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These are more than twice as frequent in uncircumcised boys [117].
Phimosis: This is generally regarded as narrowing of the foreskin orifice so as to prevent retraction of the foreskin over the glans. Phimosis is normal in very young boys, but is gone by age 3 in 90%. If still present after age 6 it is regarded as a problem. Phimosis affects at least 10% of uncircumcised males, the reported rates being: 20%, as seen by Gairdner in 5-13 year-olds, 8% at age 8 in Danish boys [259], 14% in British soldiers [258], and 9% in German youths [304] and men [309]. Although a rate of 50% in men in Japan [254] and Bali [44] has been reported, a more recent study found that by age 11-15, 77% had a retractable prepuce [166]. There is also the condition of pathological phimosis from secondary cicatrization of the foreskin orifice arising from balanitis xerotica obliterans (BXO), and for which a rate of 1% has been reported [292]. However, a recent prospective study involving 1178 boys who presented consecutively over the decade 1991-2001 and were then treated by circumcision found by histological examination that the incidence was 40%, with incidence peaking in at age 9-11 (76%), BXO being the cause of the secondary phimosis in all of these [188]. In the study as a whole, 19% of boys had early, 60% intermediate and 21% late form of BXO. The narrow foreskin opening causes urinary obstruction that can be partial or complete. Backward pressure to the kidney may impede its function and lead to high blood pressure, which is associated with increased risk of heart attack and stroke. In one series in Boston of pediatric BXO, amongst 41 patients, 52% had been referred for phimosis, 13% for balanitis and 10% for buried penis [122]. Of these, 46% underwent curative circumcision, 27% also had BXO involvement of the meatus and had not only circumcision, but meatotomy or meatoplasty, and 22% required extensive plastic surgery of the penis, including buccal mucosa grafts, demonstrating a more severe and morbid clinical course. Phimosis also increases risk of penile cancer (discussed later) and treatment by complete circumcision to prevent this outcome is advocated. It can be treated with topical steroid creams, but these need to be applied for at least a month, are not completely successful, can lead to iatrogenic Cushing's syndrome, adrenal suppression, delayed growth, skin atrophy, may need to be repeated, and of course offer no benefit in prevention of other conditions associated with having a foreskin [214, 406, 407].
Paraphimosis: This is when the retracted foreskin cannot be brought back again over the glans and is a very painful problem, relieved by circumcision or slitting the dorsal surface of the foreskin.
Elderly men: In elderly men, infections and pain from balanoposthitis (see below), phimosis and paraphimosis are seen and carers report problems in achieving optimal hygiene in uncircumcised men. The need for an appliance for urinary drainage in quadraplegics and in senile men is facilitated if they are circumcised. Nursing home staff have particular difficulty performing their duty of washing the genital area of uncircumcised elderly men, particularly with the onset of dementia. Such men can react violently towards staff or family during attempts to wash under the foreskin. This is an under-recognized problem and far from the mind of a parent or neonatologist when considering circumcision for an infant, so that information on the gerontological perspective should also be given at birth [114].
Frenular chordee: This results from an unusually thick and often tight frenulum and prevents the foreskin from fully retracting, being present in a quarter of all uncircumcised males [137]. This problem can be solved by excising the frenulum during a circumcision. Frenoplasty (removing just the tight frenulum) is also possible.
Psychological sequelae: Follow-up 5 years later of 117 boys circumcised for phimosis, balanitis scarring of the prepuce, or ballooning when urinating found that 95% expressed complete satisfaction and the only psychological effect was slight shyness in the school change-room in 9% of boys in this Swedish study [339, 340]. The study showed that parents had nothing to fear for their son's psychological well-being from circumcision.
