Data were obtained for all patients
() and no patient was
lost to follow-up. 18 were referred for circumcision on religious grounds. For
the remaining 82 the main referral complaint was of non-retractability or
phimosis; 37 (45% of the 82) were referred explicitly for some form of
operation such as 'operative intervention', 'circumcision'
or 'stretch'. 7 patients were referred because of a white lump under
the foreskin, with no appreciation that this represented smegma.
One hundred foreskin referrals: categorization of patients according to
treatment decision made at first clinic
Of the 82 referred on non-religious grounds, 24 (29%) were deemed not to
require treatment and were discharged immediately, 31 (38%) were prescribed a
six-week course of topical steroid, 9 (11%) were listed for preputioplasty, 7
(9%) were listed for adhesiolysis, 7 (9%) were listed for circumcision, and 4
(5%) were listed for other surgery (excision midline raphe cyst, excision
sebaceous cyst, division tethering frenulum, hooded foreskin repair).
Of the 7 patients listed initially for circumcision, 5 had a clinical
diagnosis of BXO, 1 had a preputial fistula, and 1 had a 'thickened
phimosis' with a ventral retention cyst; of the 9 listed for a
preputioplasty, 8 had a phimosis with a phimotic band and 1 had a phimosis and
recurrent balantis. Of the 31 patients treated with topical steroid, 21 (68%)
had a retractable foreskin at follow-up and were discharged; 2 patients
underwent a further course which proved successful, 2 were managed
subsequently with a successful adhesiolysis, and 2 foreskins became
retractable over a longer timescale with several further courses of steroid
not run serially. Overall success rate for topical steroid was therefore 25/31
(81%). 4 of these patients were subsequently listed for surgery, either
preputioplasty (3) or circumcision (1).
12 of the 82 patients (15%) had a preputioplasty either as the initial
treatment (9) or as secondary treatment (3). A good result was obtained in 10,
but 2 required circumcision for recurrent phimosis. Adhesiolysis was
universally successful for preputial adhesions.
In summary, 10 (12%) of the 82 patients referred for non-religious reasons
underwent circumcision (5 for a clinical diagnosis of BXO; 2 for failed
preputioplasty; 1 after failure of steroid cream; 1 for a preputial fistula
after hypospadias repair done a decade previously; 1 for a large ventral
retention cyst). 6 patients (1 in the religious circumcision group) were
identified preoperatively by the hospital clinician as having features
suggestive of BXO, confirmed histologically in 4; in no case had this
diagnosis been suggested in the referral letter.