Trends in pediatric circumcision in Belgium and the Brussels University Hospital from


Indications for pediatric circumcision



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Indications for pediatric circumcision


The British Association of Peadiatric Surgeons advises that there is rarely a clinical indication for circumcision.30 The only strictly medical reasons to circumcise a boy are pathologic phimosis and recurrent troublesome episodes of balanoposthitis.14 Other reasons to circumcise are the preventive health benefits, religious or cultural motives and social determinants.1

Phimosis


Phimosis is a condition in which the foreskin cannot be retracted over the glans penis.31 There are two types of phimosis: physiologic and pathologic phimosis. Around 96% of males at birth have a non-retractile foreskin.2 This is a physiologic phimosis and results from fused mucosa of the glans penis and the inner lining of the foreskin.32 It is a common condition in boys up to 3 years old and also occurs in older age. The foreskin becomes gradually retractable secondary to keratinisation of the inner epithelium and intermittent erections.33 Only 4% of the newborns have a fully retractable foreskin. In 20% of 2 year olds, the foreskin cannot be retracted over the glans.2 8% of 6-7 year olds and 1% of 16-17 year olds have a non-retractable foreskin.34

A phimosis is pathologic when the failure to retract is secondary to distal scarring of the prepuce. This appears as a contracted white fibrous ring around the preputial orifice.31 The incidence of pathologic phimosis is 0.4 per 1000 boys per year or 0.6% of boys are affected by their 15th birthday.35 The possible consequences of a pathologic phimosis are pain, skin irritation, local infections, bleeding, dysuria, hematuria, frequent episodes of urinary tract infections and painful erections.36

A physiologic phimosis requires no medical treatment. A 6- to 8- week course of topical steroids can help to speed up the progress, but this is not needed in all cases. A proper reassurance of normalcy and reinforcement of correct preputial hygiene are required.31,37

A pathologic phimosis requires a medical treatment. Since the latter half of the 19th century, surgical correction has been the standard therapy.5 This surgery includes circumcision, preputioplasty, dorsal slit, frenolotomy and meatoplasty.36 For more than 2 decades, topical steroids have been tried as an alternative for surgical correction and it has showed good results.38 In randomized controlled trials the efficacy figures of a 4 to 8 week treatment with topical steroids vary from 65 up to 95%.39 Studies also show that it is a less expensive alternative for surgery. The reduction in costs from a treatment with topical steroids ranges from 27.3% to 75%.40,41,42 The treatment is well tolerated. Neither local nor systemic side effects are seen. Topical steroid application does not significantly alter the morning blood level of cortisol.33,37,43





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