Commissioning Policy Individual Funding Request

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1 Commissioning Policy Individual Funding Request Penile Conditions - Surgical Opinion and Treatment Policy including Circumcision in all male patients over the age of 18 years Prior Approval Policy Date Adopted: Version: Individual Funding Request Team - A partnership between Bristol, North Somerset and South Gloucestershire Clinical Commissioning Groups

2 Document Control Title of document Penile Conditions- Surgical Opinion and Treatment Policy including Circumcision over 18 years old Authors job title(s) IFR Manager Document version v Supersedes Circumcision Policy v Clinical approval March 2017 Discussion and Approval by 29 March 2017 Clinical Policy Review Group (CPRG) Discussion and Approval by CCG June 2017 Governing Body Date of Adoption: 14 August 2017 Publication/issue date 14 August 2017 Review date August 2020 Application Form Version Control v Equality and Impact Assessment TBC Page 2

3 THIS IS A PRIOR APPROVAL ACCESS POLICY TREATMENT MAY BE PROVIDED WHERE PATIENTS MEET THE CRITERIA BELOW THIS POLICY RELATES TO ALL MALE PATIENTS OVER 18 YEARS Penile Conditions - Surgical Opinion and Treatment Policy including Circumcision in all male patients over the age of 18 years Policy Statement & Date of Adoption: 14 August 2017 Penile Conditions - Surgical Opinion and Treatment including Circumcision for all male patients over the age of 18 years is not routinely funded by the CCG and is subject to this restricted policy. General Principles Treatment should only be given in line with these general principles. Where patients are unable to meet these principles in addition to the specific treatment criteria set out in this policy, funding approval may be sought from the CCG Individual Funding Panel by submission of an IFR application. 1. Each Clinician reviewing the patient for this condition should assess the patient against the criteria within this policy prior to treatment. When submitting a referral form it is the responsibility of the referring clinician to clearly demonstrate how the patient meets the published access criteria. 2. Patients will only meet the criteria within this policy where there is evidence that the treatment requested is effective and the patient has the potential to benefit from the proposed treatment. Where the patient has previously been provided with the treatment with limited or diminishing benefit, it is unlikely that they will qualify for further treatment and the IFR Team should be approached for advice. 3. Patients with an elevated BMI of 30 or more are likely to receive fewer benefits from surgery and should be encouraged to lose weight further prior to seeking surgery. In addition, the risks of surgery are significantly increased. (Thelwall, 2015) 4. Patients who are smokers should be referred to smoking cessation services in order to reduce the risk of surgery and improve healing. (Loof S., 2014) 5. Funding approval must be secured by primary care prior to referring patients seeking corrective surgery. Referring patients to secondary care without funding approval having been secured not only incurs significant costs in out-patient appointments for patients that may not qualify for surgery, but inappropriately raises the patient s expectation of treatment. 6. In line with the published document Guidance - Who Applies for Funding?, where referrals to secondary care are accepted without funding approval having been secured, responsibility for securing funding approval will fall to secondary care. Page 3

4 7. On limited occasions, the CCG may approve funding for an assessment only in order to confirm or obtain evidence demonstrating whether a patient meets the criteria for funding. In such cases, patients should be made aware that the assessment does not mean that they will be provided with surgery and surgery will only be provided where it can be demonstrated that the patients meets the criteria to access treatment in this policy. 8. Where funding approval is given by the Individual Funding Panel, it will be available for a specified period of time, normally one year. Treatment will normally be funded for 1 procedure only and not for multiple treatments within this timescale. 9. The policy does not include patients with suspected malignancy who should continue to be referred under 2 week wait pathway rules for assessment and testing as appropriate. Page 4

