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Pediatric Urology

Prevalence of Phimosis in Males of All


Ages: Systematic Review
Brian J. Morris, Jim G. Matthews, and John N. Krieger
CONTEXT Phimosis is considered virtually universal in newborn males and likely to resolve within a few
years. Persistent phimosis can result in pain, sexual dysfunctions, increased risk of penile inflamma-
tory conditions and penile cancer. There are two forms − primary phimosis and secondary phimo-
sis − the latter often representing a consequence of lichen sclerosis, diabetes and obesity.
OBJECTIVES To conduct a systematic review to determine the prevalence of phimosis at different ages.
DATA SOURCES PubMed, Google Scholar, the Cochrane Library, and bibliographies of original studies were
searched using the keyword phimosis.
STUDY Studies containing original data on phimosis at any age.
SELECTION
DATA Two reviewers independently verified study design, extracted data and rated studies for quality.
EXTRACTION
RESULTS Forty-three eligible studies were included: 27 from PubMed, 4 from Google Scholar, and 12 from
bibliography searches. Phimosis was reported in most newborns, then gradually decreased in preva-
lence. Most studies did not differentiate primary from secondary phimosis, so values reported were
net phimosis prevalence. There were 13 studies with data for males age ≥18 years. In all, 962 of
17,136 men had been diagnosed with phimosis (range 0.5%−13%). A random effects model
found risk of phimosis in men was 3.4% (95% CI 1.8−6.6).
CONCLUSION Phimosis takes many years to resolve. Apart from spontaneous resolution, clinical interventions also
contribute to the gradual reduction in prevalence among uncircumcised boys. The wide range of phi-
mosis prevalence reported in adulthood may reflect variability in the extent of foreskin-preserving treat-
ment of phimosis in different study cohorts. UROLOGY 135: 124−132, 2020. © 2019 Elsevier Inc.

P
himosis is a common problem in adult and pediat- it causes pain or difficulty with erections and sexual pene-
ric urology.1 It is a condition in which the prepuce tration in adolescence and adulthood. Phimosis increases
cannot be retracted over the glans penis owing to risk of inflammation of the foreskin and underlying glans
narrowing of the preputial orifice and/or adhesions (balanoposthitis), urinary retention, urinary tract infections
between the glans and the prepuce. (UTI), and penile cancer.
Most boys are born with nonretractable foreskins, con- The aim of the present study was to conduct the first sys-
sidered to be “physiological phimosis.” Adhesions between tematic review to determine the overall prevalence of phi-
the prepuce and glans normally separate gradually with mosis in males of different ages. Such an evaluation of
growth, often with few if any adverse effects.2,3 Ballooning research findings would permit a better understanding of the
on urination can contribute to resolution of physiological natural history and consequences of this condition, as well
phimosis. Phimosis may be considered “pathological” when as provide better guidance for clinicians, better recommen-
dations for parents and patients, and improve recommenda-
tions for public health policy.
Financial Disclosure: Brian J Morris is a member of a not-for-profit professional, gov-
ernment-registered, medical association, the Circumcision Academy of Australia, which
makes available on its website evidence-based educational material on male circumcision,
together with contact information about medical practitioners who perform circumcision in MATERIALS AND METHODS
Australia. He does not receive income from this organization. John N Krieger provided
advice and supported the legal help to University of Washington for the patenting of a cir- Search Strategy and Data Abstraction
cumcision device. He did not receive any income from this.
Searches were conducted by the first and last authors, each of
Funding: None.
From the School of Medical Sciences and Bosch Institute, University of Sydney, New whom is experienced in publication of systematic reviews. All rel-
South Wales, Australia; the Sydney Informatics Hub, University of Sydney, New South evant published data, of any appropriate study design and involv-
Wales, Australia; and the University of Washington School of Medicine, Department of ing any age, race, and religion, were included. Owing to
Urology, Seattle, WA inconsistent and poorly documented diagnostic criteria, we judged
Address correspondence to: Brian J. Morris, D.Sc., Ph.D., School of Medical Scien-
ces, Building F13, Sydney Medical School, University of Sydney, Sydney, New South
it best to include all studies reporting a diagnosis simply of phimo-
Wales 2006, Australia. E-mail: brian.morris@sydney.edu.au sis. Sequential searches involved PubMed, Google Scholar, and
Submitted: August 14, 2019, accepted (with revisions): October 15, 2019 the Cochrane Central Register of randomized controlled trials
124 https://doi.org/10.1016/j.urology.2019.10.003 © 2019 Elsevier Inc.
0090-4295 All rights reserved.
(RCT) for articles using the keyword "phimosis" on June 26, estimator for t 2, logit transformation, Clopper-Pearson confi-
2019. Titles and abstracts were examined and the full texts of dence interval for individual studies, continuity correction of 0.5
articles with the potential to meet our inclusion criteria were in studies with 0 cell frequencies (this was only used to calculate
examined. Bibliographies were studied to identify further relevant individual study results).
articles. Articles containing original data on general population
prevalence of phimosis in uncircumcised males were included.
Inclusion criteria included English language articles or foreign RESULTS
language articles having an English-language abstract and/or main Figure 1 summarizes the search strategy and results in accord with the
text containing the necessary data. Articles on phimosis in PRISMA statement.9 Table 1 provides a chronological list of the
females, animals or ophthalmology were excluded, as were articles articles retrieved, together with a summary of the findings of each.2-
on paraphimosis, hypospadias, treatment of phimosis, and phimo- 4,10-49
These were sourced as follows. The PubMed search yielded
sis in males with medical conditions in which phimosis is more 1455 “hits,” of which 272,4,14,17,18,20,21,23-25,27-30,33-35,37-39,41-
common (namely penile cancer4,5). Most studies did not report 43,45,46,48,49
fulfilled the inclusion criteria. Google Scholar yielded
on nature of phimosis and appeared to have included both physio- 4 further articles.3,11,22,26 The Cochrane database yielded no further
logical and pathological phimosis. We quoted from each article to results. Thirteen additional publications10,12,13,15,16,19,31,32,36,40,44,47,50
indicate what criteria the study authors used to define phimosis. were found in searches of bibliographies of the articles included. The
Articles were reviewed by the first and last authors using a stan- full text of one of these50 was not, however, available owing to the
dardized data-extraction form. Where necessary, phimosis fre- journal website having an erroneous link to an unrelated article, so
quencies were calculated from the published information. Articles was excluded. In all, 43 articles were included for evaluation and
that met the inclusion criteria were assessed for quality using the data retrieval. The total number of males from all studies combined
Scottish Intercollegiate Guidelines Network grading criteria.6 was 94,956.
Those rated “2−” and above were reviewed in detail. Figure 2 is a Forest plot of phimosis prevalence from the 13 stud-
ies that provided data for males aged ≥18 years (men). In all, 962
Statistical Analyses of 17,136 men had a diagnosis of phimosis. Risk of phimosis was
Statistical analyses were conducted using R7 and utilizing the calculated as 5.6% (95% CI 5.3-6.0) using a fixed effects model,
meta package.8 The following parameters were used: random and 3.4% (95% CI 1.8-6.6) using a random effects model. Hetero-
intercept logistic regression model, maximum-likelihood geneity of the data was high (I2 = 99%, t 2 = 1.37, P <.001).

