Those who have been keeping their eye on circumcision, circumcision
advocates and their alibis, will no doubt be aware that the diagnosis of
"phimosis" is far too commonly given as a pretext to circumcise an
older child. This is the reason most often cited by parents who claim that circumcision on their child "had to be done." Circumcision is also marketed as prophylaxis for "phimosis"
by those who advocate or have to gain from performing the procedure.
It must be asked, how is it that after thousands of years of evolution, human males evolved to be born with a problematic sexual organ?
Is it that the human penis is inherently problematic?
Or is it that there is no real problem, and opportunistic physicians have been successful in characterizing perfectly normal, healthy stages in male genital development as "problematic," when they're actually not?
American and European Physicians Don't Learn The Same Thing
America and Europe are different in many ways. One of the biggest differences between both continents is circumcision and anatomically correct male genitals. Whereas circumcision, particularly the routine circumcision of infant males, is a common, culturally ingrained practice in the United States, it is rare or virtually not practiced in Europe, except among Jews and Muslims.
Perhaps due to Judeo-Christian roots, people in both continents share a taboo surrounding nakedness, so they are unaware of each others' practices. People in Europe often believe that circumcision is limited to religious groups, such as Judaism and Islam, and generally believe that their American counterparts hold male circumcision in the same regard; people in America believe anyone who's anyone is circumcised. It often comes to a shocking surprise to people in either country, when they find out the truth; Americans are surprised that the rest of the English-speaking world does not circumcise, and Europeans are horrified to find out that in America, male newborns are often circumcised.
It is no surprise, then, that American and European physicians hold different views when it comes to male genitals and circumcision. What they learn in medical school concerning male genital development is vastly different; while European physicians are taught to regard unaltered male genitals as nature made them as healthy and normal, American physicians are taught to look at the same genitals as aliens from another planet. While in Europe, physicians are taught to look at the foreskin as an intrinsic part of the male organ, akin to labia in female organs, in the United States, the physicians are taught to treat the presence of a foreskin as a superfluous growth and a liability. Indeed, some hospitals will list the presence of a foreskin alongside other medical problems.
This picture was taken at an American hospital. Notice that being uncircumcised
is a "problem," along side hearing loss and poor growth and weight gain.
To Europeans, penises in American textbooks may appear strange, as they are depicted as circumcised, as if this is they the human penis appears in nature. To Americans, pictures of penises may be "Ew, gross!" The foreskin, if mentioned at all in American textbooks, is often described as "that loose piece of flesh at the end of a penis, which is removed in circumcision." Whereas European textbooks present the penis as-is and moves on, American textbooks must describe various reasons why circumcision is performed, and why parents ought to make a "decision." Circumcision prevents cancer, STDs, makes it easier to clean, and, it prevents phimosis. What good parent wouldn't want to prevent all these problems in their children?
Of course, when comparing world data, it's not entirely clear that circumcision prevents much. Not a single medical organization recommends male circumcision based on any of the claimed "benefits." Circumcised males are still susceptible to cancer and any STD one can name. The latest canard used to justify male infant circumcision is that it prevents HIV transmission. No, scratch that; it's supposed to "reduce the transmission of HIV transmission by 60%," a claim that doesn't really mean much of anything, as even if it were true, even those who promote circumcision as HIV prevention must stress that circumcised males and their partners must continue to wear condoms. (In other words, male circumcision fails.)
The one valid concern is phimosis, an actual physical condition that is exclusive to males with anatomically correct genitalia.
But what precisely *is* phimosis?
Who gets it?
What causes it?
How common is it in actuality?
When and if it is necessary, what treatment options are available?
When is a situation not "phimosis" but a normal stage in development?
I'm writing this blog post to answer these questions and more.
Here, readers will learn what all physicians should be learning in medical school, but is often omitted in American medical curricula. The sources used for this blog post are cited for reference.
The Facts
What is phimosis?
The word "phimosis" originates from the Greek word phimos (φῑμός)
which means "muzzle". "Phimosis" is a vague term used
to describe any situation where, in intact males, the foreskin cannot be
retracted to reveal the glans, or the head of the penis. The term may
also refer to clitoral phimosis in women, whereby the clitoral hood
cannot be retracted, limiting exposure of the glans clitoridis.
What are the normal stages of development?
