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ARTICLES:
D. M. Fergusson, J. M. Lawton, and F. T. Shannon
Neonatal Circumcision and Penile Problems: An 8-Year Longitudinal Study
Pediatrics 1988; 81: 537-541 [Abstract] [PDF]
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eLetters published:

[Read eLetters] Control of confounding factors needed.
George Hill   (3 November 2004)
[Read eLetters] Balanitis and the uncircumcised male
Jake H Waskett   (12 June 2005)

Control of confounding factors needed. 3 November 2004
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George Hill,
Independent Researcher

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Re: Control of confounding factors needed.

iconbuster{at}earthlink.net George Hill

Dear Editor:

This report by Fergusson et al. has received considerable attention as it has been cited by several medical societies in their position statements on male circumcision. It is, therefore, worthy of careful examination.

Fergusson et al. find that circumcised boys have 1) more penile problems in the first year of life, while 2) uncircumcised boys have more penile problems in the span from 1 to 8 year of age. The first finding is well supported by the medical literature. The foreskin is protective1 and the removal of the foreskin is well documented to cause meatitis, meatal ulcers, and meatal stenosis.2,3

The second finding, however, is worthy of careful examination as it is counterintuitive. Fergusson et al. reported more inflammation, more phimosis, and, most curiously, an equal amount of post-circumcision infection in uncircumcised boys, as compared with circumcised boys.

The reported increase in inflammation in uncircumcised boys is especially problematical. It is not clear whether risk the inflammation is inherent in the prepuce or is caused by confounding environmental factors for which Fergusson et al. did not control. For example, forcible premature retraction of the prepuce or excesive washing4 is known to cause inflammation. The authors do not tell us what sort of hygenic care was practiced in New Zealand in those years. The prepuce of prepubertal boys should be left alone and only the outside should be washed.5 Improper hygienic care may have caused the reported high rates of inflammation in uncircumcised boys.

The reported high rates of phimosis are also deserving of some scrutiny. Most boys are born with non-retractile foreskins,6 which only gradually become retractable over a period of many years. Most boys in the 1-8 year-age-range have normal, healthy, non-retractile foreskins.7,8. Confusion by medical doctors of the normal non-retractile developing prepuce with the pathological condition of phimosis has been and remains a problem.9,10 In many cases, pathological phimosis cannot properly be diagnosed until after puberty. Fergusson et al. do not report the diagnostic standards used to diagnose phimosis among the boys in the New Zealand birth cohort. Therefore, it is unclear whether the reported incidence of phimosis was truly phimosis or misdiagnosis of a normal condition.

A later study of boys from birth to age 18 by Van Howe found substantially more penile problems in circumcised boys.11

The authors' failure to control for confounding environmental factors leave unclear whether the reported problems with the foreskin actually were caused by the simple presence of the foreskin or were the result of environmental problems such as improper hygenic care and the misdiagnosis of phimosis. In any case, the reported problems (inflammation and phimosis) were minor and so are easily and effectively treated with conservative therapy.12,13 They do not support non-therapeutic circumcision of the newborn.

