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.

Note: For a high-level overview of this document, please see "Summary for Members and Families" below.

Medically Necessary:

1. Penile circumcision is considered medically necessary when the individual has any of the following conditions:
   1. Preputial neoplasms; or
   2. Recurrent balanitis; or
   3. Recurrent balanoposthitis; or
   4. Risk reduction for individuals at high risk of HIV infection; or
   5. Symptomatic phimosis; or
   6. Paraphimosis; or
   7. Tears of the frenulum; or
   8. Trauma to the foreskin requiring surgical treatment.
       
2. 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.

This document describes clinical studies and expert recommendations, and explains when penile circumcision is clinically appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

Penile circumcision is surgery to remove the foreskin, the skin that covers the head of the penis. This document applies to people older than 4 weeks of corrected age and does not address routine newborn circumcision.

There needs to be a medical reason to perform circumcision beyond the newborn period. Circumcision may help treat certain medical problems involving the foreskin or penis. It may also lower the risk of human immunodeficiency virus (HIV) infection in some people at high risk.

Like any surgery, circumcision can cause pain, bleeding, infection, or other surgical complications. The decision to have circumcision depends on the person's medical condition and expected benefits and risks.

What the Studies Show

Circumcision has been studied for several medical conditions. Research shows it can help treat problems such as severe foreskin narrowing, repeated inflammation or infection of the foreskin and head of the penis, foreskin injuries, and some rare growths affecting the foreskin. In people with foreskin disease caused by a long-term inflammatory skin condition called lichen sclerosus, circumcision often improves symptoms and may cure the disease when medicines do not work.

Studies suggest circumcision may also lower the risk of some sexually transmitted infections, including people at high risk of being infected with HIV. However, the amount of benefit varies among different groups of people. Circumcision is not a complete method of HIV prevention and does not replace other prevention strategies.

The procedure has risks, including bleeding, infection, pain, scarring, and possible complications from anesthesia. Healthcare providers weigh these risks against the expected benefits for each person.

When is Penile Circumcision Clinically Appropriate?

Penile circumcision may be appropriate in these situations:

• The person has a growth or tumor affecting the foreskin; or
• The person has repeated balanitis, which is inflammation of the head of the penis; or
• The person has repeated balanoposthitis, which is inflammation of both the foreskin and the head of the penis; or
• The person is at high risk of HIV infection and circumcision is being considered to reduce that risk; or
• The person has symptomatic phimosis, meaning the foreskin is too tight and causes symptoms; or
• The person has paraphimosis, a condition in which the foreskin becomes trapped behind the head of the penis and cannot return to its normal position; or
• The person has tears of the frenulum, the tissue that connects the foreskin to the penis; or
• The person has a foreskin injury that requires surgery; or
• The person is having surgery to repair a congenital abnormality of the penis.

When is this not Clinically Appropriate?

Penile circumcision is not clinically appropriate when the situations listed above are not present. Studies support circumcision for the specific conditions listed above. The evidence does not show that circumcision improves health for other situations. Better studies are needed to know if circumcision improves health in situations outside the listed clinical indications. Penile circumcision is not clinically appropriate in scenarios other than those listed above.

(Return to Description)

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.

Summary

Elective penile circumcision in the newborn period is outside the scope of this guideline, although professional guidance recognizes that its health benefits may justify the procedure for families who choose it. Circumcision beyond the newborn period generally requires general anesthesia. Circumcision is medically necessary for selected indications, including HIV risk reduction in high-risk populations, symptomatic or pathologic foreskin disease, recurrent inflammatory conditions refractory to conservative treatment, selected congenital reconstruction, and preputial neoplasms. For HIV prevention, voluntary medical male circumcision reduces female-to-male heterosexual acquisition by approximately 59%, and emerging evidence supports risk reduction among primarily insertive men who have sex with men, though evidence remains insufficient to support routine circumcision for all men who have sex with men (MSM) or for prevention related to receptive anal exposure.

