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:

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.

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. Guidelines by the American Urological Association (AUA, 2023), the American Academy of Family Physicians (AAFP, 2023), and the Centers for Disease Control and Prevention (CDC, 2018) state 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.

Randomized controlled trials (RCTs) confirm that voluntary medical male circumcision (VMMC) lowers the risk of heterosexually acquired human immunodeficiency virus (HIV) infection by roughly 59%, with supporting cohort data showing a 50% reduction. A 2024 multicenter RCT extends these findings to predominantly insertive men who have sex with men (MSM), indicating a 91% relative risk reduction, although evidence remains insufficient for receptive intercourse. Beyond HIV, VMMC is associated with decreased prevalence of several sexually transmitted infections, including infections caused by human papillomavirus, herpes simplex virus 2, bacterial vaginosis, and Trichomonas vaginalis. Circumcision is also a definitive therapy for pathological foreskin conditions, offering a cure for conditions such as lichen sclerosus (LS), pathological phimosis, and treatment‑refractory balanitis.

Discussion

Voluntary Medical Male Circumcision in Heterosexual Epidemics

RCTs consolidated in the World Health Organization (WHO) 2020 guideline demonstrate that VMMC confers an approximate 59% relative risk 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).

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 versus 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

Circumcision is a primary, often curative, surgical treatment for 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).

Recurrent Balanitis and Balanoposthitis

For recurrent balanitis and balanoposthitis, circumcision is reserved for cases that remain refractory to hygiene measures, topical corticosteroids, and antibiotics (BAPU, 2017; Edwards, 2023). Recurrent balanitis, balanoposthitis and paraphimosis are recognized by AUA (AUA 2023) and AAFP (Holman, 1999) as indications for circumcision beyond the neonatal period. Effective treatment of balanitis and balanoposthitis is often provided through treatment of the underlying condition (Anandan, 2018; Celis, 2014; Clouston, 2011). A tear of the frenulum impairs or eliminates its function in maintaining normal foreskin position in the unretracted state and is recognized by AAFP as an indication for circumcision (Holman, 1999). Surgical intervention is recommended for individuals experiencing persistent, severe inflammation after conservative management.

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 scarring (pathological phimosis) persists despite topical corticosteroids or when specific underlying conditions exist (British Association of Urological Surgeons [BAUS], 2016; Hohlfeld, 2021; Kirtschig, 2024; Moreno, 2024). 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 (BAPU, 2017; BAUS, 2016; Kirtschig, 2024). Circumcision becomes a consideration only for recurrent episodes.

Absolute indications beyond phimosis and paraphimosis are uncommon and include penile malignancy or traumatic, irreparable foreskin injury. Circumcision may be performed as part of the surgical repair of congenital urethrogenital defects, such as hypospadias, because the foreskin is typically needed to reconstruct the urethra and surrounding tissues (AUA, 2023). Relative indications may involve a tight foreskin causing pain or sexual dysfunction.

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. 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. 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.
5. 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.
6. 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/all/neonatal-circumcision.html. Accessed on July 7, 2025.
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 2023. Available at: https://www.auanet.org/about-us/policy-and-position-statements/circumcision. Accessed on July 7, 2025.
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 of Pediatric Urologists. Management of foreskin conditions: statement from the British Association of Pediatric Urologists on behalf of the British Association of Pediatric Surgeons and The Association of Pediatric Anesthetists. 2017. Available at: https://www.baps.org.uk/resources/management-foreskin-conditions/. Accessed July 7, 2025.
6. British Association of Urological Surgeons, British Association of Pediatric Surgeons, British Association of Pediatric Urologists. Commissioning guide: foreskin conditions. London: The Royal College of Surgeons of England; 2016. Available from: https://www.baps.org.uk/wp-content/uploads/2016/05/Revised-Foreskin-conditions-commissioning-guide-for-consultation-02051....pdf Accessed July 11, 2025.
7. 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.
8. 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.
9. Holman JR, Stuessi KA, Adult Circumcision. Am Fam Physician. 1999; 59(6):1514-1518.
10. 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.
11. Lewis FM, Tatnall SS, Velangi CB, et al. Guidelines for the management of lichen sclerosus. Br J Dermatol. 2018; 178(4):839-853.
12. Moreno G, Ramirez C, Corbalán J, Peñaloza B, Morel Marambio M, Pantoja T. Topical corticosteroids for treating phimosis in boys. Cochrane Database Syst Rev. 2024; 1:CD008973.
13. 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 July 7, 2025.
14. 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 July 7, 2025.

Circumcision

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