Saving the Normal Foreskin

British Medical Journal (London), Volume 306: Pages 1-2, 2 January 1993.

By Andrew Gordon and Jack Collin

Widespread confusion over what the medical indications for circumcision are.

Religious considerations apart, the commonest indications for circumcision in current surgical practice are phimosis, preputial adhesions, ballooning of the foreskin and balanitis. Although these indications are widely accepted, consideration of the embryology, development, and pathology of the prepuce suggests that their validity is open to doubt.

The foreskin develops early in intrauterine life as a protuberance of penile epidermis that grows forwards over the glans and adheres to it. Both glans and prepuce are covered by stratified squamous epithelium, and separation occurs at a variable time from before birth to several years afterwards by desquamation. The term phimosis (from the greek word for muzzling) is often incorrectly applied to any foreskin that cannot be retracted.

To discourage unnecessary circumcision a distinction needs to be made between physiological and pathological non-retractability. Gairdner, who examined a large number of normal children during their first five months of life, observed that at birth only 4% of children had fully retractile prepuces, while in half the prepuce was partially retractile.1 By the age of 5 years slightly more than 90% of boys had retractile foreskins.

Additional information was provided by Øster, who examined almost 2000 schoolchildren between the ages of 6 and 17 in whom no medical or surgical intervention had taken place.2 In the 6-7 year age group 91% of boys had retractile prepuces (a similar figure to that of Gairdner) and the incidence of spontaneously retractile foreskin increased yearly until by 17 years only 1% remained non-retractile. Why this 1% of 17 year olds still had a non-retractile foreskin was not stated, but data from a subsequent study suggest that they were probably suffering from balanitis xerotica obliterans.3 This curious condition of unknown aetiology is characterised by dermal oedema, lymphocytic infiltration, basal cell degeneration, and atrophy of the stratum malpighii. Although resolution, successful medical treatment, and recently, laser treatment for balanitis xerotica obliterans have been reported,4 circumcision remains the mainstay of treatment. The condition may, however, also involve the glans or urethral meatus, resulting in meatal stenosis.5

Other indications for circumcision are less clear cut, but few would dispute that recurrent balanoposthitis warrants surgical treatment. Despite the clinical impression that balanitis is common in young boys, the only detailed study of this condition reported an incidence of 4% in all boys aged up to 14.6 A specific organism was found in only about one third of cases, and the aetiology was uncertain. The incidence may be higher in uncircumcised children before the age of 8, although morbidity due to balanoposthitis may be offset at least partly by penile problems in children who are circumcised.7,8 Although the inflammation is usually mild, on occasions it causes great distress. The condition, however, is self limiting, and few children suffer more than one episode.6 Plainly a single attack of balanitis, which is sometimes seen in boys with normal foreskins, is not a sufficient indication for circumcision. One study found penile inflammation in one of seven uncircumcised children but most problems resolved after a single medical consultation.1

The increased number of urinary tract infections seen in uncircumcised young children may be due to "hospital strains" of p fimbriated Escherichia coli acquired in the unnatural environment of modern obstetric units9 rather than being directly related to the foreskin. Paraphimosis is rare in children and unlikely to account for a substantial number of circumcisions. Although ballooning on micturition is a commonly cited indication, the studies of Gairdner1 and Øster2 suggest that if this physical sign is ignored the symptoms will resolve as the foreskin becomes spontaneously retractile (unless balanitis xerotica obliterans develops). Preputial adhesions represent a stage in the normal process of separation of the two epithelial surfaces of the prepuce and glans. In Øster's study no preputial adhesions were seen in 95 boys aged 17, none of whom had undergone any operative procedure for separation of adhesions2 - strongly suggesting that adhesions resolve themselves spontaneously without treatment.

These data suggest that overall between 1% and 2% of boys need circumcision for medical indications. The cumulative national rate of circumcision for boys by the age of 15 is almost 7%.10 If findings from Liverpool are representative of the rest of Britain10 then many unnecessary circumcisions are being performed. each year at considerable cost to the health service and morbidity for patients. In the population served by the Oxford Regional Health Authority during the year to September 1990, 978 boys were circumcised out of a total estimated population of 299600 - a rate of 0.33% a year (statistics unit of Oxford Regional Health Authority). If this rate operated annually then 5.6% of boys aged 17 would be circumcised - not substantially different from the Mersey figure.10

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Gordon and Collin estimated in 1993 that only about 1% and 2% of boys needed circumcision for medical indications. Since then, many non-destructive, non-traumatic, effective treatments for balanitis and non-retractile foreskin have been developed.

