Circumcision for phimosis and other medical indications in Western Australian boys

To the Editor: The study by Spilsbury and colleagues provides new data on rates of phimosis, balanoposthitis, and lichen sclerosus.1 However, it does cite sources — Øster2 and Shankar and Rickwood3 — that indicate very low rates of phimosis. Øster was a school medical officer who followed up his subjects for several years, making frequent penile inspections and giving them continual instruction on prepuce care. Without such extraordinary attention, it would be highly unlikely the general population would have such low rates of phimosis.

Shankar and Rickwood's definition of pathological phimosis was limited to cases of phimosis-related circumcision with confimed BXO (balanitis xerotica obliterans). This is a very narrow definition, as there can be preputial tightness not associated with BXO, and many cases would be left untreated. A broader definition would be "difficulty in retracting the prepuce at an age when retraction should be easily accomplished". In addition to pathological phimosis, greatly prolonged physiological phimosis should be considered an abnormality, as it also precludes retraction and full hygiene. Even Gairdner, who generally opposed circumcision, acknowledged this, because of the increased risk of penile cancer associated with delayed retractability.4 He found that 20% of 200 uncircumcised boys aged 5–13 years did not have full retractability. Saitmacher found that 8.7% of 229 German youths aged 15–17 years had phimosis.5 Because Spilsbury et al cite the unusually low rates of phimosis from Øster and Shankar and Rickwoods as a benchmark, the rates encountered in Western Australia will seem excessive.

The postneonatal circumcisions through age 5 years may be the result of difficulty in getting physicians to perform prophylactic neonatal circumcisions — just as the study states. This is unfortunate, as, in terms of accruing maximal benefits with minimal risk and pain, the neonatal period is the ideal age for circumcision.

Parents should be given full information and then be empowered to decide on behalf of their newborn sons. The present system encourages delays and mendacity. As to the therapeutic circumcisions performed after the age of 5 years, perhaps at some point parents have decided against the short-term fix — steroid creams which may or may not work — and have opted for circumcision, as it will definitely immediately eliminate retraction difficulties and preclude virtually all penile problems associated with the uncircumcised state in the future. The higher rates in country areas with their harsh environment may reflect pragmatic, long-term preventive maintenance thinking.