Figure 1. Flow diagram showing search strategy used and results.

UROLOGY 135, 2020 125


Table 1. Prevalence of phimosis in uncircumcised males in all relevant studies retrieved from PubMed, Google Scholar, and
bibliographies, together with study details
Publication Country Age Cases/Total % Notes QR
Henstell et al USA (European 7-21 y (av. 12 y) 57/609 9.4 “phimosis” 2−
(1934)10 parentage) (609
males)
Gairdner (1949)11 UK Newborn 96/100 96 “phimosis” 2−
(100 boys) =0.5 y 80 Percentages
=1 y 50 only were
=2 y 20 given for
=3 y 10 boys aged
=4 y 9 0.5-<5 y
5-13 y 12/200 6
Osmond (1953)12 UK (1095 British ≥18 y 85/1095 7.8 “nonretractable” 2+
National
Servicemen)
Saitmacher (1960)13 Germany (229 15-≤17 y 20/229 8.7 “phimosis” 2−
males)
€berlein (1967)14
Scho Germany (3000 17-≤38 y 263/3000 8.8 “phimosis” 2+
males) (84.2% aged
18-≤22 y)
Oster (1968)2 Denmark (9545 6-≤7 y 46/591 7.8 physiological 2+
boys)
8-≤9 y 86/1374 6.3 (except for 3 that had
iatrogenic
acquired
phimosis)
10-≤11 y 96/1662 5.8
12-≤13 y 77/2523 3.1
14-≤15 y 34/2744 1.2
16− ≤17 y 6/651 0.9
Chung (1971)15 South Korea (3302 ≥18 y 17/3302 0.6 “12 cases 2+
men) were cong-
enital phim-
osis and 5
acquired
phimosis”
Lau and Ching Hong Kong (1235 0-<6 mo 68/68 100 “nonretractable 2+
(1982)16 Chinese foreskin”
boys; incl. 41
circumcised)
6-<12 mo 79/82 96
1-<2 y 55/156 35
2-<3 y 25/109 23
3-<4 y 26/123 21
4-<5 y 20/136 17
5-<6 y 35/93 16
6-<7 y 15/117 13
7-<8 y 9/61 15
8-<9 y 5/65 8
9-<10 y 4/64 6
10-<11 y 5/72 7
11-<12 y 3/68 4
Herzog and Alverez USA (229 boys;all ≤6 mo 4/16 25 “nonretract-foreskin” 2+
(1986)17 races) symptomati
≥1-<2 y 14/51 27
≥2-<4 y 8/41 19
≥4-<5 y 3/28 11
≥5-<6 y 2/28 7
≥6-≤12 y 6/65 9
Fergusson et al New Zealand (591 0-<8 y 95/591 16 “phimosis” 2−
(1988)18 boys)
Kayaba et al (1996)3 Japan (600 Japanese 0-<6 mo 24/51 68 “highly 2+
boys) unretractable
prepuce (types
I and II)”
Continued

