EUF-344; No.

of Pages 2

E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 17 ) X X X – X X X

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Point of Focus Debate: For

Phimosis in a 10-yr-old Boy Without Urinary Infection—How to

Inform Parents: For Circumcision

Marco Castagnetti a,*, Ciro Esposito b

a
Section for Pediatric Urology, University Hospital of Padova, Padua, Italy; b Department of Paediatrics, Federico II University of Naples, Naples, Italy

Phimosis is common in children [1]. The prepuce is not
retractile in almost all neonates; however, it remains so only
in a minority of boys after puberty [2]. The androgen
stimulation of the foreskin occurring at puberty is consid-
ered to account for the improvement. Similar results can be
achieved at an earlier age with topic administration of
steroids creams, which mimic androgen stimulation. The
effect of these treatments, however, can be only transient
lasting as long as the cream is applied [3].
Despite the benign behavior of phimosis in children,
many problems can occur while waiting for spontaneous
improvement to occur. The two most common complaints
are urinary symptoms, such as preputial ballooning during
voiding or local infections (ie, balanitis). Under these
circumstances, surgery can become necessary because
of the symptoms themselves, or because the recurrent
infections determine progressive scarring of the foreskin.
Also in the absence of infections, scar-like alterations of
the prepuce requiring circumcision, can occur due to the
development of balanitis xerotica obliterans (BXO), the
genital variant of lichen sclerosus et atrophicus [1]. BXO is
seldom recognized before referral to a surgeon for circum-
cision, whereas its timely diagnosis and treatment is
paramount [4,5]. Indeed, circumcision is generally cura-
tive whereas the untreated condition can extend to the
external urethral meatus or the urethra causing meatal
stenosis or urethral strictures [4,5]. In BXO patients, topic
steroids can be adjuvant to surgery, whereas they are
unlikely to be curative if used alone [5]. Finally, attempts
to pull down a narrow foreskin can cause the development
of preputial scarring unresponsive to androgen stimula-
tion at puberty.
Therefore, a 10-yr-old boy presenting at the outpatient
clinic for a phimosis can be puzzling, even though asymp-
tomatic. Spontaneous improvement can still occur, but all
the above-mentioned problems have to be ruled out. His-
tory taking is essential to appreciate previous attempts at
preputial retraction or local treatments with steroid creams
(and their effect thereof). On physical examination, assess-
ment of the stage of pubertal development (eg, Tanner
stage) is necessary to gauge whether spontaneous improve-
ment can still be expected. In postpubertal boys, a minor
preputial ring can also be bothersome, particularly during
erection, and warrants surgery. Sometimes, this ring cannot
be noticed on physical examination, but the patient may
clearly report difficulty at preputial retraction during erec-
tion. Finally, any signs of local scarring secondary to previ-
ous infections, attempts at forceful foreskin retraction, or
BXO should be looked for. These typically present like a
whitish ring in the foreskin [1].
If the tight foreskin looks otherwise normal and the
patient is still prepubertal, watchful waiting until after
puberty can be considered. Nevertheless, circumcision
can still be an option for families keen to fix the problem
once and for all. Arguments in favor of circumcision include
the following. To begin with, the chance of spontaneous
improvement decreases as the child grows older. Second,
the procedure might have some medical benefits reducing
long-life risk to develop urinary tract infections, sexually
transmitted diseases, and penile carcinoma [6]. Approxi-
mately half of the male population in the world is circum-
cised and these include men in western countries where
neonatal circumcision is promoted for its putative medical
benefits.

* Corresponding author. Section for Paediatric Urology, University Hospital of Padova, Monoblocco Ospedaliero, Via Giustiniani 2, Padua 35100, Italy.
Tel. +39 049 8212737; Fax: +39 049 8212721.
E-mail address: marcocastagnetti@hotmail.com (M. Castagnetti).

http://dx.doi.org/10.1016/j.euf.2017.06.003
2405-4569/© 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Please cite this article in press as: Castagnetti M, Esposito C, Phimosis in a 10-yr-old Boy Without Urinary Infection—How to
Inform Parents: For Circumcision. Eur Urol Focus (2017), http://dx.doi.org/10.1016/j.euf.2017.06.003
EUF-344; No. of Pages 2
2 E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 17 ) X X X – X X X
The procedure is fraught with low morbidity [6,7]. Seri-
ous complications, such as glans/penile amputation or
trapped penis due to excessive skin removal, are rare as
long as the circumcision is performed by well-trained pro-
viders [6]. Minor acute complications include bleeding (any
family history of coagulation disorders should be ruled out
carefully) and infections (a sterile technique should be
used). Unsatisfactory cosmetic results may not be as infre-
quent as one would expect for a minor procedure [8]. In the
long run, meatal stenosis requiring a meatotomy is the most
common complication occurring in about 1% of patients [8].
Two additional peculiar concerns related to circumcision
should finally be taken into account. The first is that the
procedure might adversely affect penile sexual function or
sensitivity, or sexual satisfaction. The best evidence avail-
able to date does not support this belief [9]. The second is
that an elective circumcision performed in a child without
an active clinical problem might be considered an unnec-
essary mutilation performed without patient consent, and,
as such, might violate the child’s rights to body integrity and
self-determination [10]. The dispute is mainly related to
circumcision in the infant, but suggests that, although the
responsibility of the choice lies with the parents, a 10-yr-old
boy should be involved in the decision-making whenever
possible.
Conflicts of interest: The authors have nothing to disclose.
Please cite this article in press as: Castagnetti M, Esposito C, Phimosis in a 10-yr-old Boy Without Urinary Infection—How to
Inform Parents: For Circumcision. Eur Urol Focus (2017), http://dx.doi.org/10.1016/j.euf.2017.06.003
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