P.A. DEWAN, Tieu HC, Chieng BS
Phimosis: is circumcision necessary?
Urology Unit, Women's and Children's Hospital, and the Departments of Surgery and Paediatrics, University of Adelaide, Adelaide, Australia.
J Paediatr Child Health 1996 Aug;32(4):285-9

Abstract:
Circumcision has been the traditional treatment for phimosis, but now is not the only management option, the best of which appears to be topical steroid application. Importantly, the literature suggests that phimosis probably is over-diagnosed, indicating that a prospective, randomized controlled study is needed to compare the non-circumcision options. Such a study would require consensus on the diagnostic criteria for phimosis; therefore, a more exacting definition would be needed and is suggested. Despite the non-controlled data on medical treatment of true phimosis, there seems little doubt that surgical intervention is not needed for all male infants with adherence of the foreskin to the glans, a non-retractable foreskin or, indeed, true phimosis.

... circumcision is the oldest and most performed surgical procedure in the world.

The most common stated medical indication for circumcision is phimosis, however, the definition of this condition is obscure in most publications.

Defining Phimosis
Øster found that the prepuce is retractable in ... 99% at 17 years of age. (My Note: one of the repeated "misreadings" of Øster:)

Little is known or written about the aetology of true phimosis, despite the supposed frequency varying from 4 to 10%.

In his text book in 1948 Winsbery-White defined phimosis as the congenital or acquired narrowing of the preputial opening, characterised by a non-retractable foreskin without adherence, which can lead to retention of secretions .. irritation .. balanitis .. interference with micturition ... pressure on the bladder, ureters and kidneys. (10)

A more precise and practical guide to the difference between a non-retractable and a phimotic foreskin is as follows, when the normal but non-retractable infant foreskin is examined, attempted gentle retraction results in the distal part of the foreskin pouting, and the narrow portion is proximal to the tip of the prepuce (Fig 1). Forced retraction of such a foreskin can result in splitting as is well demonstrated in the figures presented by Stenram et al. In contrast true phimosis produces a cone-shaped foreskin during the same gentle retraction manoeuvre, with a fibrotic, circular band that forms the most distal and narrowest part of the prepuce (Fig 2).

Confusion about the definition of true phimosis is highlighted by the study of Griffiths and Frank, who found that of 128 boys with a medical reason for referral to a paediatric urologist for circumcision, only 30 had true phimosis (although they did not give an exacting definition). (12) They suggested that ballooning and non-retracability is often over-interpreted, in some cases, the referring practitioner may have used the term "phimosis" to facilitate referral, thus further confusing the debate on the appropriate management of phimosis.

Techniques of Phimosis Management
Non-operative
.... Steroid cream is a painless, less complicated and more economical alternative to circumcision for the treatment of phimosis. Wright had a success rate of 80% (89 of 111 boys) using a 0.05% betamethasone. Kikiros et al. reported an improvement in 33 of 42 boys (78%) with 0.05% betamethasone, and in 18 of 21 boys (86%) with hydrocortisone, but they considered that the betamethasone worked more quickly. Another steroid cream, 0.05% clobetasol propionate, has also been used successfully by Jorgersen and Svensson. ........

..... Observed recurrence of phimosis after topical steroid treatment ... makes it important to commence retraction of the foreskin a number of times each day, once the phimosis has resolved.

Summary
... From the published results thus far 0.05% betamethasone appears to be more effective than 1% hydrocortisone. It would appear that regular retraction of the foreskin is necessary after initial success has been achieved ... However, a double-bind randomized control study of different steroids and placebo is needed to assess the relative effectiveness of each of the steroid options. Long-term follow up is needed to assess the recurrence risk, ...