Discussion

Voluntary Medical Male Circumcision in Heterosexual Epidemics

Randomized controlled trials consolidated in the World Health Organization (WHO) 2020 guideline demonstrate that VMMC confers an approximate 59% relative risk (RR) reduction (95% confidence interval [CI], 44%-70%) in heterosexually acquired HIV infection (WHO, 2020). A pooled analysis of 17 prospective cohorts showed a 50% lower risk of HIV infection in circumcised men, including when VMMC was implemented alongside antiretroviral treatment scale‑up (WHO, 2020). In communities where VMMC services expanded in parallel with increasing antiretroviral treatment coverage, the incidence reduction was 44% for circumcised compared to uncircumcised men (WHO, 2020). The WHO identifies VMMC as an efficacious HIV‑prevention option within combination strategies (WHO, 2020).

The CDC provides recommendations for penile circumcision and prevention of HIV infection, noting that African-American and Hispanic men have higher risk of HIV infection and lower male circumcision rates than white non-Hispanic males. The agency has found uncircumcised heterosexual men living in areas with high HIV prevalence are likely to experience the most risk-reduction benefit from elective male circumcision (CDC, 2018).

The biological basis for risk reduction is linked to changes in the penile microbiome. VMMC decreases total bacterial load, reduces foreskin inflammation, and shifts the sub‑preputial flora from anaerobes to common aerobic skin species, lowering the density of bacteria associated with seroconversion and immune activation (Galiwango, 2024).

Despite demonstrated efficacy, the WHO notes limited uptake among adult men in some settings, constraining population‑level impact (WHO, 2020). VMMC thus remains a benchmark against which emerging HIV‑prevention approaches are compared.

Insertive MSM and the First Randomized Evidence

Historically, the evidence that VMMC reduces HIV risk for MSM was primarily observational (WHO, 2020). A 2024 RCT evaluated VMMC among 247 HIV‑seronegative, uncircumcised MSM aged 18-49 years who predominantly practiced insertive anal intercourse (Gao, 2024). HIV incidence was 0.0 per 100 person‑years (95% CI, 0.0-3.1) in the circumcised group, compared with 4.1 per 100 person‑years (95% CI, 1.3-9.5) in the control group. This corresponds to a hazard ratio of 0.09 (95% CI, 0.00-0.81; p=0.029). The log‑rank test was significant (p=0.025), and the number needed to treat to prevent 1 infection was approximately 25. The authors found no evidence of increased risk behavior among the circumcised men (risk compensation). Generalizability is limited because receptive intercourse was excluded and event numbers were modest. The WHO 2020 guideline therefore still states that VMMC is not recommended to prevent HIV infection transmitted through sex between men, given insufficient evidence for receptive anal intercourse. However, the guideline still recommends VMMC for MSM who also have vaginal sex with women (WHO, 2020).

A systematic review and meta-analysis by Davis included 49 observational studies with more than 150,000 MSM participants. Circumcision was associated with lower HIV acquisition in the unadjusted meta-analysis (odds ratio [OR], 0.57; 95% CI, 0.33-0.98; p=0.043), and the adjusted pooled estimate also favored circumcision (pooled ratio of ratios, 0.53; 95% CI, 0.34-0.83; p=0.006). These findings support a risk-stratified role for circumcision in primarily insertive MSM at high HIV risk when used as part of a broader HIV-prevention strategy, but they do not establish circumcision as a universal HIV-prevention intervention for all MSM or as protection for receptive anal exposure (Davis, 2026; WHO, 2020).

Broader Sexually Transmitted Infection Benefits

The 2020 WHO recommendations state that VMMC is associated with lower rates of human papillomavirus, herpes simplex virus 2, bacterial vaginosis, and Trichomonas vaginalis in circumcised men and their female partners (WHO, 2020). Modeling suggests that VMMC scale‑up could prevent approximately 20% of cervical cancer cases in Uganda under certain scenarios. Real‑world data from a South African mining cohort (n=339) showed reduced sexually transmitted infection incidence in circumcised compared to uncircumcised men (Iyemosolo, 2021).

The same microbiome alterations thought to reduce HIV susceptibility are believed to drive these broader effects (Galiwango, 2024). Collectively, the epidemiologic and mechanistic evidence strengthens the public‑health rationale for VMMC well beyond HIV prevention (Iyemosolo, 2021; WHO, 2020).