At Birth
Typically, when a baby boy is born, the
prepuce is long with a narrow tip.(1)(2) Retraction is not possible in
the majority of infants because the narrow tip will not pass over the
glans penis. Moreover, it is normal for the inner mucosal surface of the
prepuce to be fused with the underlying mucosal surface of the glans,
or head of the penis,(1)(2)(4)(5) by
means of a membrane called synechia, also known as the balano-preputial
membrane or balano-preputial lamina,(1) further preventing retraction. This attachment forms early in fetal
development and provides a protective cocoon for the delicate
developing glans.(6) It is normal for the foreskin to be non-retractable in infancy and early childhood.(6)
Retraction of the Foreskin
In normal development, the foreskin
usually separates from the glans and becomes retractable with age.(4) As
the infant matures into a boy and the boy into a man, the tip of the
prepuce becomes wider, and the shaft of the penis grows, making the tip
of the prepuce appear shorter. The membrane that bonds the inner
surface of the prepuce with the glans penis spontaneously disintegrates
and releases the prepuce to separate from the glans. The prepuce
spontaneously becomes retractable.
In order for retraction to occur, the foreskin must have
separated from the glans and the opening of the foreskin must have
widened to allow it to slip back over the glans. Throughout childhood
and adolescence, there is a release of hormones. As hormone levels rise,
the fiber-dense tissue of the prepuce is replaced with a more elastic
tissue. A boy will begin to explore his genitals as he grows, and as time
passes, the elastic tissue will allow the opening of the foreskin to
widen. This can happen at any age but it is not common in young boys.
The amount of time it takes for a boy's
foreskin to become fully retractable varies from boy to boy; this
process can take many years for some boys, and yet minutes for others.
In some boys, the foreskin may not be retractable until after
puberty.(7)(8)(9) This is an entirely normal stage of development and
should not be diagnosed as any kind of "problem."
When Does Retraction Happen?
According to the experience of doctors
and researchers in cultures where circumcision is
uncommon, retraction happens at varying ages, and a non-retractable
foreskin rarely requires treatment. Observations from doctors in
Denmark, and Japan and other countries indicate that spontaneous
loosening usually occurs with increasing maturity.(7)(8)(9)(10)(11)(12)
Non-retractability is considered normal for males up to and including adolescence. The
process whereby the foreskin and glans gradually separate may not be
complete until the age of 17.(4) A Danish survey (2005) reported that
average age of first
foreskin retraction is 10.4 years.(13) Marques et al (2005) reported
that 99% of boys can retract their foreskins by age 14.(12)(14)(15)(16)
One may expect 50% of 10-year-old boys; 90% of
16-year-old boys; and 98-99% of 18 year-old males to have a fully
retractable foreskin. Treatment is seldom necessary.
A 1999 study by Cold and Taylor shows that at 6 to 7 years,
approximately 60% of the boys had natural adhesions. At 10-11 years,
close to 50% of the boys still had adhesions. At 14-15, approximately
only 10% of the boys had adhesions. As they approach the age of 17, only
a very small percentage of boys will have adhesions. That means that,
left uncircumcised, most boys will be able to retract their foreskin
before they are 17 years old.
Foreskin Retraction as Observed in Children in Other Countries
Jakob Øster, a Danish physician who conducted school examinations,
reported his findings on the examination of school-boys in Denmark,
where circumcision is rare.(7)
Øster (1968) found that the incidence of fusion of the foreskin with
the glans penis steadily declines with increasing age and foreskin
retractability increases with age.(7)
Kayaba et al. (1996) also investigated the development of foreskin
retraction in boys from age 0 to age 15.5, and they also reported
increasing retractability with increasing age. Kayaba et al. reported
that about only 42% of boys aged 8-10 have fully retractile
foreskin, but the percentage increases to 62.9% in boys aged
11-15.(8) Imamura (1997) reported that 77% of boys aged 11-15 had
retractile foreskin.
Thorvaldsen and Meyhoff (2005) conducted
a
survey of 4000 young men in Denmark. They report that the mean age of
first foreskin retraction is 10.4 years in Denmark.(13) Non-retractile
foreskin is the more common condition until about 10-11 years of age.
Current medical literature indicates that the foreskin is
non-retractable in the majority of males until they begin to approach
puberty. Until a boy begins to reach sexual maturity, non-retractability
of the foreskin is a normal part of growing up.
