Editorial comment


This paper clearly recognises the current controversies surrounding childhood circumcision and recommends preservation of the prepuce whenever possible, an approach to be applauded and that is now adopted by most paediatric specialists in 2003. The authors are to be congratulated for investigating patient satisfaction after preputial plasty, and report good results, with > 80% of their patients happy with both the functional and cosmetic results. They also report a very low complication rate of 2%, but it is unclear how carefully this was assessed in the postoperative questionnaire. However, in a previous prospective study of single-incision dorsal preputial plasty, significant complication rates were reported, i.e. infected/inflamed penis (10%), huge oedema (2%), recurrent adhesions (2%), unretractile foreskin (4%) and a poor cosmetic result (2%) [1]. These complication rates were significantly lower than for circumcision, but still inform the reader that preputial plasty carries the potential for significant morbidity, a fact that must weigh heavily when recommending it for controversial or poorly founded indications.

The authors state that foreskin problems should be solved before school age, and on examining their patient population it would seem that most interventions (70%) were for preputial ballooning or asymptomatic unretractile foreskins in boys with a mean age of 5.8 years. This is a cause for concern; in his classic paper, Oster [2] stated; ‘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’. Oster showed that preputial adhesions interfering with complete retraction were present in 63% of 6–7-year-olds, decreasing to 3% in 16–17-year-olds; no adhesions were noted in 95 17-year-olds. Rickwood [3] also stated; ‘During infancy, an unretractile foreskin is often associated with ballooning… It is self-limiting, resolving as the prepuce naturally becomes more retractile’. This would also reflect my clinical experience and on the basis of the evidence available, no active measures are required for uncomplicated unretractile foreskins or for preputial adhesions. From these findings it would seem that most patients undergoing triple-incision plasty would have achieved completely retractile foreskins with no surgery if they were left to develop normally.

Although this paper acknowledges the potential for spontaneous resolution of these ‘foreskin problems’, many boys were still subjected to surgical intervention because ‘parents wanted an immediate solution’. I would suggest that, considering the evidence base, what is required here is parent education and reassurance rather than surgery, saving the child from trauma and the over-stretched health services from unnecessary costly interventions.