Lichen Sclerosus and Balanitis Xerotica Obliterans (BXO)

Circumcision is a primary, often curative, surgical treatment for lichen sclerosus (LS), also termed balanitis xerotica obliterans, particularly when medical therapy fails or disease progresses (Clouston, 2011). LS frequently causes pathological phimosis, characterized by scarring and a non‑retractile foreskin (British Association of Paediatric Urologists [BAPU], 2017; Celis, 2014). Potent topical corticosteroids constitute first‑line therapy (Clouston, 2011; Lewis, 2018), but circumcision is indicated when steroids fail to resolve phimosis or severe symptoms persist (Celis, 2014). The procedure is curative in most boys and in 92% of adult men when disease is confined to the foreskin and glans (Clouston, 2011). Histopathological examination of the excised foreskin is mandatory to confirm diagnosis and exclude precancerous or malignant changes (Celis, 2014).

Pediatric histopathology data further support the distinction between physiologic non-retractability and pathologic phimosis. In a single-center retrospective study of 48 pediatric individuals undergoing circumcision for phimosis, Aboukhatwah reported histologic male genital lichen sclerosus in 34 cases (71%). Among children clinically classified as having physiologic phimosis, 23 of 33 (70%) had histologic lichen sclerosus, and clinical-pathologic concordance was low. These findings support careful assessment for occult lichen sclerosus when pediatric phimosis is symptomatic, scarred, persistent, or otherwise clinically concerning; they do not support routine circumcision for uncomplicated physiologic non-retractability (Aboukhatwah, 2025).

Recurrent Balanitis and Balanoposthitis

Circumcision is generally reserved for recurrent balanitis or balanoposthitis that is refractory to hygiene measures and appropriate topical or antimicrobial therapy. The 2025 British Association for Sexual Health and HIV (BASHH) balanoposthitis guideline supports diagnostic evaluation and medical treatment first, with urology referral and possible circumcision when disease is recurrent, associated with clinically significant phimosis, suspicious for penile intraepithelial neoplasia or malignancy, or otherwise not resolving with appropriate management. This is consistent with other urology and dermatology guidance recognizing recurrent balanitis, recurrent balanoposthitis, paraphimosis, frenular tears, and persistent severe inflammation after conservative management as accepted indications for circumcision (BAPU, 2017; BASHH, 2025; Edwards, 2023).

Indications for Circumcision in Pathological Foreskin Conditions

Physiologic versus Pathologic Phimosis

The foreskin is a redundant fold protecting the glans penis and urethral meatus. By 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 (Baskin, 2019). The American Academy of Pediatrics (AAP)/American College of Obstetrics and Gynecologists (ACOG) guidelines for perinatal care (2017) state 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.

Pathological Phimosis

Circumcision is indicated when phimosis is symptomatic, pathologic, scarred, associated with lichen sclerosus/ BXO, or persistent despite an adequate course of topical corticosteroid therapy.

Current European Association of Urology (EAU) pediatric urology guidance identifies physiologic non-retractability, adhesions, and ballooning before puberty as common developmental findings, while recommending topical corticosteroids as first-line therapy for symptomatic phimosis and circumcision for BXO or phimosis refractory to treatment (EAU, 2026; Moreno, 2024). In adults with symptomatic phimosis, prospective individual-reported data demonstrate clinically meaningful functional impact and improvement after circumcision, including improved International Index of Erectile Function-15 (IIEF-15) scores, genital self-image scores, and high reported satisfaction at 6 months (Falis, 2026). Additional indications include recurrent urinary tract infection in boys with pre‑existing urinary tract abnormalities.

Paraphimosis and Other Indications

Paraphimosis is a urologic emergency that occurs when the retracted foreskin (prepuce) of an uncircumcised penis becomes trapped behind the glans and cannot be returned to its normal position. This leads to venous and lymphatic congestion, swelling that can lead to progressive constriction, impaired blood flow, and risk of ischemia and necrosis of the glans if not treated promptly. Management of paraphimosis prioritizes immediate manual reduction, as reflected in guidance from the British Association of Urological Surgeons (BAUS) and others (BAPU, 2017; BAUS, 2016; EAU, 2026; Kirtschig, 2024). Circumcision becomes a consideration only for recurrent episodes or when urgent surgical management is needed because manual reduction fails.