When is "phimosis" a problem?
Given the empirical facts stated above, it is already mistaken to assume
that just because the foreskin cannot be retracted to reveal the head
of the penis, a male has some sort of pathological condition. As
evidenced by the facts given above, the great majority of male children
who have anatomically correct genitals will have foreskins that cannot
be retracted, and it is a mistake to assume that all children undergo
this transitory "illness" where they can't retract their foreskins, akin
to the mumps, measles or chicken pox. Girls do not begin to menstruate
until the onset of puberty, and they are not considered to be suffering
any sort of medical condition until then.
Non-retractability of the foreskin may pose a problem if it continues
well past puberty. Typically the foreskin has dilated to allow
retraction as a result of the release of hormones. In a small percentage
of males, the production of these hormones is insufficient, and the
foreskin fails to dilate, resulting in a condition known as "
preputial stenosis,"
or, a narrow foreskin. This condition may make hygiene and sexual
intercourse difficult, if not impossible, but not always. In older men
that have bad hygiene habits and who smoke regularly, having a
non-retractile foreskin can increase the chances of developing penile
cancer.
There is another reason why the foreskin may not be retractable in a
male, and that is because he has suffered an infection with
balanitis xerotica obliterans,
or
BXO for short. In this case, the tip of the foreskin is
scarred and
indurated, and has the
histological features of a pathological
infection. The foreskin of a male who has suffered an infection with BXO
will have developed a
fibrotic ring, which makes retraction difficult
or impossible. It is this
pathologically induced non-retractability
which can be correctly termed "
phimosis." To differentiate normal stages
of development, and even the physiological state of a foreskin which
has failed to dilate as a result of lack of hormones, from
pathologically-caused non-retractability, doctors have invented the term
"true phimosis." It is non-retractability caused by pathological infection with BXO that can be considered an actual problem.
Can phimosis be cured?
It is estimated that
2% of males go their entire lives without their
foreskins ever becoming retractable. How this condition can be treated
will depend on what the actual problem is. The physiological condition
where a foreskin has failed to dilate as the result of a lack of
hormones, otherwise known as
"preputial stenosis," tends to respond to
steroid cream therapy, coupled with stretching exercises and/or
stretching
devices.
Non-retractability as a result of a BXO infection, however is different,
as this is caused by a resulting fibrotic ring at the end of the
foreskin, which is
scarification that may or may not respond to steroid
cream treatment or stretching exercises.
It is non-retractability caused
by BXO infection that can be genuinely considered a problem which may
call for corrective surgery.
It should be noted that
non-retractability of the foreskin as a result
of BXO infection occurs in less than 1% of males. Additionally, it
should be noted that even when a case of "true phimosis" may require
surgical correction, it does not always entail a complete removal of the
prepuce.
There are procedures that can correct phimosis which can
preserve the foreskin and its functions. Surgical methods range from the
complete removal of the
foreskin (circumcision) to more minor operations to relieve foreskin
tightness, such as a "
dorsal slit" (AKA "
superincision") a "
ventral
slit" (AKA "
subterincision") and "
preputioplasty."
If treatment should
be necessary, it should not be done until after puberty and the male
can weigh the therapeutic options and give informed consent.(9)
How should a genuine case of phimosis be diagnosed?
In order to correctly determine that there is a real problem occurring
in a male, a learned doctor will begin by ruling a few things out.
If, for example, a child hasn't reached puberty yet, and because
non-retractability is common for this age group, the doctor should
consider that the child may be experiencing normal stages of
development.
If, for example, a child hasn't reached puberty yet,
but he was able retract his foreskin previously, it may be probable that the child may have experienced an infection with BXO.
If, for example, an adult male who has already gone through puberty
still has a non-retractile foreskin, the doctor needs to determine if
this is a physiological problem caused by a lack of hormones (preputial
stenosis), or if it is a pathological problem as a result of infection
with BXO (AKA "true phimosis").
Because non-retractibility of the foreskin can be both a normal stage of development,
and
a pathological problem, it can be very easy for doctors to make an
inadvertent, or even deliberate misdiagnosis. Particularly in countries
like the United States, where circumcision is a perceived norm, and
doctors may not be educated in the differences between normal stages of
development and phimosis as a pathological condition, it can be very
easy for doctors to say that a child is suffering a condition that may
require surgical correction, where in fact, there is actually none.
