This site discusses phimosis in its specific forms of phimotic ring, frenulum breve, adhesions or skinbridges. During erection these conditions inhibit the relationship between foreskin and glans. This functionally restricts the erection, and thus has an effect on the sexuality. With our culture's attitudes on health care, it would be appropriate to encourage early prevention.

Jan 2021 : Please read the new summary.

A Criticism of
The incidence of phimosis in boys

K.R. Shankar and A.M.K.Rickwood
BJU Int 1999 Jul;84(1):101-2

Shankar and Rickwood
The incidence of pathological phimosis in boys was 0.4 cases/1000 boys per year, or 0.6% of boys affected by their 15th birthday, a value lower than previous estimates and exceeded more than eight-fold by the proportion of English boys currently circumcised for `phimosis`

RS. So, the point seems to be that circumcision is performed too often ... I agree but while I agree with their basic attitude and their results, their research and methods leaves much to be desired - the evidence needs to be re-evaluated.

RS: First confusion is the title - this study is not the incidence of phimosis - this study is an attempt to measure how often BXO occurrs in cases of phimosis when the phimosis is discovered up to age 15 and treated by circumcision.

Shankar and Rickwood
There is general acceptance that pathological phimosis, with cicatrization of the preputial orifice, usually caused by balanitis xerotica obliterans (BXO) represents the one absolute indication for circumcision. However, the incidence of this complaint and hence the proportion of boys unquestionably needing circumcision remains to be established, as the little data that exists enable only an approximation.

RS. How often BXO or LSA occurrs with phimosis has already been measured by M. Meuli, et al 10%; Kristiansen et al 15%; Chalmers et al. 14% and Clemmensen 19%. - Shankar and Rickwood make no mention of these figures.

Shankar and Rickwood "Among 173 boys serially examined by Øster from 6-17 years of age, three developed `secondary` phimosis, presumptively pathological, giving an incidence of 1.7%"

RS. Øster serially examined 1,968 boys not 173 - the adolescents who had persistant phimosis at the end of Øster`s 7 years education and examinations must be included in any well researched speculation -

RS: (Of great speculative interest - when we take such statistical acrobatics seriously is - 3 boys with secondary phimosis into 1,968 gives an incidence of 0.0656% and this is considerably less than Shankar and Rickwood 0.6% showing perhaps that early monitoring and education can help to prevent LSA.)

Shankar and Rickwood "The study comprised a review of all medically indicated circumcisions performed for `phimosis` at Alder Hey Children`s Hospital during the 2 years from July 1996 onward, on boys resident in the Liverpool and Sefton Health Districts. These Districts, with a population of boys aged 0-14 years of »76 000, are serviced exclusively for paediatric purposes by this hospital."

RS. Am I truly meant to believe that in England where children are not monitored that every case of phimosis is discovered? The point is that the cases which were discovered were the more noticable cases e.g. those cases where an infection was present.

Shankar and Rickwood:

During the 2-year period reviewed, 62 boys were circumcised for typical cicatrizing pathological phimosis, one 4 years old, the remainder aged 5-14 years. The circumcision specimens were examined histologically in 51 instances, 43 (84%) revealing appearances characteristic of BXO and nine of nonspecific dermal fibrosis. During this same period, 30 boys (aged 0-14 years) were circumcised for developmental unretractability of the foreskin.(`physiological phimosis`).

RS so again I must question the statistical exactness of this study : 43 plus nine equals 52, yet there were only 51 histological examinations - and 30 boys with phimoses which might have stretched were circumcised.

RS We might well ask what happened to the other boys with unnoticed non-pathological phimosis? Then even to exaggerate Meuli; Kristiansen; Chalmers and Clemmensen`s statistic and estimate 20% of cases of phimosis are due to LSA, then against 43 cases of LSA we would expect to find at least 172 cases of `physiological phimosis` - and only 30 of these were discovered and treated (probably inappropriately) with circumcision - where are the 142 boys who are being presently being ignored by the English health care system?

RS: again I call for a routine monitoring and education of those boys who are unaware of retraction please see Øster and "The Validity of Routine Medical Checks and Education"