These are more than twice as frequent in uncircumcised boys [191].
Phimosis:
Phimosis (‘to tie with a string’ [462]) is generally regarded as narrowing of the foreskin orifice so as to prevent retraction of the foreskin over the glans. It may arise from physiological adhesion of the foreskin to the glans or to fibrous adhesions. It consists of a permanent preputial constriction often to a pinpoint [512]. Trapped secretions and build-up of smegma predispose to poor hygiene, local infections, later penile cancer, and painful erections [512]. Severe phimosis may lead to urinary tract infections, localized skin infections, pain when passing urine, retention of urine, kidney stones, and sexual dysfunction [366].
Phimosis is normal in very young boys, but is gone by age 3 in 90%. If still present after age 6 it is regarded as a problem. Phimosis affects at least 10% of uncircumcised males, the reported rates being: 20%, as seen by Gairdner in 5–13 year-olds [192], 8% at age 8 in Danish boys [416], 9% in New York [590], 14% in British soldiers [415], and 9% in German youths [486] and men [495]. Although a rate of 50% in men in Japan [409] and Bali [74] has been reported, a more recent study found that by age 11-15, 77% had a retractable prepuce, i.e., rate of phimosis was 23% [263]. Amongst 13 year-old Japanese boys the incidence of phimosis was 16% [292].
In Taiwan the rate of phimosis in one study was 17% in first-grade boys (age 7), 10% in fourth-grade boys (age 10), and 1.2% in seventh-grade boys (age 13), although many more had partial phimosis [255]. In a different study of boys in the same school years and ages, 0.3% of 13 year-old Taiwanese boys had phimosis [303]. Incidence of circumcision was 7% at age 10, and 9% at age 13 in these studies. In an earlier study, however, the rate of phimosis in 10-13 year-old boys was 37% [551].
There is also the condition of pathological phimosis from secondary cicatrization of the foreskin orifice arising from balanitis xerotica obliterans (BXO). Once thought to be rare and a disorder presenting in adulthood, BXO is now regarded as common in young boys, in whom treatment by circumcision is advocated to prevent the complications that occur later in life [653]. Thus whereas a rate of 1% has been reported [467], others find an incidence in the UK of 5-6% in uncircumcised boys under 18 and under 15, respectively [221, 257]. A study in Plymouth found BXO in 35% of the 80% of boys aged 3 months to 16 years (mean 6) who had been circumcised following foreskin problems [653].
Histological abnormalities were seen in 85% of those circumcised, chronic inflammation in 47%, and fibrosis in 3% [653]. In this study, overall BXO frequency in the boys referred was 12%. Similarly, a prospective study involving 1,178 boys in Budapest who presented consecutively over the decade 1991-2001 and were then treated by circumcision found by histological examination that BXO incidence was 40%, peaking at age 9-11 (76%), BXO being the cause of the secondary phimosis in all of these [301]. In the study as a whole, 19% of boys had early, 60% intermediate and 21% late form of BXO.
The narrow foreskin opening causes urinary obstruction that can be partial or complete. As well as urethral stenosis, meatal stenosis is seen, making it a significant condition [653]. Indeed, BXO is generally regarded as an indication for circumcision [653]. In one series in Boston of pediatric BXO, amongst 41 patients, 52% had been referred for phimosis, 13% for balanitis and 10% for buried penis [196]. Of these, 46% underwent curative circumcision, 27% also had BXO involvement of the meatus and had not only circumcision, but meatotomy or meatoplasty, and 22% required extensive plastic surgery of the penis, including buccal mucosa grafts, demonstrating a more severe and morbid clinical course.
Phimosis also increases risk of penile cancer (discussed later) and treatment by complete circumcision to prevent this outcome is advocated.
Phimosis can be treated with topical steroid creams, but these need to be applied for at least a month, are not completely successful, can lead to iatrogenic Cushing’s syndrome, adrenal suppression, delayed growth, skin atrophy, and offer no benefit in prevention of other conditions associated with having a foreskin [312, 342, 652, 656].
Paraphimosis: This is when the retracted foreskin cannot be brought back again over the glans and is a very painful problem. Backward pressure to the kidney may impede its function and have cardiovascular consequences. It is relieved by circumcision or slitting the dorsal surface of the foreskin.
The foreskin problems referred to above also mean intercourse is painful.
Zipper injury: In uncircumcised boys the foreskin can become accidentally entrapped in zippers, resulting in pain, trauma, swelling and scarring of this appendage. Foreskin accidents in men can also occur.
Elderly men: In elderly men, infections and pain from balanoposthitis (see below), phimosis and paraphimosis are seen and carers report problems in achieving optimal hygiene in uncircumcised men. The need for an appliance for urinary drainage in quadraplegics and in senile men is facilitated if they are circumcised. Nursing home staff have particular difficulty performing their duty of washing the genital area of uncircumcised elderly men, particularly with the onset of dementia. Such men can react violently towards staff or family during attempts to wash under the foreskin. This is an under-recognized problem and far from the mind of a parent or neonatologist when considering circumcision for an infant, so that information on the gerontological perspective should also be given at birth [188].
Bathroom 'splatter': Boys and men who are not circumcised can be a source of irritation if they do not retract the foreskin when they urinate, as 'splatter' will occur. Although not a medical problem, it is a source of annoyance for other people (such as a parent or partner) if it is they who have the job of cleaning the bathroom.
Frenular chordee: This results from an unusually thick and often tight frenulum and prevents the foreskin from fully retracting, being present in a quarter of all uncircumcised males [219]. The frenulum then tears during intercourse or masturbation. Since scar tissue on the foreskin is generally more fragile and less elastic than normal tissue, the tear often re-occurs causing pain, bleeding and is an impediment to sexual activity. This problem can be solved by excising the frenulum during a circumcision. Frenoplasty (removing just the tight frenulum) is also possible.
Psychological sequelae: Follow-up 5 years later of 117 boys circumcised for phimosis, balanitis scarring of the prepuce, or ballooning when urinating found that 95% expressed complete satisfaction and the only psychological effect was slight shyness in the school change-room in 9% of boys in this Swedish study [543, 544]. The study showed that parents had nothing to fear for their son's psychological well-being from circumcision.
