The American Academy of Pediatrics, Elk Grove Village, Ill, has recommended that routine neonatal circumcision be discontinued and that physicians "provide parents with information pertaining to the long-term effects of circumcision and non-circumcision."[1] As circumcision has been almost universally practiced in the United States, there is little awareness of the long-term effects of noncircumcision. A review of the British literature provides some data on the frequency of phimosis (4% to 10%),[2] paraphimosis (0.996 of male child hospital admissions),[3] and adhesions (33% of school age children).[2] There are no data on the frequency of balanitis. We feel that a knowledge of the frequency of balanitis is essential before parents can be properly counseled on the risks and benefits of circumcision. Therefore, we surveyed a group of uncircumcised patients to determine the frequency of problems ef the foreskin likely to occur in uncircumcised children.
Patients and Methods
We performed a retrospective survey of the frequency of complications among noncircumcised children, using patients circumcised at birth as a control group. The study was carried out in two primary care clinics serving an inner-city population. We questioned the parents of all boys between the ages of 4 months and 12 years attending the clinics for health supervision visits. The following information was obtained: (1) if and when the child was circumcised, if done after the newborn period, and why it was done then; (2) if the child had ever had any problems with the penis, specifically redness, swelling, pus, or sores; (3) if the child had had problems and whether he had been seen by a physician for the problem; and (4) the children were examined for the presence of phimosis (nonretractable foreskin) or adhesions. For cases in which complications were reported, we reviewed the medical record to confirm the diagnosis. Only those cases in which the diagnosis, was confirmed were included.
Balanitis was defined as redness and swelling, with or without pus, of the entire foreskin or glans. All patients with balanitis had been seen and treated by a physician. Redness without swelling or pus was defined as irritation. Adhesions were considered to be a complication if the child had made a medical visit for them or if the adhesions had ruptured, causing bleeding or irritation. Phimosis was considered to be a complication only when a patient had symptoms, such as dysuria, that were attributed to the phimosis by a physician. A circumcision performed on an older child for "phimosis" was not considered a complication unless the child had been symptomatic.
Results were analyzed for statistical significance using the X2 method.
Results
A total of 545 patients were enrolled in the study. There were 272 uncircumcised patients and 273 who circumcised at birth. The circumcision status by ethnic group is shown in Table 1. The majority of Hispanics (80%) were not circumcised; the situation was reversed in other ethnic groups.
Table 1: Circumcision Status by Ethnic Group
| No. (%) | ||||
|---|---|---|---|---|
| Hispanic | Black | Other | Total | |
| Circumcised | ||||
| Birth | 44 (19) | 185 (75) | 44 (70) | 273 (50) |
| Later | 9 (4) | 11 (5) | 2 (3) | 22 (4) |
| Uncircumcised | ||||
| Uncircumcised | 183 (77) | 50 (20) | 17 (27) | 250 (46) |
| Total | ||||
| Total | 236 (100) | 246 (100) | 63 (100) | 545 (100) |
The types and frequencies of complications are shown in Table 2. Complications occurred in 14.3% of the uncircumcised and in 5.9% of the circumcised children (P=.001). Balanitis was the most common complication, having occurred in 5.9% of the uncircumcised and 2.9% of the circumcised children (P = not significant). Of the 24 patients with balanitis, 11 were treated with oral antibiotics; the rest were treated with topical therapy. Paraphimosis occurred in two patients and symptomatic phimosis in eight. Irritation was found more commonly among the uncircumcised children, but problems with adhesions were found equally in both groups. Although not all reported episodes of complications were seen by a physician, 78% were. Most complications that were not seen were classified as irritation. The frequency of medical visits was significantly higher in the uncircumcised group (10.3% vs 5.5%, P=.05).
Table 2: Complications
| No. (%) | ||
|---|---|---|
| Uncircumcised | Circumcised | |
| Total patients | 272 | 273 |
| Complications | ||
| Balanitis | 16 (5.9) | 8 (2.9)* |
| Irritation | 10 (3.6) | 3 (1.1)* |
| Adhesions | 4 (1.5) | 4 (1.5) |
| Phimosis | 7 (2.6) | 1 (0.4) |
| Paraphimosis | 2 (0.7) | 0 (0) |
| Total complications | 39 (14.3) | 16 (5.9)* |
| Medical visits | 28 (10.3) | 15 (5.5)* |
*P <= 0.05
Since this was a retrospective survey, we could not determine the annual incidence of complications. When calculated by patient-years of exposure, the frequency of complications in the uncircumcised group was 40/1,000 patient-years and the frequency of medical visits was 29/1,000 patient-years. Among the circumcised patients, the frequency of complications was 16/1,000 patient-years, and of medical visits, 15/1,000 patient-years. The relative risk of complications in the uncircumcised group was 2.4 times that of the circumcised group; for balanitis the relative risk was 2.0 times that of the circumcised group. Complications occurred in all age groups at similar rates.
Hispanics reported more complications, both in the circumcised and uncircumcised groups. Among the uncircumcised children, Hispanics had a complication rate of 17.2% vs 7.5% for all others (P =. 05). Among the circumcised children, the Hispanics also had a higher complication rate; 13.6% vs 4.3%. The rate of medical visits was the same in all ethnic groups; of the total complications reported by Hispanics, 77% had made a medical visit, whereas among the non-Hispanics, 81% had made a medical visit.
Of the patients who were not circumcised at birth (N=272), 22 patients (8%) were circumcised later. Eleven circumcisions were done for medical reasons: five for phimosis, three for balanitis, one for chordee, one for multiple contaminated urine cultures, and one because the child was "unable to void." Eleven were done without medical indication.
