Why are Children Referred for Circumcision?

Most of the 30 000 circumcisions performed in the United Kingdom each year are done on boys aged under 15.¹ Controversy exists over whether all these procedures are necessary or justified.^1,2 Gairdner reported that the foreskin develops entirely normally and free of all problems in all but 1% of boys by the age of 15.³ Rickwood and Walker, however, suggest that up to 6% of boys in the Mersey region are circumcised by the age of 15.¹ This highlights a discrepancy in the expected and observed rates of circumcision. To address this we audited all referrals from general practitioners forpenile problems to this unit.

Patients, methods, and results

We prospectively assessed all new patients referred to this paediatric surgical unit for a penile problem (excluding hypospadias) over six months and recorded the reasons for referral, symptoms, and referral diagnosis. Of the 464 new patients seen, 69 were referred for a penile problem (median age 4.2 years (range 2 months - 14.3 years)).

Thirty four children were referred with a request for circumcision, 27 for advice only, and eight for a second opinion. The commonest referral diagnosis were tight foreskin (26 cases), phimosis (25), and balanitis (9) (table). The nine other children were referred with unscarred non-retractile foreskin (6), unscarred non-retractile foreskin (2), and a long redundant foreskin what was ventrally deficient (1). The main symptoms on referral were balanitis (25), tight foreskin (19), ballooning on micturition (10), and recurrent balanitis (6). Five patients were referred with other symptoms: insufficent foreskin (1), redundant foreskin (1), mild dorsal hood (1), preputial adhesion (1), and inspissated smegma (1). Two were referred for religious and one for non-religious circumcision. For one child, who was asympomatic, the referral letter simply read, "Please see this boy regarding his foreskin."

Our findings on examination were that 29 of the children referred had a healthy retractile foreskin and 30 had a healthy non-retractile foreskin. (table). Most of those in the second group were aged under 6. Nine children were found to have a phimosis.

Fourteen children were listed for circumcision, nine because of phimosis, one because the long redundant foreskin caused urinary dribbling, and two for religious reasons. The other two children had an unscarred non-retractile foreskin but were listed for circumcision because of their ages (10.8 and 14.4 years) the failure of conservative management, and parental pressure.

Comment

Table: Referral diagnosis and finding on examination for boys referred to a pediatric surgical unit.
Referral diagnosis	Clean retractile foreskin	Clean non-retractile foreskin	Phimosis
Tight foreskin(n=26)	9	16	1
Phimosis(n=25)	9	8	8
Balanitis(n=9)	5	4
Other(n=9*)	6	2
*includes one child with long redundant foreskin.

At birth the prepuce adheres to the glans in most infants. Separation occurs so that 15% of infants have a retractile foreskin at 6 months, 50% at 1 year, and more than 90% at three years.³ Although phimosis indicates a pathological state (scarring of the foreskin), it is also wrongly used to describe non-retractile foreskin. Only nine children were found to have a genuine phimosis. Balanitis was the commonest referral symptom. It is argued that a non-retractile foreskin predisposes to attacks of balanitis because secretions and debris are retained under the foreskin and may become infected. Eight of the nine boys referred with balanitis, however had a healthy foreskin, which was retractile in five. Escala and Rickwood found that less than half of all boys presenting with balanitis had a recurrence.⁴ Also, although a quarter of the boys had a fully retractile prepuce, some continued to have episodes of balanitis despite apparently adequate hygiene. The practice of separating preputial adhesions² is therefore contentious, and we do not routinely practice it. We perform religious circumcisions on the premise that it is better done in a suitable environment than in the community where it may not be done safely.⁵

Note:

The statement in the paragraph above that more than 90% of boys have retractile foreskins three years of age is incorrect. It is based on more than half-century-old incorrect data that was supplied by Gairdner in 1949. Numerous later studies have shown this figure to be incorrect. CIRP believes that about 44% of boys have retractile foreskins by age ten. See Normal Development for more information.

Confusion over the term phimosis continues, so that many children are thought to have a pathological condition when often there is none. Greater understanding among paediatric surgeons and general practitioners of the definition of diagnoses and normal preputial development should lead to a decreased rate of referral and reduce anxiety of parents andpatients.

References

Department of Paediatric Surgery
University Hospital, Queens Medical Centre, Nottingham NG7 8HD

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