Clinical UM Guideline

Penile circumcision is a surgical procedure to remove the foreskin of the penis. This document addresses penile circumcision for individuals older than 4 weeks in corrected age (corrected age is defined as birth age minus the number of weeks a child is born prematurely).

Note: This document does not address routine penile circumcisions performed for the term or preterm infant in the newborn period.

Medically Necessary:

Penile circumcision is considered medically necessary when the individual has any of the following conditions:

• Preputial neoplasms; or
• Recurrent balanitis; or
• Recurrent balanoposthitis; or
• Risk reduction for individuals at high risk of HIV infection; or
• Symptomatic phimosis; or
• Paraphimosis; or
• Tears of the frenulum; or
• Trauma to the foreskin requiring surgical treatment.

Penile circumcision is considered medically necessary when the individual is undergoing surgical repair of congenital urethral or genital abnormalities.

Not Medically Necessary:

Penile circumcision is considered not medically necessary when the criteria listed above have not been met.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for all other diagnoses not listed, or when the code describes a procedure designated in the Clinical Indications section as not medically necessary.

Elective penile circumcision of an infant in the newborn period is outside the scope of this guideline. Guidelines by American Urological Association (AUA, 2018), American Academy of Family Physicians (AAFP, 2018), and the Centers for Disease Control and Prevention (CDC, 2018) have determined that the health benefits of circumcision in the newborn period are sufficient to justify the procedure for families choosing it. The AUA notes that general anesthesia is generally required for circumcision beyond the newborn period.

There are several conditions that create a medical need for circumcision beyond the newborn period.

Phimosis is the inability to retract the foreskin. This condition can be physiologic or pathologic. The foreskin is a redundant fold protecting the glans penis and urethral meatus. This fold begins developing in the first trimester of pregnancy. By the time of full-term birth, the foreskin is usually fully developed; however, most individuals are born with adhesions between the glans and the inner squamous epithelium of the foreskin. These adhesions prevent full retraction of the foreskin in almost all newborns and prevent full visualization of the urethral meatus in more than half (Baskin, 2005).

Inability to retract the foreskin is normal in most newborns. This condition is known as physiologic phimosis and does not require surgical treatment (McGregor, 2007). Full retraction of the foreskin may not develop until adulthood, but most individuals develop an ability to fully or partially retract the foreskin by their teenage years.

The American Academy of Pediatrics (AAP)/American College of Obstetrics and Gynecologists (ACOG) guidelines for perinatal care (2017) states that, because of physiologic adhesions, the foreskin usually does not retract fully for several years and should not be forcibly retracted. Thus, an unretractable foreskin in a neonate and young infant does not warrant circumcision.

Pathologic phimosis is due to scarring from infection or inflammation. This can lead to inflammation of the glans penis (balanitis) or of the foreskin and glans penis (balanoposthitis). Balanitis and balanoposthitis can be caused by several factors such as bacteria common in urinary tract infections and sexually transmissible pathogens including human papilloma virus (HPV). Balanitis may also be due to a variety of dermatologic conditions including eczema, psoriasis, lichen planus, and lichen sclerosis (Lewis, 2018). Effective treatment of balanitis and balanoposthitis is often provided through treatment of the underlying condition (Anandan, 2018; Celis, 2014; Clouston, 2011).

Paraphimosis occurs when scarring of the foreskin prevents return to its normal position after retraction. This can result in constriction proximal to the glans penis leading to progressive venous and lymphatic engorgement that can develop into arterial constriction over hours to days. Paraphimosis is a urologic emergency requiring urgent reduction of the foreskin (AAFP, 1999; Little, 2005).

Recurrent balanitis, balanoposthitis and paraphimosis are recognized by AUA (AUA 2018) and AAFP (Holman, 1999) as indications for circumcision beyond the neonatal period. A tear of the frenulum impairs or eliminates its function in maintaining normal foreskin position in the unretracted state. Such a tear is recognized by AAFP as an indication for circumcision.

Maternal herpes simplex infection has been proposed as an indication to delay newborn penile circumcision. The AAP and the ACOG guidelines for perinatal care (2017) state:

There are no data indicating that the circumcision of newborn male infants who may have been exposed to herpes simplex virus at birth should be postponed. It may be prudent, however, to delay circumcision for approximately 1 month for those at highest risk of disease (e.g. male infants delivered vaginally by women with active genital lesions).

