A urology consultant declined to consider options other than a circumcision for his lesion
24. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this, and we have not found any indications that something has gone wrong.
25. Mr Y says during his consultation on 4 August 2023, a urology consultant declined to consider alternative options other than a circumcision for his presenting symptoms, such as a biopsy for his lesion.
26. Mr Y told us at the time of attending for the initial consultation he had no pictures or evidence of the lesion itself and so it would be difficult to show the seriousness of the condition and what treatment was needed to remedy this.
27. The Trust’s responses explained that prior to the procedure the consultant had examined Mr Y’s presenting symptoms of LS and was concerned his lesion could be early malignant or premalignant (different stages of potential cancerous development). It also explained the consultant noted Mr Y had a tight foreskin. The Trust said the consultant discussed this with Mr Y, and recommended a circumcision in what was thought was his best interest at the time.
28. The Trust explained that prior to Mr Y’s procedure, it followed a process of informed consent and discussed the risks of the surgery. It explained Mr Y consented to the circumcision for which he signed the form. It explained it followed the correct treatment pathway.
29. We considered whether the Trust provided Mr Y with the correct treatment option for his presenting symptoms. We looked at the BAoD guidelines about the management of LS, which explains clinicians should recommend commencing treatment once a firm clinical diagnosis of male genital LS is made and should recommend topical steroids as an initial treatment.
30. The guidelines also explain clinicians should offer all patients whose persistent LS is unresponsive to topical steroid after 1–3 months and who present with a tight foreskin, to be referred to an experienced urologist for circumcision. It explains that a confirmatory biopsy is not routinely performed when the typical clinical features for LS are present.
31. A review of the medical notes shows Mr Y had been clinically diagnosed with LS and a patch of scarring as early as April 2021, which was being treated with a topical steroid cream.
32. A dermatologist also explained to Mr Y about strong topical steroid use and the possibility of a circumcision should he continue a need to use the cream.
33. The notes show as Mr Y’s LS and lesion was not responding to the steroid cream, in February 2023, his doctor referred him to the Trust’s urology department for further treatment.
34. We can see from the records on 27 July 2023, a consultant urologist at the Trust held a telephone consultation with Mr Y. They explained it was unusual to do a biopsy on the foreskin for his referred symptoms, and that the best treatment was to have circumcision, which would also confirm diagnosis of his lesion.
35. The records show a face-to-face examination also took place on 4 August. The consultant noted as Mr Y's LS was persistent for two years and unresponsive to topical steroid cream, had a tight foreskin, and an undiagnosed lesion, a circumcision was the best treatment for his presenting condition.
36. We can see from the records Mr Y consented to undergo a circumcision which then took place on 2 September 2023.
37. Our adviser gave their view the Trust appropriately provided Mr Y with the correct treatment option for his presenting symptoms, as Mr Y’s condition had not responded to the topical steroid treatment after more than three months and a biopsy is not performed for the presenting condition.
38. Considering the available evidence and advice received. Our view is that an appropriately experienced professional carried out an examination and confirmed Mr Y's diagnosis of his presenting symptoms to be LS which had not responded to topical cream and a tight foreskin, for which a circumcision is the recommended treatment, and a lesion of the penis for which a biopsy is not a recommended treatment option. This appears to be in line with the above guidelines.
39. There is no indication in the records to show the treatment offered by the Trust for Mr Y’s presentation was incorrect. We can also see a number of experienced professionals made Mr Y aware as early as April 2021, should the cream not be successful that a circumcision would be required, and that Mr Y also consented to the circumcision prior to surgery following several consultations to discuss treatment options for his presenting condition.
40. We recognise Mr Y’s concerns about not being able to have alternative treatment and wanting to avoid a circumcision. We hope our explanation gives some reassurance about what happened.
The consultant showed no compassion when explaining his lesion could be cancerous 41. Mr Y says the consultant showed no compassion when he told him his lesion could be cancerous. He says he showed him pictures of penis cancer on a computer, and after being told and shown the images, he felt no option but to agree to a circumcision.
42. The Trust explained the doctor believed that he was providing Mr Y with relevant information regarding a potential diagnosis and apologised that this caused upset and anxiety. It explained it can be difficult to gauge how much information patients wish to receive.