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Birley et al. noted that balanitis can be caused by excessive washing. It can usually be managed by correcting the overzealoushygiene, and by application of emollients.

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Medical treatment of non-retractile foreskin with betamethasone valerate 0.05% ointment has a documented 90% success rate. Full implementation of conservative non-traumatic medical treatment of nonretractile foreskin could cut the number of surgical operations needed by ten-fold. Presumably, if Gordon and Collin were to revisit this matter, their estimate of the percentage of boys who actually need surgery would drop to between 0.1% and 0.2%. Furthermore, for those very few boys who do need surgery, non-traumatic, non-destructive dorsal slit with transverse closure or lateral preputioplasty may be effective and would preserve fullanatomical function.

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Full application of newer non-traumatic medical and surgical treatments should almost totally eliminate the need for circumcision in medicalpractice.

Why then is the rate of circumcision up to six times greater than the incidence of preputial disease? Analysis of the clinical findings in children referred for circumcision reported in this week's journal suggests a difference in interpretation of symptoms and clinical signs between surgeons and general practitioners (p 28).11 Clearly confusion still exists about what constitutes "pathological" phimosis as distinct from "physiological" non-retractile foreskin. Most cases of pathological phimosis result from balanitis xerotica obliterans, while the remainder may be due to a different, distinct fibrotic disease.12 The underlying difficulty is the imprecision of the term phimosis. An important consideration is that balanitis xerotica obliterans usually develops after 5 years.5,10 The rarity of of pathological phimosis under the age of 5 is an important observation since most circumcisions are performed before this age.10

Øster wrote in the introduction to his paper2 that the publication of Gairdner's article nearly 20 years earlier seemed to have made no significant impression on clinical practice.1 Regrettably it seems that the same can be said more than 20 years after Øster's paper was published. A better understanding of the normal physiology, developmental anatomy, and pathology of the prepuce could prevent the removal of thousands of normal foreskins over thenext 20 years.

Clinical Fellow

Reader in Surgery

University of Oxford,
Nuffield Department of Surgery,
John Radcliffe Hospital,
Oxford OX3 9DU

  1. Gairdner D. The fate of the foreskin. BMJ 1949;ii: 1433-6.
  2. Øster J. Further fate of the foreskin. Arch Dis Child 1968; 43: 200-2.
  3. Rickwood AMK, Hemaltha V, Batcup G, Spitz L. Phimosis in boys. Brit J Urol 1980;52:147-50.
  4. Ratz JL. Carbon dioxide laser treatment of balanitis xerotica obliterans. J Am Acad Dermatol 1984; 10: 925-28.
  5. Bale RM, Lochhead A, Martin HC Gollow I. Balanitis xerotica obliterans in children. Pediatr Pathol 1987; 7: 617-27.
  6. Escala JM, and Rickwood AMK. Balanitis. Br J Urol 1988; 63: 196-7.
  7. Fergusson DM, Lawton JM, Shannon FT. Neonatal circumcision and penile problems: an 8-year longitudinal study. Pediatrics 1988; 81: 537-41.
  8. Stenram A, Malmfors G, Okmian G. Circumcision for phimosis: indications and results. Acta Paediatr Scand 1986; 75: 321-3.
  9. Winberg J, Bollgren I. Gothefors L. Herthelius M. Tullus K. The prepuce: a mistake of nature? Lancet 1989; i:598-9.
  10. Rickwood AMK, and Walker J. Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence? Ann Coll Surg Engl 1989; 71: 275-7.
  11. Williams N, Chell J, Kapila L. Why are children referred for circumcision? BMJ 1993. 306: 28.
  12. Clemmensen OJ, Krogh J, Petri M. The histologic spectrum of prepuces from patients with phimosis. Am J. Dermatopathol 1989; 10: 104-8. [Medline]


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