p("ANNALS OF THE ROYAL COLLEGE OF SURGERY (England), Volume 71, Number 5: Pages 275-277, September 1989.");
head("Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence?");
p("A M K RICKWOOD MA FRCS Paediatric Urologist");
p("JENNY WALKER ChM FRCS Senior Surgical Registrar
Department of Pediatric Urology, Royal Liverpool Children's Hospital") . "
(Alder Hey)");
p("Key words:CIRCUMCISION; PHIMOSIS; BALANOPOSTHITIS");
p("Summary Thirty thousand circumcisions are performed annually in
England and 70% of these are upon boys under 15 years of age.
In the Mersey Region some 950 boys are circumcised each year
for medical indications, the commonest being 'phimosis',
which accounts for 87% of cases, of whom almost one-half are
under 5 years of age. Regional practice is compared with that
of our Unit, where the majority of referrals had
developmentally non-retractile foreskin rather than true
phimosis, where circumcisions for phimosis and for
balanoposthitis occurred in almost equal numbers, and where
no example of true phimosis was seen in boys under 5 years of
age. It appears that in the Mersey
Region many boys are circumcised for development
non-retractability of the prepuce rather than for true
phimosis and that in consequence some two-thirds of the
operations are unnecessary.");
[CIRP Note: This file does not contain
figures 1,2, and 3.]");
p("Introduction
Currently, some 30 000 circumcisions are performed annually
in England under the aegis of the National Health Service,
8000 on a day case basis and 22 000 as inpatients; 21 000 are
upon boys under 15 years of age (" . llink("#n1">1") . ").
At a cost of say £100 for a day case procedure, or
£200 for an overnight stay (2") . "), this represents an annual call upon
Exchequer funds of the order of £5 200 000.
Circumcision, it seems is big business: but is it good
business?");
p("In the Mersey region, approximately
two-thirds of the 1500 circumcisions undertaken each year are
upon boys of which 94% are for medical indications, the
commest, phimosis, accounting for 87% of cases. We suggest
that many of these circumcisions are unnecessary owing to the
overdiagnosis of phimosis. This hypothesis is explored.");
p("Patients and methods
The Mersey region has a male population of 1 166 600 of
which 238 950 are boys under 15 years of age. Regional
statistics relating to circumcision for the years 1984 to
1986, inclusive, were retrieved from Hospital Inpatient
Enquiry data. Material from our unit for the period 1984 to
1987, inclusive, derives from personal diagnostic and
operative indices, including both circumcised patients and
those referred for consideration for circumcision but where
this was not performed.");
p("A diagnostic category employed by our unit
is non-retractile foreskin, where the prepuce is wholly or
partially non-retractable due to persistence of developmental
adherence between glans and foreskin ('preputial adhesions')
(" . llink("#n3">3,4") . "); this is often associated with
a preputial orfice which, although somewhat narrow, is supple
and unscarred ('physiological phimosis') (Fig. 1). This
category does not feature in Regional statistics since it is
not recognized by the International Classification of
Diseases (" . llink("#n5">5") . ") as an entity distinct
from true, pathological, phimosis, where the tip of the
prepuce is scarred and indurated (Fig. 2) and has the
histological features of Balanitis xerotica obliterans (6") . ").");
p("The policy on our unit is to recommend
circumcision where there is true phimosis or recurrent,
troublesome episodes of acute balanoposthitis. In other
cases, parents are advised that, although there is no medical
reason why their son needs to be circumcised, we will
undertake the procedure (provided there is no
contraindication) if that is their wish.");
p("Results
During the period reviewed, 4371 medically indicated
circumcisions were performed in the Mersey Region, with an
annual average of 948 procedures upon boys under 15 years of
age. This, 0.4% of boys in the Region are circumcised each
year and, if present practice continues, 6% will have been
circumcised by their fifteenth birthday.");
p("Of 420 boys referred to our unit for
consideration of circumcision, the procedure was performed in
116 (28%). The majority of the referrals had non-retractile
foreskin. These boys were usually asymptomatic, although
some, usually in the age range 2-4 years, had ballooning of
the prepuce during micturition. Only a minority had true
phimosis and ballooning of the prepuce was not a feature of
these cases. General practitioners consistently overdiagnosed
phimosis; no boy referred under 5 years of age had true
phimosis. Of older boys, only 42% had true phimosis with the
proportion rising from 15% of 5-6 year olds to 73% of
13-14-year-olds.");
TABLE IDiagnoses in boys referred for consideration of
circumcision, Urology Department, Royal Liverpool
Children's Hospital, 1984-87
No.
(%)
Non-retractile foreskin
219
(52)
Balanoposthitis
142
(34)
Phimosis
53
(34)
Other
6
(1)
Total
420
p("In the Region, the great majority of
circumcisions were performed for phimosis (Table II);
circumcisions for this indication on our unit only slightly
exceeded those for balanoposthitis. Among a total of 314 boys
referred to us in whom we considered that there was not
indication for circumcision, parents requested this procedure
in only 10 (3%).");
TABLE IIIndications for circumcision in boys under 15 years
of age. Department of Urology, Royal Liverpool
Children's Hospital (RLCH) and Mersey Regional Health
Authority (MRHA) 1984-86
MRHA
(n=2844)
RLCH
(n=116)
No.
(%)
No.
