Circumcision

Circumcision is the surgical removal of the foreskin, the fold of skin that covers the head of the penis. It is performed for medical reasons, and also for religious, cultural or personal ones. Whichever the reason, the assessment before it is the same: the anatomy is examined, the reason for the request is discussed, and alternatives are considered before any decision is made.

What circumcision is

The foreskin is a retractable double layer of skin covering the glans. Circumcision removes it, and the cut edges are closed, usually with sutures that dissolve on their own over the following weeks.

It can be carried out at any age. What differs with age is the anaesthetic, the technique chosen and the recovery, not the principle of the operation.

It is a permanent change. The foreskin cannot be restored afterwards, which is why the decision is taken unhurriedly and with the alternatives understood.

When it may be considered

Recognised medical reasons include:

• Pathological phimosis — a foreskin that cannot be retracted because of scarring, causing pain, difficulty passing urine or recurrent problems
• Balanitis and balanoposthitis — repeated inflammation or infection of the glans and foreskin that does not settle with simpler measures
• Lichen sclerosus (balanitis xerotica obliterans) — a scarring skin condition of the foreskin and glans
• After paraphimosis — where a retracted foreskin has become trapped behind the glans, an emergency in itself, circumcision may be advised afterwards to prevent recurrence
• Recurrent urinary tract infection — in selected cases, usually where another urinary problem is also present

Two cautions matter here. In young boys a foreskin that does not retract is usually normal and resolves with growth; it is not by itself a reason for surgery. And a tight frenulum that tears or tethers is often treated by frenuloplasty, a smaller procedure that leaves the foreskin in place.

Where the request is religious, cultural or personal rather than medical, it is assessed clinically in the same way, and the same information about risks and recovery applies.

How the procedure works

Circumcision is commonly performed as a day-care procedure, with discharge on the same day in most cases.

• Anaesthetic — children are usually treated under general anaesthetic. In adults the choice between general, regional and local anaesthetic with sedation depends on the individual case and is agreed beforehand.
• The operation — the foreskin is removed, bleeding points are controlled, and the skin edges are brought together with absorbable sutures. A light dressing is applied.
• Technique — conventional open surgical excision is the usual approach in adults. Device-assisted methods exist and are used in some circumstances; which is appropriate is decided case by case.

A follow-up appointment is arranged to check healing.

Preparation

• A pre-operative assessment covering medical history, current medications and allergies
• Blood-thinning medication needs to be declared, as it may need adjusting before the date — never stop prescribed medication without being told to
• Active infection or inflammation is usually treated first, and the procedure deferred until it has settled
• Fasting instructions are given where a general anaesthetic is planned, and should be followed exactly
• Arrange for someone to accompany you home after an anaesthetic
• Loose clothing and supportive underwear for afterwards are worth having ready

Recovery

Swelling and bruising are expected and settle over the first one to two weeks. Discomfort is usually manageable with the pain relief advised at discharge.

• Keep the area clean and dry, and follow the dressing instructions given
• Absorbable sutures separate on their own; they do not normally need removing
• Desk-based work is usually possible within a few days
• Heavy lifting, cycling and strenuous activity are avoided for the period advised
• Sexual activity is avoided until healing is complete — usually several weeks, with the exact point confirmed at follow-up
• For children, straddling toys and rough play are avoided during healing

Healing times vary between individuals. The follow-up appointment, rather than a fixed number of days, is what confirms that recovery is complete.

Risks and considerations

Circumcision is a common operation, but like any surgery it carries risk. Recognised ones include:

• Bleeding, occasionally needing a return to theatre
• Infection of the wound
• Pain and swelling beyond the expected period
• Too much or too little skin removed, which can require a revision procedure
• Narrowing of the urinary opening (meatal stenosis), described more often after circumcision in infancy
• Changes in sensation of the glans
• Delayed healing, or a scar that is thicker or less even than expected
• The risks of the anaesthetic itself

It is also irreversible. Risks are assessed individually before any decision, and the balance differs considerably between a clearly symptomatic adult and a child with a foreskin that is simply not yet retractable.

When to seek medical attention

Contact the treating team or seek urgent care if any of the following occur after the procedure:

• Bleeding that soaks through the dressing or does not stop with gentle, steady pressure
• Being unable to pass urine
• Spreading redness, increasing pain, discharge of pus, or fever
• Swelling that worsens rather than settles after the first few days
• The head of the penis becoming dark or dusky in colour

These are uncommon, but they need assessment rather than waiting.

Frequently asked questions