision: pathogenesis and possible
prevention. January 1981;17:45-48
General Medical Council, Guidance for Doctors asked to circumcise male children: (procedure must
take place in ‘hygienic’ conditions), September 1997.
Heart of Birmingham N.H.S religious circumcision service protocols-2005.
Iftikhar Ahmad, Circumcision in babies and children with the Plastibell technique: an easy
procedure with minimal complications. Pakistan Journal of Medical Sciences,2004;20:175-180
John Krieger et al. Adult male circumcision: results of a standardized procedure in Kisumu District,
Kenya. Reconstructive Urology,BJU international,2005;96:1109-1113
Jayanthi et al. Post-neonatal circumcision with local anaesthesia: a cost effective alternative: NHS
Economic and Evaluation Database, The centre for Reviews and Dissemination, University of York.
Published in Journal of Urology,1999:161: 1301-1303
Schmitz RF et al. Good results from circumcisions of Muslim boys performed outside the hospital.Ned Tijdschr Geneeskd. 1999; 143: 627-30.
Metcalf et al, Circumcision: a study of Current Practices. Clinical Pediatrics, August 1983; 22:575-579
Smith C et al. Office pediatric urologic procedures from a parental perspective. Feb 2000.Urology:2:272-6
Clair DLet al. Pediatric office procedures. Urol Clin North Am, Nov 1988:15, 715-23
Personal reply from the Department of Health to an e-mail, 7 June 2006.
Williams and Kapila. Complications of circumcision. British Journal of Surgery, 1993;80:1231-1236
Ozdemir. Significantly increased complications risks with mass circumcisions. British Journal of
Urology, July 1997;80;136-139
R Wheeler. Legal challenges in Paediatric Surgery. New law Journal , November 2001
Gerharz et al. Medicolegal aspects of male circumcision. British Journal of Urology,
Dr Noor Ahmad
Response to position statement from the Association of Reform & Liberal Mohelim
The ARLM is a group of doctors who perform religious, ritual and non-therapeutic circumcisions,mostly for the Jewish Reform & Liberal communities, but extending to other communities (non-Jewish) as well. We start from the premise that circumcision is required by our religion, is not illegalin this country, and therefore must be allowed. However, our particular association dictates that wemust all be doctors, all trained to an appropriate level, and we all agree to abide by certain standardsof performance and conduct in relation to circumcision.
All of the standards we agree to are encompassed in the GMC guidelines, and in particular we agreethat the interest of the child are paramount, safe medical practice must be observed, and religiousrequirements must never override medical requirement when the safety of the child is at risk.
We believe that circumcision in the home is a safe procedure (having taken appropriate steps toensure sterility of instruments etc) and analgesia is necessary, though can be provided by a variety ofconventional medical approaches. Pre-op assessment, consent, method of circumcision, post-op careand note keeping must follow standard medical guidelines.
We disagree with the complication rates quoted in the position paper: home circumcision in theneonatal period does not produce the level of complications quoted, and we have yearly internalaudits which can demonstrate this. The complication rate is only at the level quoted when olderchildren, hospital circumcisions, medical (therapeutic) circumcisions and adult circumcisions are allmixed in the figures.
We therefore believe that circumcisions in the community can and should be a safe procedure,although would agree that standards (such as those drawn up by our association) should apply to alldoctors performing circumcisions in the community. Those standards are more akin to minor surgeryin General Practice that the standards that apply to hospital surgical procedures.
Nigel Zoltie, MB, ChB, FRCS, FCEMChairman, ARLM
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