Absolute indications beyond phimosis and paraphimosis are uncommon and include penile malignancy or traumatic, irreparable foreskin injury. Circumcision may also be performed as part of surgical repair of congenital urethral or genital abnormalities, but reconstructive planning is important because the foreskin may be needed for repair. EAU pediatric guidance cautions against simple circumcision when phimosis coexists with buried penis, congenital penile curvature, epispadias, or hypospadias. In hypospadias repair, a 2025 systematic review and meta-analysis found similar rates of urethrocutaneous fistula, meatal stenosis, and glans dehiscence for foreskin reconstruction compared with conventional circumcision, although skin or preputial complications were higher with foreskin reconstruction (RR, 2.89; 95% CI, 1.20-6.97). These findings support individualized reconstructive planning rather than routine removal or preservation of foreskin in congenital repair (AUA, 2023; Borkar, 2025; EAU, 2026). Relative indications may involve a tight foreskin causing pain or sexual dysfunction.

Preputial neoplasms and penile malignancy are uncommon but established indications for therapeutic circumcision in selected cases. European Association of Urology-American Society of Clinical Oncology (EAU-ASCO) penile cancer guidance supports organ-sparing approaches, including circumcision, for selected lesions confined to the glans or prepuce. European Society for Medical Oncology-European Reference Network for Rare Adult Solid Cancers (ESMO-EURACAN) guidance similarly recommends circumcision as initial treatment for biopsy-proven penile intraepithelial neoplasia involving the glans or prepuce and recognizes circumcision, with or without wider local excision, as an option for selected superficial or localized lesions. These oncology guidelines support the current preputial neoplasm criterion but do not support routine circumcision solely for cancer prevention (EAU-ASCO, 2026; Muneer, 2024).

Special Considerations

Maternal herpes simplex infection has been proposed as an indication to delay newborn penile circumcision. The AAP and 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 (for example, male infants delivered vaginally by women with active genital lesions).

Adhesions of the prepuce: areas where the inner surface of the foreskin (prepuce) is abnormally attached to the glans penis. These adhesions may be:

Physiologic (normal in infants and young boys): due to natural fusion between the glans and foreskin at birth, which typically resolves with age; or
Pathologic: caused by inflammation, infection, trauma, or scarring, leading to abnormal and potentially persistent attachments.

Balanitis: Inflammation of the glans penis.

Balanoposthitis: Inflammation of the foreskin and the glans penis.

Balanitis xerotica obliterans: An alternative term for lichen sclerosus when it affects the penis; a chronic inflammatory condition that causes scarring and phimosis.

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.

Hypospadias: A congenital anomaly in which the urethra opens on the underside of the penis rather than at the tip.

Lichen sclerosus (LS): A chronic inflammatory skin condition that can affect the foreskin and glans penis. This can lead to pathological phimosis, paraphimosis, and increased risk of penile intraepithelial neoplasia (PeIN) and malignant transformation to squamous cell carcinoma. Circumcision may be indicated when medical therapy fails.

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

Paraphimosis: A condition in which the foreskin is retracted and cannot return to its anatomic position. This is a urologic emergency that may lead to swelling, pain, ischemia, and necrosis. Manual reduction is the first-line therapy. Circumcision may be needed if non-surgical treatments fail.

Pathological phimosis: Constriction of the foreskin due to scarring from infection or inflammation that prevents retraction, as opposed to the normal physiologic type.

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

Physiologic phimosis: The normal inability to retract the foreskin in newborns and young children due to developmental adhesions; does not require surgical treatment.

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.

Urethral meatus: The external opening of the urethra, located at the tip of the glans penis in males. This is the opening through which urine and semen exit the body.

Voluntary medical male circumcision (VMMC): Elective circumcision performed specifically as an HIV prevention strategy, particularly in areas with high HIV prevalence.

