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"