Circumcision may be performed as part of a surgical repair of congenital urethrogenital defects or after resection of neoplasms of the penis. Hypospadias is a congenital anomaly in which the urethra opens on the underside of the penis. Surgical repair of this condition places the urethra at the end of the penis. Removal of the foreskin is usually necessary to support this procedure.

The use of circumcision as a prophylactic method for HIV infection and other conditions has been shown to be an effective approach in Africa (Iyemosolo, 2021). This has been used as the basis for recommendations for circumcision by the World Health Organization (WHO, 2020). The CDC provides recommendations regarding penile circumcision and prevention of HIV infection and notes the following:

… African-American and Hispanic men have higher risk of HIV infection and lower male circumcision rates than white non-Hispanic males. Similar randomized clinical trials have not been conducted in the United States, but based on evidence from the African trials of the efficacy of male circumcision to prevent HIV transmission, uncircumcised heterosexual men living in areas with high HIV prevalence are likely to experience the most risk-reduction benefit from elective male circumcision.

Balanitis: Inflammation of the glans penis.

Balanoposthitis: Inflammation of the foreskin and the glans penis.

Corrected Age: Chronologic age reduced by the number of weeks born before 40 weeks gestation.

Frenulum: A band of tissue connecting two other structures. The frenulum of the glans penis connects the foreskin to the glans helping to maintain the position of the foreskin over the glans in the unretracted state.

Newborn Period: The time between birth and a corrected age of 1 month.

Phimosis: Constriction of the foreskin which may result in narrowing preventing the foreskin from being retracted.

Paraphimosis: A condition in which the foreskin is retracted and cannot return to its anatomic position. This may lead to swelling, pain, ischemia, and necrosis.

Posthitis: Inflammation of the foreskin.

Prepuce: The fold of skin that covers the head of the penis, also a similar fold of skin above the clitoris.

Preputial: Related to the prepuce.

Peer Reviewed Publications:

1. Anandan L, Mohammed A. Surgical management of buried penis in adults. Cent European J Urol. 2018; 71(3):346-352.
2. Celis S, Reed F, Murphy F, et al. Balanitis xerotica obliterans in children and adolescents: a literature review and clinical series. J Pediatr Urol. 2014; 10(1):34-39.
3. Clouston D, Hall A, Lawrentschuk N. Penile lichen sclerosus (balanitis xerotica obliterans). BJU Int. 2011; 108 Suppl 2:14-9.
4. Iyemosolo BM, Chivese T, Esterhuizen TM. A comparison of the prevalence of sexually transmitted infections among circumcised and uncircumcised adult males in Rustenburg, South Africa: a cross-sectional study. BMC Public Health. 2021; 21(1):656.
5. Little B, White M. Treatment options for paraphimosis. Int J Clin Pract. 2005; 59(5):591-593.
6. McGregor TB, Pike JG, Leonard MP. Pathologic and physiologic phimosis: approach to the phimotic foreskin. Can Fam Physician. 2007; 53(3):445-448.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Family Physicians. Neonatal Circumcision. 2018. Available at: https://www.aafp.org/about/policies/all/neonatal-circumcision.html. Accessed on August 11, 2023.
2. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 8th ed. Elk Grove Village (IL): AAP; Washington, DC: American College of Obstetricians and Gynecologists; 2017.
3. American Urological Association. Circumcision. Reaffirmed October 2018. Available at: https://www.auanet.org/about-us/policy-and-position-statements/circumcision. Accessed on August 11, 2023.
4. Baskin LS, Giramonti KM. Circumcision. In: Handbook of Pediatric Urology, 3rd ed, Baskin LS, Kogan BA, Stock JA (Eds). Lippincott Williams and Wilkins, Philadelphia 2019.
5. Holman JR, Stuessi KA, Adult Circumcision. Am Fam Physician. 1999; 59(6):1514-1518.
6. United States Centers for Disease Control and Prevention. Information for providers to share with male patients and parents regarding male circumcision and the prevention of HIV infection, sexually transmitted infections, and other health outcomes. 2018. Available at: https://stacks.cdc.gov/view/cdc/58456. Accessed on August 11, 2023.
7. World Health Organization (WHO) Preventing HIV through safe voluntary medical male circumcision for adolescent boys and men in generalized HIV epidemics: recommendations and key considerations. 2020. Available at: https://www.who.int/publications/i/item/978-92-4-000854-0. Accessed on August 11, 2023.

Circumcision

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