Volume 178 - Issue 11
Circumcision for phimosis and other medical indications in Western Australian boys
Author: George Hill
Med J Aust 2003; 178 (11): 587. || doi: 10.5694/j.1326-5377.2003.tb05367.x
Published online: 2 June 2003
Published online: 2 June 2003
To the Editor: Spilsbury et al argue that "improved education for physicians, and perhaps parents, with regard to foreskin development and management is required."1 However, updating of textbooks and medical curricula is required to accomplish this objective. Articles by Caldamone et al2 and Cendron et al3 are two examples of incorrect data in text books.
Gairdner was the first to provide data on the normal development ...
To the Editor: Spilsbury et al argue that "improved education for physicians, and perhaps parents, with regard to foreskin development and management is required."1 However, updating of textbooks and medical curricula is required to accomplish this objective. Articles by Caldamone et al2 and Cendron et al3 are two examples of incorrect data in text books.
Gairdner was the first to provide data on the normal development of the foreskin in young boys.4 Gairdner incorrectly believed that 92% of boys would have a retractile prepuce by age 5 years. Unfortunately, Gairdner's data was wrong.5 Gairdner achieved his artificially high rate of retractability by first "running a probe around the preputial space" to break the normal physiological fusion between the foreskin and glans penis,4 a procedure few would recommend today because of pain, trauma, risk of infection, and iatrogenic creation of adhesions. As stated above, some textbooks continue to uncritically parrot Gairdner's incorrect data.
The error has been further compounded by the confusing presentation of data in Øster's otherwise excellent study.6 Øster presents information about the incidence of "phimosis", "tight foreskin", and "adhesions" in separate tables. To obtain the percentage of boys in each age group with partially or completely non-retractile foreskins, it is necessary to sum the percentage incidence of these conditions. When that is done, Øster's data are very similar to those provided by Kayaba et al7 on the development of the retractile prepuce. Therefore, according to current research, about 50% of boys will have a retractile prepuce by age 10 years and about 99% will have a retractile prepuce by the completion of puberty. The non-retractile foreskin is normal in boys and no cause for concern.
Based on the data of Øster6 and Kayaba et al,7 Doctors Opposing Circumcision believes that the new rule-of-thumb should be that about 50% of boys will have a retractile prepuce by age 10 and about 99% will have a retractile prepuce by the completion of puberty. This information needs to be incorporated into textbooks, medical curricula, and information provided to the public.
When the normal development of the prepuce is properly understood, one can easily see that patiently awaiting the natural development of preputial retractability will usually eliminate the need for medical or surgical intervention. Better information about the normal development of the foreskin should relieve parental anxiety and reduce false diagnoses of phimosis in boys.
References
- Spilsbury K, Semmens JB, Wisniewski ZS, Holman CDJ. Circumcision for phimosis and other medical indications in Western Australian boys. Med J Aust 2003; 178: 155-158. <eMJA full text>
- Caldamone AA, Schulman S, Rabinowitz R. Outpatient pediatric urology. In: Gillenwater JY, Grayhack JT, Howards SS, Duckett JW, eds. Adult and pediatric urology. Vol. 3. St Louis: Mosby, 1996: 2730. i1082482
- Cendron M, Elder JS, Duckett JW. Perinatal urology. In: Gillenwater JY, Grayhack JT, Howards SS, Duckett JW, eds. Adult and pediatric urology. Vol. 1. St Louis: Mosby, 1996: 2152. i1082484
- Gairdner D. The fate of the foreskin: a study of circumcision. BMJ 1949; 2: 1433-1437. i1082486
- Wright JE. Further to the "further fate of the foreskin": Update on the natural history of the foreskin. Med J Aust 1994; 160: 134-135. i1082488
- Øster J. Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child 1968; 43: 200-220. i1082490
- Kayaba H, Tamura H, Kitajima S, et al. Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol 1996; 156: 1813-1815. i1082492
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