George Hill

  1. Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Inf 1998;74(5):364-7.
  2. Brennemann J. The ulcerated meatus in the circumcised child. Am J Dis Child 1921;21:38-47.
  3. Freud P. The ulcerated urethral meatus in male children. J Pediatr 1947;31(4):131-41.
  4. Birley HDL, Luzzi GA, Bell R. Clinical features and management of recurrent balanitis: association with atopy and genital washing. Genitourin Med 1993;69(5):400-3.
  5. Care of the Uncircumcised Penis: Guidelines for Parents (pamphlet). Elk Grove Village, IL: American Academy of Pediatrics, 1984.
  6. Gairdner D. The fate of the foreskin: a study of circumcision. Br Med J 1949;2:1433-7.
  7. Øster J. Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish Schoolboys. Arch Dis Child 1968;43:200-3.
  8. Kayaba H, Tamura H, Kitajima S, et al. Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol 1996;156(5):1813-5.
  9. Rickwood AMK, Walker J. Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence? Ann R Coll Surg Engl 1989;71(5):275-7.
  10. Spilsbury K, Semmens JB, Wisniewski ZS. et al. Circumcision for phimosis and other medical indications in Western Australian boys. Med J Aust 2003 178 (4): 155-8.
  11. Van Howe RS. Variability in penile appearance and penile findings: a prospective study. Brit J Urol 1997;80:776-82.
  12. Edwards S. Balanitis and balanoposthitis: a review. Genitourin Med 1996;72(3):155-9.
  13. Berdeu D, Sauze L, Ha-Vinh P. Blum-Boisgard C. Cost-effectiveness analysis of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect. BJU Int 2001;87(3):239-44.
Balanitis and the uncircumcised male 12 June 2005
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Jake H Waskett,
Independent researcher
N/a

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Re: Balanitis and the uncircumcised male

jake{at}waskett.org Jake H Waskett

Editor,

Hill expresses surprise1 at the higher rates of inflammation in uncircumcised boys older than one year reported by Fergusson et al. However, this finding is well supported by other reports in the literature. Indeed, Van Howe's study,2 cited by Hill, appears to be unique in reporting lower rates in uncircumcised males (that study was limited by the fact that only 36 of the 468 boys studies were uncircumcised).

Herzog and Alvarez found greater rates of both balanitis (6% versus 3%) and irritation (4% versus 1%) in uncircumcised children, though this was not statistically significant.3

Circumcision appears to have a protective effect in adulthood. Fakjian et al. report on a study of randomly selected adult dermatology patients.4 2.3% of circumcised men were found to have balanitis, compared with 12.5% of uncircumcised men. In Wilson's study of Canadian soldiers,5 all of the balanitis cases were uncircumcised, while only 52% of the control group were uncircumcised. Hart reported that balanitis was almost entirely confined to the uncircumcised in Australian soldiers, though 74% of soldiers overall were circumcised.6 Reporting on a study of penile yeasts, Davidson reported that although similar rates were found in circumcised and uncircumcised males, circumcised men had significantly fewer symptoms.7 In another study of dermatology patients, Mallon et al. found that 84% of those with penile infections were uncircumcised, versus 52% of controls.8 The researchers calculated an age-adjusted odds ratio of 3.24 for penile skin diseases associated with the presence of the foreskin.

The foreskin is a warm, moist fold of skin,9 beneath which can be found desquamated epithelial debris, fats and proteins.10 These conditions would seem to encourage the growth of bacteria, and research has shown that is the case. Not only this, the prepuce has also been identified as the site of a diminished immune response.11

Serour et al. found a higher prevalence of pathogenic bacteria in the subpreputial space.12 Fussell et al. found that pathogenic bacteria adhere to the mucosal lining of the foreskin.13 Wiswell et al. found greater likelihood, as well as higher concentrations, of pathogenic bacteria in glans and urethral cultures taken from uncircumcised children.14 Glennon et al. found Proteus mirabilis in 22.6% of periurethral area and urethral meatus swabs from uncircumcised children, versus only 1.7% of circumcised children.15 Neubert and Lentze reported greater density of bacteria in uncircumcised males.16 Cascio et al. reported that antibiotics were ineffective at reducing bacterial colonisation of the prepuce.17 Savas et al. suggest that the prepuce acts as a faecal reservoir.18 Wijesinha et al. tested a number of boys before and after circumcision for uropathogens.19 Before circumcision, 52% had uropathogens. After, none had. Gunsar et al. reported similar findings,20 from 64% before circumcision to 10% afterwards. Bhargava and Thin report that carriage of group B streptococci may be associated with balanitis.21 This was also noted by Jackson et al.22

