Here are a few nuggets of information regarding physiologic phimosis for the non-informed urologist (can't believe he's a specialist!!!!). Naturally, these studies come from more foreskin-friendly countries.
1. From AAP (Care of the Uncircumcised Penis, Elk Grove Village, IL: American Academy of Pediatrics, 1999.)
"What is foreskin retraction? Foreskin retraction occurs when the foreskin can be pulled away from the glans toward the abdomen. This process happens on its own. When it happens is different for every child. Most boys will be able to retract their foreskins by the time that they are 18 years old... Caring for your son's uncircumcised penis requires no special action. Remember, foreskin retraction will occur naturally and should never be forced."
A few abstracts from PubMed (bold-face mine):
2. Int J Urol. 2006 Jul;13(7):968-70. Foreskin development before adolescence in 2149 schoolboys. Hsieh TF, Chang CH, Chang SS.
Department of Urology, China Medical University Hospital, Taichung, Taiwan.
BACKGROUND: We examined the external genitalia of 2149 elementary schoolboys in the suburban area of Taichung in Taiwan for an understanding of foreskin development before adolescence. METHODS: The study's subjects comprised 692 first-grade boys, 725 fourth-grade boys, and 732 seventh-grade boys. The foreskin's condition was classified as: type I (normal prepuce), type II (adhesion of prepuce), type III (partial phimosis), type IV (phimosis) and type V (circumcised foreskin). Other abnormalities of the genitalia also were recorded. All of the examinations were performed by the same urologist. RESULTS: The incidence of type I foreskin was 8.2% in first-grade boys, 21.0% in fourth-grade boys, and 58.1% in seventh-grade boys. The incidence of type IV foreskin was 17.1% in first-grade boys, 9.7% in fourth-grade boys, and 1.2% in seventh-grade boys. Only one boy had balanoposthitis. Other abnormalities included inguinal hernia (n = 2), hydrocele (n = 12), cryptorchitism (n = 8), varicocele (n = 22), and subcoronal-type hypospadia (n = 1). CONCLUSIONS: Physiological phimosis declines with age. Most boys with phimosis in this study did not require treatment.
3. BJU Int. 1999 Jul;84(1):101-2.The incidence of phimosis in boys.Shankar KR, Rickwood AM. Department of Paediatric Urology, Alder Hey Children's Hospital, *********, UK.
OBJECTIVE: To establish the incidence of pathological phimosis in boys. PATIENTS AND METHODS: A 2-year review of circumcisions was performed for phimosis among a known population of boys, with the histological findings of the circumcision specimens assessed. RESULTS: Sixty-two boys (all but one aged 5-14 years) had typical pathological (cicatrizing) phimosis and among the 51 circumcision specimens examined histologically, 43 (84%) showed appearances of balanitis xerotica obliterans. During the same period, 30 boys were circumcised for developmental unretractability of the foreskin ('physiological phimosis').
CONCLUSIONS: The incidence of pathological phimosis in boys was 0.4 cases/1000 boys per year, or 0. 6% of boys affected by their 15th birthday, a value lower than previous estimates and exceeded more than eight-fold by the proportion of English boys currently circumcised for 'phimosis'.
4. Hinyokika Kiyo. 2004 May;50(5):305-8. Preputial development in Japanese boys. Ishikawa E, Kawakita M. Department of Urology, Ishikawa clinic.
The natural course of preputial development is still not clearly understood. The preputial retractability was evaluated in 242 Japanese boys. The incidence of having a retractable prepuce gradually increased with age from 0% at age 1 year to 77% by the age of 11 to 15 years.
In 48 boys, preputial development was followed up for 2 to 10 years with the self-retract maneuver. Non-retractable prepuce was found in 9 boys, which then became retractable within 2-7 years. The prepuce became retractable in most of the boys with balanoposthitis. In conclusion, forced retraction or circumcision is unnecessary for phimosis in boys with or without balanoposthitis.
5. Zhonghua Nan Ke Xue. 2006 Mar;12(3):249-50. Analysis of shape and retractability of the prepuce in 1,015 Chinese boys aged from 0 to 18 years old. Wang MH, Wang ZX, Sun M, Jiang X, Hu TZ. Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdou, China. email@example.com
OBJECTIVE: To evaluate the characteristics of the preputial development in Chinese boys and indications as well as occasion of circumcision. METHODS: The shape and retractability of prepuce were evaluated in 1,015 Chinese boys from 0 to 18 years old without heteroplasia of prepuce and penis. RESULTS: Ratio of children with phimosis decreases progressively with increasing age, from 64.09% in the first group (0 approximately 3 years old) to 7.66% in the fourth group (11 approximately 18 years old). CONCLUSION: Phimosis and incomplete separation of the prepuce is normal in the neonate and infant. Prepuce will separate from the glans progressively till adolescence, so it's unnecessary to perform circumcision for them when without any complications.
6. Circumcision for phimosis and other medical indications in Western Australian boys.Spilsbury K, Semmens JB, Wisniewski ZS, Holman CD.