Peer Reviewed Publications:

1. Aboukhatwah N, Jerkovic Gulin S, Bunker CB, et al. Lichen sclerosus in paediatric patients with phimosis undergoing circumcision. Skin Health Dis. 2025; 5:426-431.
2. Borkar N, Sharma C, Das K, et al. Foreskin reconstruction or conventional circumcision in hypospadias: a systematic review and meta-analysis. J Indian Assoc Pediatr Surg. 2025; 30:576-583.
3. 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.
4. Clouston D, Hall A, Lawrentschuk N. Penile lichen sclerosus (balanitis xerotica obliterans). BJU Int. 2011; 108 Suppl 2:14-19.
5. Davis SM, Fellows I, de Leon O, et al. Circumcision for HIV prevention in men who have sex with men: an updated meta-analysis. J Acquir Immune Defic Syndr. 2026; 101(4):335-345.
6. Falis M, Grudzinska M, Michalowska W, et al. Adult circumcision for symptomatic phimosis in Poland: six-month patient-reported sexual function and psychosocial outcomes from a Central European low-circumcision setting. J Clin Med. 2026; 15:3499.
7. Galiwango RM, Okech B, Park DE, et al. Impact of antimicrobials on penile HIV susceptibility and immunology in uncircumcised men: a randomized phase 1/2 clinical trial. Cell Rep Med. 2024; 5 (9):101705.
8. Gao Y, Zhan Y, Sun Y, et al. Efficacy of voluntary medical male circumcision to prevent HIV infection among men who have sex with men: a randomized controlled trial. Ann Intern Med. 2024; 177:719-728.
9. 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.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Family Physicians. Neonatal Circumcision. 2023. Available at: https://www.aafp.org/about/policies/neonatal-circumcision. Accessed on August 17, 2026.
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/aua-statements/circumcision. Accessed on August 17, 2026.
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. British Association for Sexual Health and HIV. BASHH guideline on the management of balanoposthitis and related penile skin conditions. Version 05. August 2025. Available at: https://www.bashh.org/resources/144/updated_guidelines_on_the_management_of_balanoposthitis_2025/. Accessed on August 17, 2026.
6. British Association of Paediatric Urologists. 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 Anesthetists. 2017. Available at: https://www.baps.org.uk/resources/management-foreskin-conditions/. Accessed on August 17, 2026.
7. British Association of Urological Surgeons, British Association of Paediatric Surgeons, British Association of Paediatric Urologists. Commissioning guide: foreskin conditions. London: The Royal College of Surgeons of England; 2016. Available at: https://www.baps.org.uk/wp-content/uploads/2016/05/Revised-Foreskin-conditions-commissioning-guide-for-consultation-02051....pdf. Accessed on August 17, 2026.
8. Edwards SK, Bunker CB, van der Snoek EM, van der Meijden WI. 2022 European guideline for the management of balanoposthitis. J Eur Acad Dermatol Venereol. 2023; 37(6):1104-1117.
9. European Association of Urology. EAU Guidelines on Paediatric Urology. Limited text update March 2026. Available at: https://uroweb.org/guidelines/paediatric-urology. Accessed on August 17, 2026.
10. European Association of Urology and American Society of Clinical Oncology. EAU-ASCO collaborative guidelines on penile cancer. 2026. Available at: https://uroweb.org/guidelines/penile-cancer. Accessed on August 17, 2026.
11. Hohlfeld A, Ebrahim S, Shaik MZ, Kredo T. Circumcision devices versus standard surgical techniques in adolescent and adult male circumcisions. Cochrane Database Syst Rev. 2021;3(3):CD012250.
12. Holman JR, Stuessi KA. Adult circumcision. Am Fam Physician. 1999; 59(6):1514-1518.
13. Kirtschig G, Kinberger M, Kreuter A, et al. EuroGuiderm guideline on lichen sclerosus-treatment of lichen sclerosus. J Eur Acad Dermatol Venereol. 2024; 38(10):1874-1909.
14. Lewis FM, Tatnall SS, Velangi CB, et al. Guidelines for the management of lichen sclerosus. Br J Dermatol. 2018; 178(4):839-853.
15. Moreno G, Ramirez C, Corbalán J, et al. Topical corticosteroids for treating phimosis in boys. Cochrane Database Syst Rev. 2024; 1:CD008973.
16. Muneer A, Bandini M, Compérat E, et al. Penile cancer: ESMO-EURACAN clinical practice guideline for diagnosis, treatment and follow-up. ESMO Open. 2024; 9:103481.
17. 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 17, 2026.
18. 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 17, 2026.

Circumcision

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