The hygiene of the patients was generally good. Only 11% of the uncircum cised and 7% of the circumcised children were described as having fair or poor hygiene (P = not significant).
The prevalence of phimosis on physical examination is shown in Table 3. The prevalence was highest in infants 1 year of age or less (25%) and decreased progressively to 9% in school-age children. Only 5% of the children had significant adhesions on physical examination.
Table 3: Phimosis by Age
| % | |||
|---|---|---|---|
| Age | Total No. | Retractable | Phimosis |
| 6 mo | 16 | 75 | 25 |
| 1 yr | 51 | 73 | 27 |
| 2 yr | 41 | 81 | 19 |
| 3 yr | 30 | 87 | 13 |
| 4 yr | 28 | 89 | 11 |
| 5 yr | 28 | 93 | 7 |
| 6-12 yr | 65 | 91 | 9 |
Comment
There are no previous population based studies of the frequency of balanitis in noncircumcised children. A report from England[4] states that "most school-age children suffer from balanitis," but no evidence is given to corroborate this statement. Osborn et al[5] surveyed a group of US pediatricians and found that they estimated the frequency of balanitis to be from 0% to 10%. The frequency that we found (4%) falls within these limits. We found balanitis was twice as frequent among the uncircumcised as the circumcised children, but the difference was not statistically significant.
Minor problems (irritation, adhesions) were more common in the uncircumcised group, but the frequency was low in both groups. Metcalf et al,[6] in a survey of 230 circumcised children, found that 13% reported complications. More than half of these problems were adhesions. Other problems were meatitis, poor hygiene, and phimosis requiring revision of circumcision. We found that only 3% of circumcised children had complications other than balanitis, but we did not include poor hygiene as a complication, nor did we consider adhesions a problem unless a medical visit was made because of them.
Many people feel that proper hygiene will prevent balanitis and other problems with the foreskin, although this has never been documented. But hygiene is notoriously difficult to enforce, particularly in such a "sensitive" area. We found no significant difference in penile hygiene between the circumcised and the uncircumcised. Metcalf et al[6] reported concerns about hygiene in 3% of mothers of boys who had been circumcised. Osborn et al[5] found that even pediatricians are confused about proper hygienic care for the uncircumcised. A recent publication of the American Academy of Pediatrics[7] states that it is not necessary to retract the foreskin in order to clean it: "Leave the penis alone." The American College of Obstetricians and Gynecologists disagrees.[8]
The natural history of the uncircumcised foreskin has been documented by Gairdner[3] and Oster.[2] Gairdner[3] found that 50% had a fully retractable foreskin by age 1 year and 80% by age 2 years. Oster[2] found 96% of schoolboys had a fully retractable foreskin. Our results were similar.
The major limitation of this study is that of any retrospective study -- reliance on the history. We eliminated the risks of overreporting by reviewing the patients' records and only including those cases in which the diagnosis of balanitis was confirmed. But underreporting surely occurred and the true frequency of complications may be higher than we have found. As this should apply to both the circumcised and the uncircumcised, the relative risk of complications would not be expected to change.
Another limitation of this study is that, as the decision to circumcise is mainly a cultural one, our uncircumcised patients were largely from one ethnic group. Ethnic group was as important as circumcision status in determining the frequency of complications; Hispanics reported more complications in both the circumcised and uncircumcised groups. We can only theorize about the reasons behind this. Because utilization of medical services is not higher for Hispanics[9,10] and hygiene was found to be similar in Hispanics and non-Hispanics, perhaps Hispanic mothers are more preoccupied with such problems and more likely to remember and report them. Further prospective studies must be done on a broader population group when there are larger numbers of uncircumcised children. Our data show that, in all ethnic groups, uncircumcised children do have more complications, although the numbers are too small to reach statistical significance.
Pediatricians should expect to see more patients with balanitis and irritation of the foreskin when more children are not circumcised. Parents should be aware that such complications may occur, but that they are neither serious nor life threatening.
References
- Committee on the Fetus and Newborn. Report of the ad hoc task force on circumcision. Pediatrics 1975;56:610-611.
- Oster J. Further fate of the foreskin. Arch Dis Child 1968;43:200-203.
- Gairdner D. The fate of the foreskin: A study of circumcision. Br Med J 1949;2:1433-1437.
- St John Hunt D, Newill RGD, Gibson OB. Three Englishmen favor circumcision and why they do so. Pediatrics 1977;60:563-564.
- Osborn LM, Metcalf TJ, Mariani EM. Hygienic care in uncircumcised infants. Pediatrics 1981;67:365-367.
- Metcalf TJ, Osborn LM, Mariani EM: Circumcision: A study of current practices. Clin Pediatr 1983;22:575-579.
- Care for the Uncircumcised Penis. Elk Grove Village, Ill, American Academy of Pediatrics, 1984.
- Circumcision: A Personal Choice. Washington, DC, American College of Obstetricians and Gynecologists, 1984.
- Gilman SC, Bruhn JG. A comparison of utilization of community primary health care and school health services by urban Mexican-Americans and Anglo elementary school children. Med Care 1981;19:223-232.
- Roberts RE, Lee ES. Medical care by Mexican-Americans: Evidence from the Human Population Laboratory studies. Med Care 1980; 18:266-281.
- Oster J. Further fate of the foreskin. Arch Dis Child 1968;43:200-203.
Accepted for publication Oct 16, 1985.
From the Division of Ambulatory Pediatrics, The Children's Hospital, Boston, and the Department of Pediatrics, Harvard Medical School, Boston. Reprint requests to Comprehensive Child Health Program, The Children's Hospital, 300 Longwood Ave, Boston, MA 02115 (Dr Herzog).