Centre for Health Services Research, School of Population Health, University of Western Australia, 35 Stirling Highway, Crawley, WA 6009. firstname.lastname@example.org
OBJECTIVE: To investigate the incidence rate of circumcision for phimosis and other medically indicated reasons in Western Australian boys from 1 January 1981 to 31 December 1999. DESIGN AND SETTING: A population-based incidence study using hospital discharge data of all circumcisions performed in all WA hospitals during the study period. MAIN OUTCOME MEASURES: Changes in the incidence rate of circumcision for medically indicated reasons. RESULTS: The rate of medically indicated circumcisions increased in boys aged less than 15 years during the study period. Phimosis was the most common medical indication for circumcision in all age groups. The rate of circumcision associated with phimosis was eight times that associated with balanoposthitis and 21 times that of balanitis xerotica obliterans. Boys aged less than five years had the highest rate of circumcision to treat phimosis, at 4.6 per 1000 person-years, representing about 300 circumcisions per year. Boys aged less than five years living in country areas were 1.5 times more likely to be circumcised for phimosis than boys living in metropolitan Perth. CONCLUSION: The rate of circumcision to treat phimosis in boys aged less than 15 years is seven times the expected incidence rate for phimosis. Many boys are circumcised before reaching five years of age, despite phimosis being rare in this age group.
7. Acta Paediatr Jpn. 1997 Aug;39(4):403-5. Phimosis of infants and young children in Japan.Imamura E. Department of Pediatrics, International Medical Center of Japan, Tokyo, Japan.
The prepuce and glans was examined in 4521 healthy infants and young children with a birthweight over 2600 g. There were 3238 infants aged 1-12 months and 1283 children aged 3 years. There is no custom of circumcision in Japan. The term phimosis implies the adhesion of the prepuce and glans, which cannot be separated by manipulation. Phimosis was found in 88.5% of infants aged 1-3 months, and the corresponding figures at the ages of 4-6 months, 7-9 months, 10-12 months and 3 years were: 74.4, 63.9, 58.0 and 35.0%, respectively.
However, cases where the prepuce could be retracted by gentle manipulation were found in 3.0% of infants aged 1-3 months, 19.9% of those aged 10-12 months and increased to 38.4% of children aged 3 years, which exceeded the rate of phimosis. The complete adhesion of prepuce and glans was found in many infants, and a small space between the prepuce and glans was observed in some cases of 3-year-old boys. The smegma was notable in only 16 cases (0.5%) of infants and in 5 cases (0.4%) of the 3-year-olds. Balanoposthitis was found in only one case of the 3-year-olds. It is not recommended to separate the foreskin by manipulation, which sometimes leads to bleeding or paraphimosis. And it is not necessary to surgically correct phimosis in infancy and early childhood except in the case of accompanying urological disturbance.
8. J Urol. 2003 Mar;169(3):1106-8. Treatment of phimosis with topical steroids in 194 children.Ashfield JE, Nickel KR, Siemens DR, MacNeily AE, Nickel JC. Department of Urology, Queen's University and Kingston General Hospital, Ontario, Canada.
PURPOSE: Topical steroids have been advocated as an effective economical alternative to circumcision in boys with phimosis. We evaluated the effectiveness of topical steroid therapy as primary treatment in 194 patients with phimosis. METHODS: Between January 1996 and November 2000, 228 boys 16 years old or younger were referred for consideration of circumcision. When intervention was determined to be necessary, a 6-week course of topical steroids was used as primary treatment. Efficacy of treatment was evaluated at 3 months from initiation of therapy. RESULTS: Of the 228 patients 15 had such a mild degree of phimosis that no intervention was believed to be necessary, 19 were scheduled directly for circumcision due to cosmetic reasons, parent wishes, or severe phimosis with associated voiding problems and the remaining 194 received topical steroids as primary treatment. Of these 194 patients 25 had coexisting balanitis and 4 had a history of urinary tract infection. Conservative treatment was successful in 87%, 88% and 75% of patients with phimosis alone, coexisting balanitis and history of urinary tract infection, respectively. Overall, circumcision was avoided in 87% of patients treated with topical steroids.
CONCLUSION: Topical steroids are becoming the standard conservative measure for treating phimosis. Our study supports this trend, with an overall efficacy of 87%.
9. Pediatrics. 1998 Oct;102(4):E43. Cost-effective treatment of phimosis.Van Howe RS. Department of Pediatrics, Marshfield Clinic-Lakeland Center, Minocqua, WI 54548, USA.
OBJECTIVE: To determine the most cost-effective treatment for phimosis. DESIGN: The costs of three treatment strategies for treating phimosis were evaluated using a decision-tree analysis. Three therapeutic approaches were considered: circumcision, preputial plasty (the use of plastic surgical techniques to enlarge the preputial opening without removing tissue), and topical therapy with steroids and nonsteroidal antiinflammatories. Published failure and complication rates were used to calculate the cost per case. Outcome Measures. Cost in dollars to treat each case of phimosis. RESULTS: Topical steroid therapy was the most cost-effective strategy, costing between $758 and $800 per case. Preputial plasty cost between $2515 and $2580 per case. Circumcision cost between $3009 and $3241 per case. CONCLUSIONS: The most cost-effective management for treating phimosis is to initiate topical therapy. Daily external application from the tip of the foreskin to the glandis corona with betamethasone 0.05% cream for 4 to 6 weeks has been demonstrated to be very effective, resulting in a 75% savings compared with circumcision. Surgical intervention should not be considered until topical therapy has been given an adequate trial. When contemplating surgery, the lower morbidity, lower costs, and tissue preservation of preputial plasty may make it preferable.