A paper published in The Medical Journal of Australia, MJA 2003 178 (4): 155-158. The authors conclude that the rate of circumcision to treat phimosis in boys aged less than 15 years is seven times the expected incidence rate for phimosis. Many boys are circumcised before reaching five years of age, despite phimosis being rare in this age group. Phimosis appears to be a false diagnoses to justify circumcision when the surgery is not truly medically necessary.
Phimosis is the narrowing of the preputial orifice, leading to an inability to retract the foreskin, or prepuce, over the glans penis. Severe phimosis may cause pain on voiding, urinary retention, urinary tract infections, localised skin infections, and calculi, and later in life may be associated with sexual dysfunction and squamous-cell carcinoma. Phimosis is often secondary to recurrent infections or inflammatory scleroses, such as balanitis xerotica obliterans, where it may be accompanied by white scarring and induration. Circumcision is a standard treatment option for phimosis, although there is increasing evidence that topical steroids are also effective. One study estimated that 0.6% of boys were affected by phimosis before reaching 15 years of age, while, in Denmark, about 1.5% of boys were affected by age 17 years. The condition rarely occurs before five years of age, and reaches its peak incidence before puberty.
Non-retractable foreskins, or preputial adhesions, occur in young boys as a normal part of penile development, and these adhesions separate over time, requiring no surgical intervention. A United Kingdom report showed that only four percent of newborns had a completely retractable prepuce, but that by two years of age this had increased to 80%.
After concerns were raised in the UK that normal preputial adhesions were being misdiagnosed as phimosis, particularly in children, and were leading to unnecessary circumcisions, the rate of circumcisions performed for medically indicated reasons declined, most notably in boys less than five years of age.
Several reasons are given for the exceedingly high rate of circumcisions for phimosis considering that true phimosis occurs less than the circumcision rate. The authors speculate that physicians may be mistaking normal penile development for pathological phimosis. The authors also speculate that doctors are still performing circumcisions at the request of parents but are coding them with a medical condition, namely, phimosis, in order to medically justify the surgery.
In the interests of best medical practice, the factors resulting in high circumcision rates to treat phimosis in young boys need to be examined. Physicians and parents concerned about preputial adhesions should be encouraged to consider alternatives and to delay circumcision. Young boys with a confirmed diagnosis of phimosis do not necessarily need to be circumcised. Topical steroids have been shown to be a cost-effective approach in reversing phimosis
The authors suggest that improved education for physicians, and perhaps parents, with regard to foreskin development and management is required.