43. We considered whether the Trust provided necessary information to Mr Y regarding his medical condition. We looked at the BAoD guidelines about the management of lichen sclerosis and the GMC Good Medical Practice.
44. The BAoD guidelines explain, ‘Patients with Lichen Sclerosis have an increased risk of penile cancer’.
45. GMC, ‘Good Medical Practice’, paragraph 28 states: The exchange of information between medical professionals and patients is central to good decision making. You must give patients the information they want or need in a way they can understand. This includes information about:
• their condition(s), likely progression, and any uncertainties about diagnosis and prognosis • the options for treating or managing the condition(s), including the option to take no action • the potential benefits, risks of harm, uncertainties about, and likelihood of success for each option.
46. As above, we can see clinicians made Mr Y aware as early as April 2021, of what to look out for in terms of new growths or ulcerations and about the risk of skin cancer reported with LS.
47. From the records we can also see a consultant urologist discussed the possibility of Mr Y’s lesion being cancerous with him in July and August 2023, both over the phone and face-to-face, when considering and discussing treatment for his referral and presenting symptoms.
48. Our adviser gave their view it was correct for the consultant to inform Mr Y regarding the risk of penile cancer in this situation due to his presenting symptoms.
49. Our view is that the urologist spoke with Mr Y promptly over the phone and face-to-face to provide information about his condition, treatment options, prognosis, and any worries he may have about his care. This appears to be in line with the above GMC guidelines.
50. It appears the consultant provided information to give Mr Y a more informative view of his condition, and we cannot see any indication they intended to be uncompassionate.
51. We understand this must have been very worrying news for Mr Y to receive and it would have been a stressful time and can see the consultant and the Trust apologised for any upset the information shared with Mr Y may have caused.
52. We understand Mr Y would have been concerned about the information he received. We hope our explanation of the actions taken provides him with some reassurance about what happened.
The consultant failed to acknowledge that the procedure had left him with excess skin.
53. Mr Y says during an appointment on 19 September, the consultant failed to acknowledge that the procedure had left him with excess skin.
54. The Trust’s response explained on 19 September, two consultants saw Mr Y in the department. It said it was sorry to hear Mr Y was unhappy with the communication the initial consultant provided about his excess skin. It said it hoped the second consultant Mr Y saw the same day had provided him with some reassurance about his condition.
55. It also explained it understood that prior to Mr Y’s procedure, it followed a process of informed consent, and discussed risks of the surgery, including the risks of infection and dissatisfaction with the cosmetic results of the surgery.
56. GMC, ‘Good medical practice’, paragraph 18 states: • You must recognise a patient’s right to choose whether to accept your advice and respect their right to seek a second opinion.
57. We considered whether the consultant took the correct action when providing care to Mr Y.
58. We can see from the medical notes on 19 September, Mr Y attended an appointment with the first consultant where he explained he felt his skin was still tight and that he had excess skin. He said he wanted to complain about the operating surgeon as he believed there would be no excess skin post procedure and asked to speak with someone more senior.
59. The notes show the consultant contacted the on-call urology consultant to carry out a further review of Mr Y’s foreskin the same day.
60. The records show the on-call consultant saw Mr Y the same day and documented his surgery was healing very well. They noted due to the procedure only having been three weeks post-surgery, a further assessment would need to be carried out with a view to a potential modification of the circumcision should Mr Y remain unhappy.
61. The records show that on 29 November, Mr Y attended a further assessment with the second consultant who noted Mr Y was healing well. However, as Mr Y felt there was redundant skin and remained unhappy with the outcome of the procedure, the consultant agreed this could be modified. Surgery to modify the circumcision took place at the Trust on 26 January 2024.
62. We can also see prior to the circumcision, the consultant explained the risks of the procedure to Mr Y of which he signed consent to take place. This included information about the risks of infection and dissatisfaction with the cosmetic results of the surgery.
63. Our view is that the consultant recognised Mr Y was upset and unhappy with his assessment of Mr Y’s excess skin and so provided a further opinion for Mr Y for his presenting symptoms by way of another consultant the same day. This appears to be in line with the above GMC guidelines.
64. We are pleased to see Mr Y went on to receive further surgery to remedy his excess skin.
65. We recognise the difficult time Mr Y went through and the impact his surgery had on his mental health. We hope our explanation helps to provide reassurance about what happened.