5 Rationale for introducing this policy This policy has been developed to support the clinical appropriate surgery to the Penis/ Foreskin in line with these published clinically approved criteria. Surgery will not be considered on Social or Religious grounds. Background What do we mean by Surgical Treatment for Penile Conditions? Male circumcision is the surgical removal of the foreskin. The foreskin is the hood of skin covering the end of the penis, which can be gently pulled back. This is the most commonly known term. As this term is the most commonly used it can be incorrectly used to mean any surgical treatment to the foreskin and can regularly be confused with the term Preputioplasty. A Preputioplasty is a surgical procedure to widen a tight foreskin. This is not a removal of foreskin. A Frenuplasty is another surgical term used which refers to the removal of the binding skin of the frenulum which can restrict movement of the foreskin. This procedure can be carried out to free up this movement without removing the foreskin. There are a number of clinical presentations of conditions which may warrant consideration of a Circumcision and/ or other Surgical Treatment included within the scope of this restricted policy. These are: Pathological Phimosis - This condition is caused by scarring of the foreskin opening leading to symptoms and non-retractability of the prepuce - usually due to Balanitis Xerotica Obliterans [BXO] or lichen sclerosis a long-term skin disorder resulting in white scarring of the prepuce. Paraphimosis a condition where the foreskin cannot be reduced, i.e. pulled back to its normal position covering the glans penis whilst flaccid. Isolated episodes of Paraphimosis will normally need immediate treatment with manual manipulation of the swollen foreskin tissue. A healthcare professional may rub a local anaesthetic gel on to the glans to help reduce pain and inflammation. They may then apply pressure to the head of the penis while pushing the foreskin forward. In severe cases of Paraphimosis, local anaesthetic gel can be applied to the penis and a small slit is made in the foreskin to help relieve the pressure Balanitis or Balanoposthitis Balanitis is inflammation of the glans penis. When the foreskin is also affected, it is termed Balanoposthitis. Conservative management can include but is not limited to: Page 5

6 o o o o Topical antibiotics Antifungals Low-potency steroid creams Proper hygiene and regular washing is useful for the prevention of balanoposthitis. Since anaerobic conditions are necessary for growth of the offending organisms, simple exposure to air and local cleansing is most often effective Physiological Phimosis a tight foreskin that can't be retracted. This is common in males 10 years of age and younger, is normal, and does not require intervention. A non-retractile foreskin usually becomes retractable during the course of puberty. If phimosis in older children or adults is not causing acute and severe problems, non-surgical measures may be effective. Non-surgical measures can include: o o Topical steroid creams Manual stretching of the foreskin Risks As with all types of surgery, circumcision has some risks although these are rare with circumcision carried out for medical reasons in England, with bleeding and infection being the most common. Other complications can include: A decrease in sensation in the penis, particularly during sex Damage to the tube that carries urine inside the penis (urethra), causing it to narrow and making it hard to pass urine Removal of too much shaft skin together with the foreskin Accidental amputation of the head of the penis, which is very rare A blood infection or blood poisoning (septicaemia) A poor cosmetic result (NHS Choices, 2014) Page 6

7 Surgical treatments allowed under this restricted policy are: SURGICAL TREATMENT What this means Funding Route Circumcision Surgical removal of foreskin Prior Approval access if clinically appropriate (see grey box) Preputioplasty Frenuloplasty of prepuce of penis or Frenectomy Surgical operation to the prepuce / foreskin which widens a narrow non-retractile foreskin Surgical release of the short frenulum Prior Approval access if clinically appropriate (see grey box) Individual Funding Request needed CLINICAL TERM Phimosis Paraphimosis Balanitis Balanitis Xerorica Obliterans (BXO) Cancer of the Penis What this means Tight Foreskin - where foreskin is too tight to be pulled back over the head of the penis Where the foreskin can t be returned to its original position after being pulled back Where the foreskin and head of the penis become inflamed and infected A condition that causes phimosis and, in some cases, also affects the head of the penis which can become scarred and inflamed A very rare type of cancer Page 7

