Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence?

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 age¹. At a cost of say £100 for a day case procedure, or £200 for an overnight stay², 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?

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.

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.

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)^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 Diseases⁵ 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 obliterans⁶.

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.

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.

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.

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%).

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).

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.

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 (φ ιμοσ ις, 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, phimosis⁶, 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, Gairdner³ 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 adhesions⁴. 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's⁴ 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 allcircumcision.

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.

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 series⁴ occurred in 1% of boys by their seventeenth birthday. Analysis of data from a series of cases reported from Sheffield⁶ suggests a somewhat similar incidence, 0.9% by 15 years of age. Balanoposthitis affects not more than 3% of boys⁷ 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.⁸. We advise circumcision in the event of multiple recurrences and this occurs in less than one-third of cases⁷. Since other indications for circumcision involve negligible numbers³, 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.

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.

Note:

The incidence of childhood circumcision has declined in England since the publication of this article in 1989. The decline is attributed to the increased use of evidence-based medicine (i.e., better physician education). For updated information see  Towards evidence based circumcision of English boys: survey of trends in practice.

Received 4 November 1988

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

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