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J R Soc Med. 2003 September; 96(9): 449–451.
PMCID: PMC539600

Troubles with the foreskin: one hundred consecutive referrals to paediatric surgeons

J S Huntley, DPhil MRCS, M C Bourne, MRCS, F D Munro, FRCS, and D Wilson-Storey, MD FRCS


To assess the reasons for and outcomes of referrals concerning the foreskin, 100 consecutive patients seen in paediatric clinics were followed to discharge.

18 referrals were for circumcision on religious grounds. Of the other 82, the main reason for referral was non-retractability or phimosis. At clinic, 24 (29%) of these were deemed normal for age, 31 (38%) were treated with topical steroid (successfully in 25), 9 (11%) were listed for preputioplasty, 7 (9%) were listed for adhesiolysis, 7 (9%) were listed for circumcision, and 4 were listed for other forms of surgery. 6 patients were identified as having balanitis xerotica obliterans (BXO), a condition that had not been suggested on referral.

With the advent of new treatments for foreskin disorders, circumcision is decreasingly necessary. Knowledge of the natural history of the foreskin, and the use of topical steroids, could shift the management of paediatric foreskin problems from the hospital outpatient department to primary care. BXO is not sufficiently recognized as a form of phimosis that requires operation.


Male circumcision has been practised since ancient times.1 Lately, the trend has been for fewer circumcisions2 because of medical and cultural concerns,3 greater understanding of the natural history of the foreskin4,5 and modern treatment alternatives. Such procedures include topical steroid,6 adhesiolysis,7 and preputioplasty.8 Steroid cream (0.05% betamethasone) applied topically three times a day for six weeks has proven effective (80% success rate) in the management of uncomplicated childhood phimosis.6 Adhesiolysis for asymmetric or pronounced adhesions between foreskin and glans is a simple procedure that may be performed under either local or general anaesthesia.7 Preputioplasty entails longitudinal incision of the phimotic band and transverse closure with no tissue resection.8


100 consecutive general practitioner referrals to three paediatric surgical consultants concerning the foreskin were identified in clinics at four hospitals in south-east Scotland (Royal Hospital for Sick Children, Edinburgh; Queen Margaret Hospital, Dunfermline; St John's Hospital, Livingstone; Roodlands General Hospital, Haddington) over 3½ months. Details were collated prospectively on a proforma (including referral reason, request and first-line treatment). Patients were followed until discharge.


Data were obtained for all patients (Table 1) 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.

Table 1
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.


We think that with better knowledge of foreskin disorders on the part of general practitioners, many outpatient referrals could be avoided. More than half a century ago Gairdner established the progression of foreskin retract-ability with age4—50% retractable by age 1 year, 75% by 2 years, and 90% by age 3 years. Likewise Oster, analysing the prevalence of 'phimosis' from the age of 6 years to 17 years, documented a reduction from 8% to 1%.5 Therefore, non-retractability (in the absence of scarring or other abnormality) can be considered normal for males up to and including adolescence. Moreover, for a non-retractable foreskin beyond the age of 3 years, topical steroid is reported effective in up to 80% cases.6 This option seems to be rarely instituted at primary care level. Patients with stubborn or asymmetric adhesions between the prepuce and underlying glans may be treated with simple adhesiolysis7 or initially with topical steroid.

7 of the 100 referrals were generated by concern over white lumps or 'cysts' under the foreskin which proved to be aggregations of smegma. By contrast, the 6 cases with circumferential scarring at the foreskin tip had not been recognized as possible BXO, warranting circumcision because of the danger of meatal stenosis. With respect to religious circumcision, it is our policy to perform these operations rather than see parents obtain them elsewhere at greater risk. These apart, 24 patients (29%) had incisional surgery to the foreskin. This compares with 51%

circumcised a decade ago in the same locality.9 We conclude that, with better appreciation of the natural history of the foreskin and wider use of topical steroid for phimosis, a substantial part of our caseload could be managed in primary care.


We thank all members of the paediatric surgical team who completed proforma details, and also Mr G A MacKinlay for allowing us to include his patients.


1. Gollaher DL. Circumcision. A History of the World's Most Controversial Surgery. New York: Basic Books, 2000
2. Rickwood AMK, Kenny SE, Donnell SC. Towards evidence based circumcision of English boys: survey of trends in practice. BMJ 2000;321: 792-3 [PMC free article] [PubMed]
3. Rickwood AMK, Walker J. Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence? Ann R Coll Surg Engl 1989;71: 275-7 [PMC free article] [PubMed]
4. Gairdner D. The fate of the foreskin. BMJ 1949;11: 1433-7 [PMC free article] [PubMed]
5. Oster J. Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child 1968;40: 200-3 [PMC free article] [PubMed]
6. Wright JE. The treatment of childhood phimosis with topical steroid. Aust N Z J Surg 1994;64: 327-8 [PubMed]
7. MacKinlay GA. Save the prepuce. Painless separation of preputial adhesions in the outpatient department. BMJ 1988;297: 590-1 [PMC free article] [PubMed]
8. Lane TM, South LM. Lateral preputioplasty for phimosis. J R Coll Surg Edin 1999;44: 310-12 [PubMed]
9. Lafferty PM, MacGregor FB, Scobie WG. Management of foreskin problems. Arch Dis Child 1991;66: 696-7 [PMC free article] [PubMed]

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