A total of 422 boys were seen in the clinic, median age 6 years 2 months (range, 3 months to 16 years). No boys in this series presented for circumcision for religious reasons although one boy requested circumcision because all the other male members of his family were circumcised.
shows a flow diagram of the management of these boys indicating the final outcome and the steps taken to get there. In total, 186 boys had surgery: circumcision (n = 148), adhesiolysis (n = 33), and frenuloplasty (n = 5). The majority (93.6%) of boys who were operated on were only seen once in clinic pre-operatively. All boys who had a diagnosis of BXO made in clinic were circumcised after their first presentation, others circumcised on a single presentation had a diagnosis of phimosis. Those circumcised after follow-up were predominantly diagnosed as having a phimosis; three, however, had been diagnosed as having physiological phimosis. Boys diagnosed as having preputial adhesions underwent adhesiolysis in 73.4% of cases, usually performed using topical local anaesthetic in clinic, most of these at first presentation although two boys had failed to improve by the time they were followed up and underwent adhesiolysis at their second presentation. Six of the eight boys diagnosed as having a short frenulum underwent a frenuloplasty, all but one after their first presentation; one was circumcised.
Management pathway for boys presenting for circumcision.
The vast majority of the other boys attending out-patients simply required re-assurance, being either discharged or offered an open appointment; for some parents, re-assurance took more than one clinic visit. Indeed, one boy's parents were so concerned they took up the offer of three open appointments, the decision to circumcise being taken at their fourth clinic visit; the foreskin was normal on histological analysis. A few boys had a follow-up appointment arranged; these boys either had diagnoses that may have improved with time (such as preputial adhesions or a physiological phimosis) or were unsure at their initial presentation whether they wanted surgery for their preputial problems.
The initial management plan for each boy by age group is shown in . As can be seen, the younger the boy at presentation, the more likely they were to be discharged or offered an open appointment. However, in the older age ranges, fewer boys were simply discharged, with the majority either being given follow-up appointments or offered a surgical procedure. Adhesiolysis was most commonly performed between the ages of 6 and 10 years while frenuloplasty was only contemplated for boys over the age of 10 years.
Initial management decision by age.
It is normal to find a number of chronic inflammatory cells in the prepuce; however, foreskins were only reported as showing chronic inflammation when there was a significant inflammatory infiltrate, consistent with active inflammation.
Of foreskins excised, 84.8% showed significant histological abnormalities with 34.5% of specimens having evidence of BXO. The prevalence of BXO in the population of boys studied was 12.1%. Twenty-seven boys were suspected of having BXO at their out-patient appointment; 24 (88.9%) of these were subsequently confirmed to have evidence of BXO on histological analysis. Of the five boys for whom no histological diagnosis was available, two had their surgery performed elsewhere and the other three had no histology report on their foreskin available.
shows the histological diagnoses as a proportion of each age group (having excluded those with no pathological report available; n = 143). It can be clearly seen that in the younger age groups chronic inflammation was the predominant finding, this giving way to BXO as the most common pathological finding in older boys. However, BXO was found in all age groups; the youngest boy with confirmed BXO in the excised specimen was 2 years 6 months old. Isolated fibrosis was an unusual finding restricted to those between the ages of 3 and 6 years. The proportion of normal foreskins remained constant throughout the age groups.