  1. Hill G. Control of confounding factors needed. Pediatrics. P3R Response (26 Feb 2005)
  2. Van Howe RS. Variability in penile appearance and penile findings: a prospective study. Brit J Urol. 1997; 80: 776-82
  3. Herzog LW, Alvarez SR. The frequency of foreskin problems in uncircumcised children. Am J Dis Child. 1986; 140: 254-256
  4. Fakjian N, Hunter S, Cole GW, Miller J. An argument for circumcision: prevention of balanitis in the adult. Arch Dermatol. 1990 Aug; 126: 1046-1047
  5. Wilson RA. Circumcision and venereal disease. Can Med Assoc J. 1947; 56: 54-56
  6. Hart G. Factors influencing venereal infection in a war environment. Brit J Vener Dis. 1974; 50: 68-72
  7. Davidson F. Yeasts and circumcision in the male. Brit J Vener Dis. 1977; 53: 121-122
  8. Mallon E, Hawkins D, Dinneen M, Francics N, Fearfield L, Newson R, Bunker C. Circumcision and genital dermatoses. Arch Dermatol. 2000 Mar; 136(3): 350-4
  9. Prakash S, Raghuram R, Venkatesan, et al. Sub-preputial wetness - Its nature. Ann Nat Med Sci (India). 1982; 18(3): 109-112
  10. Parkash S, Jeyakumar K, Subramanya K, et al. Human subpreputial collection: its nature and formation. J Urol. 1973; 110(2): 211-2
  11. Weiss GN, Sanders M, Westbrook KC. The distribution and density of Langerhans cells in the human prepuce: site of a diminished immune response? Isr J Med Sci. 1993 Jan;29(1):42-3.
  12. Serour F, Samra Z, Kushel Z, Gorenstein A, Dan M. Comparative periurethral bacteriology of uncircumcised and circumcised males. Genitourin Med. 1997 Aug; 73(4): 288-90
  13. Fussell EN, Kaack MB, Cherry R, Roberts JA. Adherence of bacteria to human foreskins. J Urol. 1988 Nov; 140(5): 997-1001
  14. Wiswell TE, Miller GM, Gelston HM Jr, Jones SK, Clemmings AF. Effect of circumcision status on periurethral bacterial flora during the first year of life. J Pediatr. 1988 Sep; 113(3): 442-6
  15. Glennon J, Ryan PJ, Keane CT, Rees JP. Circumcision and periurethral carriage of Proteus mirabilis in boys. Arch Dis Child. 1988 May; 63(5): 556-7
  16. Neubert U, Lentze I. The bacterial flora of preputial space. Hautarzt. 1979 Mar;30(3):149-53
  17. Cascio S, Colhoun E, Puri P. Bacterial colonization of the prepuce in boys with vesicoureteral reflux who receive antibiotic prophylaxis. J Pediatr. 2001 Jul; 139(1): 160-2
  18. Savas C, Cakmak M, Yorgancigil B, Bezir M. Comparison of preputial sac and urine cultures in healthy children. Int Urol Nephrol. 2000; 32(1): 85-7
  19. Wijesinha SS, Atkins BL, Dudley NE, Tam PK. Does circumcision alter the periurethral bacterial flora? Pediatr Surg Int. 1998 Mar; 13(2-3): 146-8
  20. Gunsar C, Kurutepe S, Alparslan O, Yilmaz O, Daglar Z, Sencan A, Genc A, Taneli C, Mir E. The effect of circumcision status on periurethral and glanular bacterial flora. Urol Int. 2004; 72(3): 212-5.
  21. Bhargava RK, Thin RN. Subpreputial carriage of aerobic micro-organisms and balanitis. Br J Vener Dis. 1983 Apr; 59(2): 131-3
  22. Jackson DH, Hinder SM, Stringer J, Easmon CS. Carriage and transmission of group B streptococci among STD clinic patients. Br J Vener Dis. 1982 Oct; 58(5): 334-7

Conflict of Interest:

None declared