ROUTINE MEDICAL CHECKS
Routine Medical Checks and Education have shown that attempts to
retract the foreskin at an early enough age result in a significant
decrease in the incidence of phimosis.
Monitoring boys before puberty encourages awareness
and stimulates the self manipulation which in some cases, is necessary
to stretch a phimosis. (It will also allow any persisting problem to
be treated in good time before puberty - allowing a healthy preparation
The usual medical approach of checking early and preventing when
possible is of particular relevance to this subject, where in some
cases, checking will provide an education which will promote prevention.
It appears routinely checking children for potential problems is an
attitude which was last urgently recommended by Schöberlein (1966)
and Bokström (1944). This recommendation was superseded ironically
by one remarkable study by Jacob Øster. Ironically because it
actually shows an even more urgent need to monitor.
Øster: Statistics and Misinterpretations
The conclusions and statistics from one study by Jacob Øster
are mirrored in publications from Dr. Spock's Baby Book (still today
a best seller) to the British Medical Journal.
In 1968 Jacob Øster (26) reported on a group of almost two thousand boys aged between 6
and 10 yrs. old. He studied them for a period of 7 to 8 years till
they were between 13 and 17 years old. He reported decreasing frequencies
for three separate categories of foreskin restriction: phimosis,
tight prepuce, and adhesions.
Many modern medical studies quote Øster's figures as 1%;
sometimes referring to "retractile foreskin", implying
phimosis (Gordon and Collin (24),),
at other times to "natural separation", implying epithelial
adhesions (Warren and Bigelow (27),).
Such confusion was partly caused by Øster who presented three
separate columns of statistics, and never gave an overall figure, in
addition he states, for example regarding 16-17 year-olds: "tight
foreskin was present in 2%" whereas in his table of statistics
he gives 1%; an analysis shows that in fact this was 1.4%. Whatever
his mathematical failings might have been, his study showed in a revolutionary
way, that phimosis was not necessarily an indication for circumcision.
Øster wrote "Phimosis is seen to be uncommon in schoolboys,
and the indications for operation even rarer if the normal development
of the prepuce is patiently awaited." This attitude has unfortunately
frequently been accepted on face value, one modern medical text
even went as far as to interpret this as meaning simply "ignoring"
such conditions and their symptoms (24).
A Re-Interpretation of Øster
Schöberlein (28) says that "in
medical examinations of 3,000 young men, mostly of an age between
18 and 22 years . . . A phimosis was found in 8.8%."
Beauge (29) was "in charge for over ten years of the routine examination
of college freshmen", he "observed several hundred cases".
He reports "Inability to retract the foreskin . . . persists
in about 10% of the subjects at the end of adolescence."
Three other studies covering altogether over 2,200 men, each report
frequencies of over 8% with phimosis, significantly all these three
unrelated studies report "It was completely unknown to some of
the examined boys that the foreskin could be retracted" (Saitmacher).
"The ignorance of these young soldiers is remarkable, many of
them expressed suprise at the condition revealed when they retracted
their foreskins: some of them had apparently never done so in their
lives" (Osmond). "most
patients were unaware that the prepuce was retractable" (Parkash).
If phimosis is largely self resolving (as claimed by Øster),
why do the other studies report such high figures?
It is clear that Øster influenced his own study. He tells
us "the boys received regular instruction about preputial hygiene"
coupled with this the boys were physically examined every year. This
caring attention and instruction started previous to puberty.
This appears to have helped relieve phimosis to some extent and
encourage the early release of adhesions. At the very least the physical
examinations with the gentle attempts at retraction, would certainly
have been an education for those boys who had not realised that their
foreskin could retract.
It appears that phimosis occurs at a rate of 1% in 17 yr.olds,
when these boys have been examined and educated for the previous seven
Øster states "The object here was to investigate the incidence
of preputial `adhesions`, phimosis, and smegma production in an unselected
group." While he realises "our actual figures for the incidence of
smegma can only be of limited significance, as the boys received regular
instruction about preputial hygiene." he does not apply this principle
to phimosis - he does not realise that his education may also have
influenced the frequency of phimosis among this very lucky selected
group of boys.
Beauge, after describing how young men with phimosis do not retract
the foreskin during masturbation, reports that instruction about this,
cured a large number of his patients. He wrote "It would appear
then that phimosis . . . diminishes in frequency with age due to the
fact of the manipulation of the penis."
Due to the anatomical difficulties involved it is clear that many boys,
some youths and even a few grown men are not aware of the possibility
of retraction (medical
reports; e.mail examples, analysis).
It is reasonable to assume that education about retraction precedes
the self manipulation which is in some cases necessary to stretch a
phimosis. A medical examination is a very simple and practical way
of educating young children that retraction is possible.
The sooner that the process of monitoring a child's ability to retract
his foreskin could begin, the more possibility the child would have
of developing a healthy foreskin which required no correction at a
later stage. The optimal time to begin monitoring and educating a boy's
ability to retract his foreskin would be while his skin structures
are flexible and developing.
The medical approach of checking early and preventing when possible
is of particular relevance to this subject, where in some cases, checking
provides an education which will promote prevention.
OF PHIMOSIS STATISTICS
A review of every medical study with original measurements on phimosis
frequencies since 1920.
Please note the repititions of Oster's mistake: modern
studies quoting and misquoting Øster leading to general
misunderstandings about statistics.
I showed this information
first in 1997 on the NGs, no-one could or has ever disagreed.
Every discussion or criticism will be published.