The false diagnosis of "Phimosis" in young boys
-Or, "what they don't know can hurt YOU"
Conservative Treatment of Phimosis:
Alternatives to Radical Circumcision
This page provides information on conservative treatments of foreskin
problems such as phimosis and preputial stenosis. In accordance with standard
medical ethics, these treatments avoid unnecessarily radical surgery,
and preserve normal physiologic function of the patient's body.
Note: Reports suggest that external irritants and other environmental factors may cause the foreskin to tighten. One such irritant that is suspected are the chemicals contained in bubble bath. Intact boys are urged to avoid the use of bubble bath. When tightness of a previously loose foreskin occurs (acquired phimosis), environmental factors and general state of health should be investigated before circumcision or conservative treatment is considered. For example, circulatory problems may cause edema of the prepuce and result in non-retractable foreskin.
What is ``phimosis''?
This section was written by pediatrician Robert Van Howe, MD, FAAP.
"Phimosis" is a vague term. In common usage, it usually means any condition in which the foreskin of the penis cannot be retracted.
Most infants are born with a foreskin that does not retract. This is normal!
"True" phimosis---better termed "preputial stenosis," because "phimosis" has so many different definitions it now is devoid of any useful meaning---occurs in less than 2% of intact males. The incidence of preputial stenosis in circumcised men is actually similar.
Of these 2%, 85-95% will respond to topical steroids. Of those who fail this, at least 75% will respond to stretching under local anesthesia, either manually or with a balloon. The arithmetic is simple: At the very most 7 boys in 10,000 may need surgery for preputial stenosis. No wonder the Canadian Paediatric Society calls circumcision an "obsolete" procedure!
There are several alternatives to radical circumcision which preserve the function of the prepuce and result in less morbidity (pain, bleeding, complications). The best article to check out is the 1994 piece by Cuckow et al. After all, why would you want to lose all of those Meissner corpuscles, the same nerve complexes which provide fine touch to the fingertips?
The ``Phony Phimosis Diagnosis''
The prepuce of boys may be tight until after puberty.1,7,8 This is an entirely normal condition and it is not phimosis. According to the experience in cultures where circumcision is uncommon, this tightness rarely requires treatment. Spontaneous loosening usually occurs with increasing maturity.1,7,8 Treatment is seldom necessary. If treatment should be necessary, it should not be done until after puberty and the male can weigh the therapeutic options and give informed consent.8It is important to note that the immature foreskin of a child must not be forced back for "cleaning" or for any other reason, because this will cause damage to the developing tissues. The child should be instructed that his foreskin will eventually retract. The first person to retract the foreskin should be the child himself.
Rickwood and colleagues provide a specific medical definition of phimosis: True phimosis is tight non-retractable foreskin caused by Balanitis Xerotica Obliterans (BXO) and is distingished by a whitish ring of hardened sclerotic skin at the tip of the prepuce.2,10 Histologic examination by a pathologist is necessary to confirm the diagnosis.2 If BXO is not present, then true phimosis is not present.2,10
A number of reports in the medical literature of the United Kingdom indicate that medical doctors are not trained to distinguish between normal developmental tight prepuce in boys and pathological phimosis.3,4,5,6,11 This results in cases of misdiagnosis of normal developmental preputial tightness as pathological phimosis in the UK. 3,4,5,6,11
CIRP has received numerous reports to indicate that normal preputial narrownessness in boys in the United States is frequently being misdiagnosed as pathological phimosis. CIRP believes that the situation in the United States is certainly not better, and probably much worse, than the situation in the United Kingdom. Parents of intact boys are also frequently instructed to force the immature foreskin back for cleaning, contrary to the recommendations of the American Academy of Pediatrics.
As a consequence of misdiagnosis and confusion of normal developmental narrowessness and non-retractablity with pathological phimosis, many unnecessary circumcisions are performed. Shankar and Rickwood found that the number of circumcisions being performed in the United Kingdom is 8 times greater than the number required.10 The number of unnecessary circumcisions performed in the United States is unknown.
Circumcision is now recommended only in confirmed cases of phimosis caused by balanitis xerotica obliterans (BXO), however newer treatments may eliminate the need for circumcision. BXO is recognized by a hardened area of whitish skin near the tip of the foreskin which prevents retraction.2,9,10,11 Shankar and Rickwood found a low incidence of only 0.4 of 1000 boys per year, and only 6 in 1000 by age 15.10 See Balanitis Xerotica Obliterans for more information. Other cases of non-retractile foreskin respond to conservative, non-destructive, non-traumatic, less costly treatment.