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Phimosis in childhood

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3678 (Published 20 June 2013) Cite this as: BMJ 2013;346:f3678

Re: Phimosis in childhood

Drake et al. in their short overview of phimosis in childhood have skipped over some rather important points.[1]

Phimosis. Phimosis is a condition, not a disease. As a condition, it does not require treatment in the absence of other complaints, especially since there is no need to see or clean the internal glans in childhood. Phimosis in childhood may be caused by a narrow tip on the foreskin, fusion of the balano-preputial lamina, or by frenulum breve.[2]

We hold the late consultant paediatrician, Douglas Gairdner and former editor of the Archives of Disease in Childhood in the very highest esteem, however, his schedule for the development of retractile foreskin in childhood [3] is now known to be inaccurate.[4] Unfortunately, his erroneous data is embedded in medical textbooks and is frequently quoted — and has resulted in countless unnecessary circumcision operations.[4]

Newer and better data has been provided by numerous clinicians.[2] Thorvaldsen & Meyhof reported that the average age of first, natural, foreskin retraction is 10.4 years,[5] and this is consistent with the recent data provided by other clinicians.[2,4]

Tissue expansion. A non-retractile foreskin sometimes persists into the teen-age years. Youths are daily being counseled online regarding manual stretching of their foreskins to make them retractable without medical or surgical intervention, in a revival of lost folk knowledge.[6] The stretching generates tissue expansion by mitosis and the increase in width and retractability is permanent.

Fusion, not adhesion. The authors have improperly used the term “adhesion” to describe the connection of the childhood foreskin to the glans penis. This is incorrect. The connection is a fusion caused by sharing the balano-preputial lamina between the foreskin and the glans penis. This fusion spontaneously disintegrates over a widely variable period of years and in some cases may persist to as late as age 18.[7]

Physician training needed. There is acute need for better training of primary care physicians on the normal development of the foreskin. Doctors Opposing Circumcision receives more than 100 complaints every year regarding primary care physicians who have prematurely forcibly retracted a child’s foreskin during an office visit, tearing the foreskin from the glans and causing trauma and exquisite pain.[9] We follow Wright[10] and advise that the first person to retract a boy’s foreskin should be the boy himself.

References

  1. Drake T. Rustom J, Davies M. Phimosis in childhood. BMJ. 2013;346:f367.
  2. The Development of Retractile Foreskin in the Child and Adolescent. Available at http://www.doctorsopposingcircumcision.org/info/retraction.html Accessed 22 August 2013.
  3. Gairdner DM. The fate of the foreskin: a study of circumcision. Br Med J. 1949;2:1433-7. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2051968/pdf/brmedj03656-0009... Accessed 22 August 2013.
  4. Denniston GC, Hill G. Gairdner was wrong. Can Fam Physician. 2010 October; 56(10): 986–7. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2954072/ Accessed 22 August 2013.
  5. Thorvaldsen MA, Meyhoff HH. Pathological or physiological phimosis? [article in Danish] Ugeskr Læger. 2005;167(17):1858–62.
  6. How to fix phimosis and tight foreskins, solutions that work. Available at http://www.network54.com/Forum/244184/ Accessed 22 August 2013.
  7. Øster J. Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child. 1968;43:200-3. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2019851/pdf/archdisch01557-0... Accessed 22 August 2013.
  8. Geisheker JV. Foreskin retraction of intact boys — an epidemic. Available at http://www.doctorsopposingcircumcision.org/info/info-forcedretraction.html Accessed 22 August 2013.
  9. Rudolph AM, Hoffman MD. PediatricsEighteenth Ed. Norwalk CT & Los Altos CA, Appleton and Lange, 1987, Chap 23.13.1 "Penis" at p1205.
  10. Wright JE. Further to the “Further Fate of the Foreskin.” Med J Aust. 1994;160:134-5.

Competing interests: No competing interests

25 August 2013
George Hill
Vice-President
John V. Geisheker, J.D., LL.M.
Doctors Opposing Circumcision
2442 NW Market Street, Suite 42, Seattle, Washington 98107-4137, USA