8 Policy: Criteria to Access Treatment PRIOR APPROVAL Funding Approval for surgical treatment will only be provided by the CCG for patients meeting one of the criteria set out below. The patient s Clinical Referrer must supply evidence with the referral to show how the patient meets the published criteria. Adult Patients 18 years plus 1. Pathological Phimosis (inability to retract foreskin) A Referral for Consideration of Surgical Treatment will be funded where there is documented evidence within the primary care records of the clinical features associated with Balanitis Xerotica Obliterans (BXO) including one or more of the following symptoms: OR - An inability to retract the foreskin - White scarring - Fissures - Redness of the prepuce - Weeping 2. Physiological Phimosis (foreskin can be retracted but is tight) A Referral for Consideration of Surgical Treatment will be funded where a patient is: a) suffering from recurrent obstruction, haematuria or pain, specifically 3 documented episodes in the preceding 12 months. (NB: Non retractile ballooning of the foreskin and spraying of urine do not need to be referred for circumcision routinely) AND b) where a minimum of 8 weeks conservative methods (hygiene, topical steroids) have proved ineffective and is documented in the patient s primary care records. OR 3. Paraphimosis which has required medical attention to reduce A Referral for Consideration of Surgical Treatment will be funded where a patient has more than one documented episode of clinically significant Paraphimosis in the preceding 12 months (clinical records to be included with the referral) Page 8

9 OR 4. Balanitis/Balanoposthitis A Referral for consideration of Surgical Treatment will be funded where a patient is: a) suffering from recurrent Balanitis/ Balanoposthitis, specifically 3 documented episodes during the preceding 12 months. AND b) where a minimum of 8 weeks conservative methods (hygiene, topical steroids) have proved ineffective and is documented within the patient s clinical records. NOTE: If you have any concerns that symptoms relate to malignancy, you should refer via the 2WW pathway Not Routinely Commissioned All patients The reported benefits of male circumcision, such as reduction of sexually transmitted infections and reduction of penile cancer risk, are insufficient to justify its therapeutic use. Circumcision for cultural, personal or religious beliefs is not routinely commissioned by the CCG. Circumcision on the sole basis of sexual functionality (i.e. due to pain during intercourse or whilst the penis is erect) is not routinely commissioned by the CCG. Exceptionality arguments on these grounds are unlikely to satisfy the CCG. Frenectomy and Frenuloplasty are not routinely commissioned by the CCG. Funding will need to be secured by submitting an IFR application to the Funding Team evidencing exceptionality. Patients who are not eligible for treatment under this policy may be considered on an individual basis where their GP or consultant believes exceptional circumstances exist that warrant deviation from the rule of this policy. Individual cases will be reviewed at the CCG s Individual Funding Request Panel upon receipt of a completed application form from the patient s GP, consultant or clinician. Applications cannot be considered from patients personally. Page 9

10 If you would like further copies of this policy or need it in another format, such as Braille or another language, please contact the Patient Advice and Liaison Service on or This policy has been developed with the aid of the following references: Use the Harvard System for referencing. (n.d.). Retrieved MAY 2017, 02, from Redditch and Bromsgrove CCG: British Association of Peadiatric Urologists. (2006, June). Management of Foreskin Conditions. Retrieved from British Association of Peadiatric Urologists: British Association of Urological Surgeons et al. (2016). Commissioning guide: Foreskin Conditions. Retrieved from British Association of Urological Surgeons:. /media/files/rcs/standards-and-research/nscc/revised-foreskin-conditions-commissioning-guiderepublished.pdf Loof S., D. B. (2014). Perioperative complications in smokers and the impact of smoking cessation interventions [Dutch]. Tijdschrift voor Geneeskunde, vol./is. 70/4( NHS Choices. (2014, January 1st). Circumcision. Retrieved June 2015, from NHS Choices: Thelwall, S. P. (2015). Impact of obesity on the risk of wound infection following surgery: results from a nationwide prospective multicentre cohort study in England. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases,, vol. 21, no. 11, p e1. Approved by (committee): Clinical Policy Review Group Date Adopted: 14/08/2017 Version: Produced by (Title) Commissioning Manager Individual Funding EIA Completion Date: TBC Undertaken by (Title): Review Date: Earliest of either NICE publication or three years from approval. CATEGORY VERSION CATEGORY VERSION CATEGORY VERSION Bristol Prior Approval North Somerset Prior Approval South Gloucestershire Prior Approval Page 10