For a correct diagnosis, a doctor who is knowledgeable about the
difference between normal stages of development and non-retractability
caused by BXO infection will
correctly have the male analyzed for signs
of lesions of BXO. Then, and only then, can a doctor properly make the
diagnosis that a male child is suffering a medical problem, and that the
child may need surgery to correct the problem.
Because
non-retractability in adult males is rare, and
"true phimosis"
(pathologically induced non-retractability) even more rare, there is a
high probability that a diagnosis for "phimosis" is actually false,
especially in children, where non-retractability of the foreskin is a
part of normal development.
Iatrogenically Induced Problems
Problems with the retraction of the
foreskin may either be the result of a lack of hormones, the result of
an infection with BXO, or, they could be iatrogenically induced. (E.g.
actually caused by the doctor himself.)
It has been widely recognized by the
medical profession
for most of the 20th century that normal male infants have foreskins
which are incompletely separated from the epithelium of the glans.(17)
The foreskin cannot be retracted without tearing the fusion and
adhesions which are commonly present between the inner foreskin and the
glans penis in normal
stages of development.
In English-language medicine, there is
an absence of proper knowledge of the foreskin and its development in
the medical curriculum. According
to McGregor et al (2005), physicians often have
difficulties distinguishing between this normal, natural state of the
penis in neonates and pre-pubecent boys and pathological
phimosis caused by BXO.(17)(18) Spilsbury et al (2003) suggest that
doctors may be likely to confuse the aforementioned conditions with
pathological phimosis.(19)
Unaware of the harmless nature of the
normal, natural
state of the penis in neonates, and the presence of
adhesions in infants and pre-pubecent boys, and unaware that this can be
damaging, doctors have been known to forcibly attempt to retract
the foreskin in healthy, developing children, just to see if it
retracts, tearing natural
adhesions and/or ripping the foreskin in the process. Furthermore, they
have been known to erroneously instruct parents that a child's foreskin
needs to be retracted in order to "clean under it," arguing that they
will develop infections otherwise.(20)
Premature, forcible retraction of the foreskin is an extremely painful,
serious, and potentially permanent injury(17). It can damage the glans
and mucous inner tissue of the foreskin. Forcibly retracting a child
could result in iatrogenically induced phimosis, where the raw, open
wounds of ripped adhesions could heal and fuse together, or where a
forcibly dilated foreskin could develop scarification, resulting in a
fibrotic ring similar to the one caused by BXO infection. Additionally,
this can result in a complication known as "paraphimosis," where the
narrow foreskin strangles the penis trapped behind an enlarged glans,
thereby necessitating surgical intervention.
It must be noted here that these problems rarely present themselves in
countries where circumcision is rare or not practiced. There is simply
no epidemic of foreskin problems in countries where male children aren't
circumcised. These problems tend to suspiciously present themselves in
countries where circumcision is common, and diagnosed by doctors who
happen to specialize in child circumcision. Children may have been
circumcised to correct "problems" that either never existed, or whom
were given their problems by ignorant doctors to begin with.
It is harmful and misleading to tell parents that a child's foreskin
must be forcibly retracted. In children whose foreskins are still
adhered to the glans, or where the foreskin has not dilated to allow the
glans, this can be a harrowing experience. Forcibly retracting a
child's foreskin "to clean under it" is the equivalent of cleaning out a
girl's vagina with a pipe cleaner. Surely, a doctor who would instruct
parents to clean
out their child's vagina would be dismissed as a
lunatic. Medical associations advise not to forcibly retract the foreskin
of an infant, as this interferes with normal penile development, and may
result in scarring or injury.(21)(22).
Camille et al (2002), in their guidance for parents, state that "[t]he
foreskin should never be forcibly retracted, as this can cause pain and
bleeding and may result in scarring and trouble with natural
retraction."(23)
Simpson & Barraclough (1998) state that "
[n]o attempt should be made
to retract a foreskin in a child unless significant separation of the
subpreputial adhesions has occurred. Failure to observe this basic rule
may result in tearing with subsequent fibrosis and consequent
[iatrogenically induced] phimosis. ..."(24)
The American Academy of Pediatrics cautions parents not to retract their
son's foreskin, but suggest that once he reaches puberty, he should
retract and gently wash with soap and water.(25) The Royal Australasian
College of Physician as well as the Canadian Paediatric Society
emphasize that the infant foreskin should be left alone and requires no
special care.(26)
Summary
The facts, which are well-documented in medical literature, speak for themselves.