(%)
Phimosis
2475
(87)
53
(45.5)
Balanoposthitis
321
(11)
51
(44.0)
Other
48
(2)
2
(2.0)
Parent's request
-
-
10
(8.5)
p("If age distribution curves (Fig. 3) of our
unit's cases of non-retractile foreskin and phimosis are
compared with Regional circumcisions for phimosis, two
features are evident. First, the Regional curve for cases of
phimosis bears strong resemblance to ours for non-retractile
foreskin; second, whereas 1164 (47%) of Regional
circumcisions for phimosis were on boys under 5 years of age,
our unit saw no example of true phimosis in boys so young.
The age distribution for our cases of true phimosis is very
similar to that previously recorded in another series
(6).");
p("Discussion
The well-rehearsed arguments favouring routine circumcision
of male neonates are not germane to our hypothesis, although
in passing it may be observed that the only proposition
commanding universal acceptance relates to the virtual
elimination of the risk of penile carcinoma, a rare disease
with only some 200 new cases in England each year.");
p("As for immediate medical indications for
circumcision of boys, the major issue clearly turns upon what
is, and what is not phimosis. The Greek derivation
(φιμοσις, muzzling)
allows application whenever the foreskin cannot be fully
retracted, but such all-embracing usage is misconceived as it
implies the existence of pathology where very often there is
none. In reality, there is a clear-cut distinction between
true, pathological, phimosis (" . llink("#n6">6") . "),
for which circumcision is unquestionably indicated, and
partial or non-retractability of the foreskin caused by
persistence of developmental adhesions between glans and
prepuce. Almost 40 years ago, Gairdner (3") . ") demonstrated this state to be both
normal and self-limiting in boys. Perhaps it was unfortunate
that he followed his patients to only five years of age, at
which time the foreskin is still wholly non-retractable in
some boys while many more retain preputial adhesions (4") . "). As a result, there remains
misconception that persistence of this condition beyond this
age requires action, be it 'preputial stretching', 'freeing
of adhesions' or even circumcision. Oster's (4") . ") study, involving almost 2000 schoolboys
followed to physical maturity, showed otherwise; by the age
of 17 years, and without any form of intervention the
foreskin had become fully retractable in all boys except in
1% who had developed true phimosis as a secondary phenomenon
and, by virtue of its natural history, requires no treatment,
least of all circumcision.");
p("Once the distinction between non-retractile
foreskin and true phimosis is clear, it becomes evident that
few, if any, of the 390 or so boys under 5 years of age
circumcised annually in the Mersey region for 'phimosis' can
have had this condition in reality and very probably the some
applies to a number of older boys. Although the proportion
cannot be calculated with any precision, available data
provides strong prima facie evidence for our
hypothesis that phimosis is much overdiagnosed and that many
unnecessary circumcisions are performed in consequence. An
idea of the somewhat arbitrary nature of the process may be
gleaned from the fact that the annual rate of circumcision of
boys, for medical indications varies among health districts
in the Region from as low as 0.3% in some to as high as 0.9%
in others.");
p("What proportion of operations would be
unlikely to survive critical scrutiny? Perhaps the simplest
approach is to estimate the requirement for circumcision of
boys and to compare this to the number actually performed.
True, pathological phimosis is the one absolute indication
for circumcision, and in Oster's large series (4") . ") occurred in 1% of boys by their
seventeenth birthday. Analysis of data from a series of cases
reported from Sheffield (" . llink("#n6">6") . ") suggests
a somewhat similar incidence, 0.9% by 15 years of age.
Balanoposthitis affects not more than 3% of boys (7") . ") and here indications for circumcision
are less certain. Some consider that the operation can be
entirely avoided by lysing preputial adhesions so as to allow
retraction of the foreskin, and giving appropriate attention
to preputial hygiene. (" . llink("#n8">8") . "). We advise
circumcision in the event of multiple recurrences and this
occurs in less than one-third of cases (7") . "). Since other indications for
circumcision involve negligible numbers (3") . "), at a generous estimate not more than
2% of boys require the operation and perhaps as few as 1%. It
is therefore likely that if 6% of boys in the Mersey Region
have indeed been circumcised by their fifteenth birthday then
two out of every three operations were unnecessary.");
p("Practice in this Region appears to reflect
that in England as a whole, where the population of boys
under 15 years of age is of the order of 4 500 000. If the
portion of religious circumcisions (6%) in the Mersey Region
is typical, then some 19 750 boyhood circumcisions nationally
are medically indicated, giving a circumcision rate of 0.44%
of boys annually, and cumulatively 6.6% by 15 years of age.
On this basis about 13 750 circumcisions each year would lack
justification. Any claim that an appreciable number are
performed at parental insistence runs counter to our
experience, namely that initiative for circumcision almost
always comes from the health care industry (general
practitioner, health visitor, school medical officer, etc);
parents, we find are usually delighted to be informed that
their son does not need circumcising.");
Received 4 November 1988");
hr();
p_small("Correspondence to Mr A M K Rickwood MA FRCS, Department of Paediatric Urology, Royal Liverpool Children's Hospital (Alder Hey), Eaton Road, Liverpool L12 2AP");
hr();
Citation:
Rickwood AMK, Walker J. Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence? Ann R Coll Surg Engl 1989;71(5):275-7.";
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