Circumcision - When circumcision may be necessary

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

Conditions that may benefit from circumcision

Paraphimosis

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

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

an examination of the penis
a cystoscopy – a medical procedure where a thin, flexible tube (catheter) with a camera on the end is inserted through the penis and up into the bladder
urinary catheterisation – a procedure in which a catheter is inserted through the penis 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. If paraphimosis is not treated, the lack of blood supply will mean that the tissue of the penis will begin to die.

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.

Paraphimosis is extremely rare in children and other treatments are preferred. Circumcision is usually only required in adults in rare cases when medication and surgery fail. Occasionally, circumcision may be recommended if someone has repeated episodes of paraphimosis.

Balanitis

Balanitis is inflammation of the foreskin, usually caused by a bacterial infection.

Symptoms of balanitis include:

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

Balanitis can be successfully treated using antibiotics. Most people do not have further infections. Circumcision is usually recommended only in adults in rare cases where someone has repeated infections (recurrent balanitis).

Urinary tract infections

A urinary tract infection (UTI) is an infection of the urinary system. It is estimated that 1 in 50 boys develop a UTI between their first and second birthdays. Around 1 in 2,000 men develop a UTI every year.

Research has found that circumcised boys are around 10 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. Circumcision is usually only recommended if a boy has a risk factor that increases the likelihood of 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 thought to reduce the risk of catching some types of sexually transmitted infections (STIs). These are:

HIV
human papilloma virus (HPV)
genital herpes
syphilis
chancroid – an uncommon STI in England that causes painful sores on the genitals

Circumcision has also been shown to reduce the chance of certain conditions occurring in female partners, including:

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 an 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.

Circumcision is thought to reduce the risk of a man getting syphilis and chancroid because:

the foreskin may provide a warm, moist environment that 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
10 times as likely to get chancroid

However, 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 that men who are circumcised in childhood are three to four times less likely to develop penile cancer than men who are uncircumcised. This is because many cases of penile cancer develop in the foreskin.

However, cancer of the penis is very rare. On average, 550 new cases are diagnosed each year in the UK. It would, therefore, be very difficult to justify routine circumcision as a method for preventing penile cancer.

However, in some rare cases a person may be more at risk, for example if they have a family history of penile cancer or a weakened immune system. In such cases, circumcision is recommended as a preventative measure.

Conditions that require circumcision

Balanitis xerotica obliterans (BXO) is a skin condition that can only be cured with circumcision. However, the condition is rare in young children and usually affects children over nine years old and adults.

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. In some cases, BXO can affect the urethra and treatment to widen the urethra may be necessary (a meatotomy).