Title: Male Circumcision Policy

Transcription

1 Item cii The Clinical Commissioning Groups for Great Yarmouth and Waveney, North Norfolk, Norwich, South Norfolk and West Norfolk, supported by North East London Commissioning Support Unit Policy Statement Title: Male Circumcision Policy Date: Great Yarmouth and Waveney CCG North Norfolk CCG Norwich CCG South Norfolk CCG West Norfolk CCG Please check the Knowledge Anglia website for the latest version of this policy.

2 Document Control Implementation date: Review date: Prepared by: Norfolk and Waveney Clinical Policy Development Group Approved by: CCG Date approved Variance Great Yarmouth and Waveney CCG North Norfolk CCG Norwich CCG South Norfolk CCG West Norfolk CCG Version Control Version Section/Para/ Appendix Version Control Sheet Description of Amendments Date Amended by Page 2 of 10

3 Table of Contents Document Control... 2 Table of Contents Policy Statement Equality Statement Glossary Plain Language Summary Definitions of condition and treatment Description of Local Need Evidence of Effectiveness Clinical Governance statement Acknowledgements References Appendices... 9 Page 3 of 10

4 1. Policy Statement Clinical Commissioning Groups (CCGs) within Norfolk and Waveney will commission interventions for male circumcision in accordance with the criteria outlined in this document. During the development of this policy it has been considered whether scientific research has shown the treatment to be of benefit to patients, (including how any benefit is balanced against possible risks) and whether its use represents the best use of NHS resources. Title/topic: Status: Male Circumcision Prior Approval Norfolk and Waveney CCGs will ONLY fund Circumcision according to the following criteria: Penile malignancy Note: if penile malignancy is suspected, referral should be via a two week wait pathway for suspected cancer Traumatic foreskin injury where it cannot be salvaged Recurrent paraphimosis Pathological Phimosis (eg caused by Lichen Sclerosus or Balanitis Xerotica Obliterans) Balanoposthitis following failure of conservative management. Congenital abnormalities Recurrent Urinary Tract Infections in patients with an abnormal urinary tract Tight foreskin causing pain on arousal/ interfering with sexual function Circumcision is NOT FUNDED for: Healthy, non-retractile foreskin (physiological phimosis) Any non-medical circumstances such as religious or social reasons Note: Female circumcision is prohibited by UK law. Conservative management: includes simple bathing in the first instance with progression to topical steroids. A prescription for topical steroids would not normally exceed three months and should have achieved maximal therapeutic benefit within this time. Antibiotics would be of use in infective conditions (Siegfried et al. 2003, Royal College of Surgeons 2013). CCG Variation: Clinical Codes for audit/monitoring N303 Circumcision. N308 Other specified operations on prepuce. N309 Unspecified operations on prepuce Policy Exclusions: For patients not meeting the above criteria or where a treatment is not routinely funded, an application should be made to the IFR panel if the referrer considers that there are clinically exceptional circumstances. Page 4 of 10

5 Note: this page will be included in the overall NRTTT/Prior Approval policy with a link to the full policy for a plain language summary and further information 2. Equality Statement The CCGs and the Clinical Policy Development Group (CPDG) are committed to ensuring equality of access and non-discrimination as enshrined in the Health and Social Care Act In carrying out its functions, the CPDG will have due regard to the different needs of protected equality groups, in line with the Equality Act This document is compliant with the NHS Constitution and the Human Rights Act Glossary Glossary Term Foreskin Phimosis Paraphimosis Balanoposthitis Lichen sclerosus Balanitis xerotica obliterans Meaning Also known as the prepuce. It is the free fold of skin that overlaps the end of the penis and draws back when the penis becomes erect. The foreskin is the part that is removed at circumcision. Phimosis refers to the inability to draw back the distal foreskin from the end of the penis. Paraphimosis is a condition in which the foreskin, once pulled back behind the end of the penis, cannot be brought down to its original position. Recurrent bacterial infection of the foreskin. A chronic inflammatory condition of the skin that mainly affects the genital area in men and women and is called BXO (balanitis xerotica obliterans) in men. The cause of the condition is not known but there is an association with other auto-immune conditions such as vitiligo and certain forms of thyroid disease. NB this is not a sexually transmitted disease. See Lichen sclerosus (above) 4. Definitions of condition and treatment Male Circumcision is a surgical procedure that involves partial or complete removal of the foreskin (prepuce). Page 5 of 10

6 Nearly all boys have a non-retractile (unable to be pulled back) foreskin at birth and as part of normal development it gradually becomes able to be pulled back without the need for circumcision. There are only a few health problems where circumcision might be a good choice for a male. These are listed in the Policy Statement in section 1 above. The proportion of partially or fully retractable foreskin by age is: Birth 4% 6 months 20% 1 year 50% 3-11 years 90% years 95% 14+ years 99% When physiological phimosis is diagnosed in a primary care assessment of foreskin condition, consultation should focus on reassurance and education of the patient or parents and child. Only a minority of children will have pathology and be subsequently listed for circumcision. Conservative management includes simple bathing in the first instance with progression to topical steroids. A prescription for topical steroids would not normally exceed three months and should have achieved maximal therapeutic benefit within this time. Antibiotics would be of use in infective conditions (Siegfried et al. 2003, Royal College of Surgeons 2013). Phimosis causing pain on arousal or interfering with sexual function in adulthood is an acceptable indication for intervention. Female circumcision is prohibited by law (HM Government 1995, HM Government 2003, HM Government 2015). 5. Description of Local Need The data below demonstrates higher levels than the national expected figures for GY&W and West Norfolk. When compared to the 10 most similar CCGs, GY&W is second highest for circumcision rates and West Norfolk is fourth. (Note that all 10 CCGs in this category are above the national level). Further analysis of this data could be explored by the individual CCGs. Table 1 - Prior approval cases time April 2014 to April 2015 (West Norfolk not included as their data is incomplete; no data for Great Yarmouth and Waveney (GY&W)) North Norwich South West GY&W Norfolk Norfolk Norfolk No data available No data available Page 6 of 10