A foreskin that is adhered to the glans and/or will not retract is a
normal stage of development in all healthy male children in infancy. The
belief that a foreskin that is "tight" and will not retract is a
problem in male infants implies that all human male children are born
with some kind of birth defect, congenital
deformity or genetic anomaly akin to a 6th finger or a cleft.
In the great majority of males, the foreskin separates from the glans
and becomes retractable as they approach puberty, without the aid of
medical or surgical intervention.
A foreskin that will not retract in older males is rare, and may or may
not be a pathological problem. In order to determine the cause of a
non-retractile foreskin, a knowledgeable doctor who understands
anatomically correct male genitals, the normal stages of development of
healthy males, and true pathological problems of male genitalia, must
run the correct analyses in order to detect the presence or absence of
pathological lesions; then, and only then, can the doctor determine
whether the problem can be remedied with conventional medicine or by
means of surgical correction.
Even when a genuine case of phimosis that necessitates surgical
intervention presents itself, circumcision, or the full excision of the
foreskin is not always called for; there are surgical interventions
which will correct phimosis while preserving the foreskin and its
functions.
Intervention to hasten the retraction of the foreskin in otherwise
healthy, prepubescent males may actually cause iatrogenically induced
problems. The forced retraction of the foreskin may itself cause
non-retractability. Forcibly dilating the foreskin causes scar tissue to
form, which may result in a fibrotic ring at the end of the foreskin.
Breaking the natural adhesions which occur between the glans and the
foreskin during normal stages of development may cause new adhesions to
form between the glans and the foreskin, becoming fused as the raw
wounds of the broken adhesions heal together. Forcibly pulling back
naturally narrow foreskin over the glans in otherwise healthy children
may result in paraphimosis, where the narrow foreskin catches behind the
glans, preventing the foreskin from returning to its neutral position
covering the glans, ironically necessitating the need for surgical
intervention.
Conclusion
It is a shame that there is a gap in medical knowledge between the United States and other English-speaking countries. The information presented here is well-documented knowledge that all doctors need to know. This is the information that a doctor needs to be giving to parents of a male child. Anything other than this is misinformation or an outright lie.
American medical curricula is either omitting information, teaching outdated information, if not outright teaching misinformation. Efforts need to be made to bring English-language curriculum on the
foreskin, the natural stages of development and genital pathology up to
date. Doctors need to educate themselves and stop dispensing erroneous
and dangerous advice to parents. They need to learn to differentiate
between the normal stages of development in human males, and actual
pathological phimosis.
Doctors who diagnose
"phimosis" in a perfectly healthy child are either uneducated when it
comes to the foreskin and natural stages of development, or may in fact
be committing medical fraud, deliberately inventing a misdiagnosis in
order to justify surgery in a healthy, non-consenting minor, and/or
collecting medicaid funds intended for actually medically necessary
surgery.
Until American medicine undergoes this long-needed overhaul, long-term visitors to the United States ought to be warned that doctors in America are often inadvertently, or quite deliberately misinformed about anatomically correct male genital anatomy, and that taking their child to an American-trained doctor could be hazardous to their child's health.
References:
1. Gairdner D. The fate of the foreskin: a study of circumcision. Br Med J 1949;2:1433-7.
2. Spence J. On Circumcision. Lancet 1964;2:902.
3. Deibert GA. The separation of the prepuce in the human penis. Anat Rec 1933;57:387-399.
4. Øster J. Further fate of the foreskin: incidence of preputial
adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child
1968;43:200-3.
5. Catzel P. The normal foreskin in the young child. (letter) S Afr
Mediense Tysskrif [South Afr Med J] 1982 (13 November 1982) 62:751.
6. Wright J.E. (February 1994). "Further to 'the further fate of the
foreskin'". The Medical Journal of Australia 160 (3): 134–5. PMID
8295581. http://www.cirp.org/library/normal/wright2/
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8. Kayaba H, Tamura H, Kitajima S, et al. Analysis of shape and
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16137407.
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http://www.caringforkids.cps.ca/handouts/circumcision.
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26. Royal Australasian College of Physicians. (2010) Circumcision of Infant Males.
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