7 Table 2 - Source- Dr Foster, report date- 23/09/2015, time period April March 2015 CCG Population admissions Rate/K Expected** Rate /K SAR* Low High Norwich South Norfolk West Norfolk GY&W North Norfolk *SAR is the ratio of the observed number of admissions for circumcision to the expected number. The ratio is expressed as an index where the expected value equals 100. Values greater than 100 suggest a higher than expected number of admissions, while values less than 100 suggest fewer admissions than expected. **Expected values are calculated using national rates. The model calculates a probability or risk of admittance for every combination of adjusted factors. The expected value is the sum of all the (probabilities multiplied by the population). 6. Evidence of Effectiveness 6.1 Overview Circumcision is a recognised treatment to prevent urinary tract infections in boys with abnormal renal tracts (Singh-Grewal et al. 2005). Evidence also supports circumcision as a treatment for Lichen Sclerosus, recurrent Balanoposthitis and adult phimosis, where conservative/medical management has failed (Kulkarni et al. 2009, Royal College of Surgeons. 2013). Non-medical indications for circumcision are not considered to be of health benefit. There is insufficient evidence with regard to risk of penile cancer and cervical cancer in women with uncircumcised partners (Singh-Grewal et al. 2005). Some observational studies have shown an association with prevention of HIV in high risk groups although a systematic review of these studies concluded that observational studies are inherently limited by confounding, which is unlikely to be fully adjusted for (Siegfried et al 2003). A recent review of peer reviewed journal articles (Bossio et al 2014) highlights the gaps in the current literature regarding long-term effects and emphasises that much of the published research is not directly applicable to a western (North American) population. Page 7 of 10

8 6.2 Safety of Procedure The Royal College of Surgeons advises that circumcision risks and complications can include anaesthetic, bleeding, infection, altered sensation, poor cosmetic result, meatal stenosis, inclusion cysts, glans amputation and urethral injury. The evidence concerning the psychological impact and altered sensation with neonatal circumcision is conflicting and indeterminate (RCS 2013). 6.3 NICE Guidance There is no relevant National Institute for Health and Care Excellence (NICE) Guidance. 6.4 Conclusions Circumcision for non-medical reasons is generally not thought to be of benefit to health and therefore not funded. Circumcision for medical conditions outlined within the policy have an evidence base to support them and this surgical option should be offered to patients when conservative measures have failed. Parents and patients should be made aware of the risks and benefits of circumcision. 7. Clinical Governance statement It is important that the implementation of this policy is seen as an opportunity to encourage team working and cooperation between commissioners, primary and secondary care providers. Service providers will be expected to collect and provide audit data on request as part of a professionally-led clinical review and audit cycle. 8. Acknowledgements We have used the following policies as a foundation to enhance the development of Norfolk s circumcision policy. Cambridge and Peterborough clinical commissioning group clinical policyhttp:// Ipswich and East Suffolk clinical commissioning group clinical policyhttp:// 9. References Page 8 of 10

9 1. Bossio J, Pukall C, Steele S (2014) A Review of the Current State of the Male Circumcision Literature The Journal Of Sexual Medicine; Vol. 11 (12), pp HM Government (1995) The Prohibition of Female Circumcision Act 1995 [online] in HM Government 2015 Serious Crime Act 3. HM Government (2003) Female Genital Mutilation Act [online] in HM Government 2015 Serious Crime Act: 4. HM Government (2015) Serious Crime Act [online] accessed on 23/11/15 at: 5. Kulkarni S, Barbagli G, Kirpekar D et al. (2009) Lichen Sclerosus of the male genitalia and urethra: surgical options and results in a multicentre international experience with 215 patients. European Urology; 55: Royal College of Surgeons (2013) Commissioning Guide: Foreskin conditions [online] accessed on 01/ at: 7. Siegfried N, Muller M, Volmink J, Deeks J, Egger M, Low N, Weiss H, Walker S, Williamson P (2003) Male circumcision for prevention of heterosexual acquisition of HIV in men. The Cochrane Database of Systematic Reviews, Issue 3. Art. No.:CD Singh-Grewal D, Macdessi J, Craig J. (2005) Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Arch Dis Child Aug; 90(8): Appendices Appendix 1: Evidence Review Date conducted: , updated Database NHS Evidence Journals and databases Result Research conducted between 2000 and Page 9 of 10

10 PICO framework, Keywords- circumcision, indications, risk, and benefits Results: see reference list above NICE Guidance NICE Clinical Knowledge Summary Scottish Intercollegiate Guidelines Network (SIGN) Cochrane Database of Systematic reviews Royal College documents General Search (Google) No NICE guidance NHS Choices: No guidance Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Arch Dis Child Aug;90(8):853-8 Royal College of Surgeons Commissioning Guide: Foreskin conditions (Benchmarking of policies from other CCGs) Cambridge and Peterborough Ipswich and East Suffolk Page 10 of 10