126 UROLOGY 135, 2020


Table 1. Continued
Publication Country Age Cases/Total % Notes QR
0.5-<1 y 14/60 43
1-<2 y 12/102 30
2-<3 y 6/72 22
3-≤4 y 8/115 11
5-≤7 y 5/98 9
8-≤10 y 3/67 7
11-≤15 y 0/35 3
Trombetta et al Italy (734 boys) =3, =6, =9 y 59/734 8.0 “phimosis” 2−
(1996)19
Imamura (1997)20 Japan (4521 boys) ≥1-≤3 mo 1312/1482 88.5 “phimosis: 2+
adhesions
of prepuce
and glans
cannot be
separated
by gentle
manipulation”
≥4-≤6 mo 493/663 74.4
≥7-≤9 mo 406/636 63.9
≥10-≤12 mo 265/457 58.0
≥3-<4 y 449/1289 35.0
Liang et al (1997)21 China (5172 males) ≥7-≤22 y 522/5172 10.1 “phimosis” 2−
Su and Yin (2001)22 Taiwan (n not given) =7 y − 28.3 “phimosis” 2−
10-≤13 y − 37
n
Morales Concepcio Cuba (400 boys) 0-≤1 y 241/337 71.5 “nonretractile” 2−
et al (2002)23 13-<16 y 1/63 1.6
Velazquez et al Paraguay (215 15/215 7.0 “nonretractable 2−
(2003)24 males; foreskin... covering
Paraguayan glans”
rural Mestizo)
Ishikawa and Japan (242 Japanese 0-≤1 y 6/10 60 “nonretractile 2−
Kawakita (2004)25 boys) prepuce”
1-≤2 y 6/21 29
3-≤4 y 15/53 28
5-≤7 y 4/51 8
8-≤10 y 4/32 12
11− ≤15 y 3/33 9
16− ≤20 y 0/25 0
≥21 y 0/17 0
Agarwal et al India (960 boys) 0-≤ 6 mo 105/171 61.4 “preputial nonretract- 2+
(2005)26 ability”
7-< 12 mo 56/113 49.5
1-< 2 y 20/116 17.2
2-< 4 y 23/121 19
4-< 6 y 2/117 1.7
6-< 8 y 1/90 1.1
8-< 10 y 1/107 0.9
10-< 12 y 1/105 0.9
Daling et al (2005)4 US (276 men Seattle 18-<50 (30.7%) 21/276 7.6 “phimosis” 2+
and western
Washington)
50-64 y (43.2%)
≥65 y (26.1%)
Thorvaldsen and Denmark (1520 Newborns − 22 “foreskin could not 2−
Meyhood (2005)27 boys) be retracted”
Age 7 y − 21
Mean age 11.6 y − 8
Hsieh et al (2006)28 Taiwan (2149 7y 118/692 17.1 “phimosis” 2+
schoolboys)
10 y 70/725 9.7
13 y 9/732 1.2
Wang et al (2006)29 China (1015 boys) 0-≤3 y − 64.1 “phimosis” 2+
≥4-<11 y − −
≥11-≤18 y − 7.7
Continued

UROLOGY 135, 2020 127


Table 1. Continued
Publication Country Age Cases/Total % Notes QR
30
Ko et al (2007) Taiwan (1145 boys) 0y 49/59 83.1 “highly unretract- 2+
able”
7y 18/433 4.5
10 y 5/367 1.5
13 y 1/345 0.3
Li et al (2007)31 China (2409 college (17-≤18 y) 324/2409 13.5 “phimosis” 2−
entrants)
Uppal et al (2007)32 India (260 men in ≥20-≤50 y 4/260 1.5* “irrectactable 2−
urban slum) (50.4% were prepuce”
≥20− ≤24y) *“3.5” in its
Discussion
Ben et al (2008)33 China (15109 males) 3-23 y 1745/15109 11.6 “phimosis” 2−
Shi (2009)34 China 19- ≤68 y 11/269 4.1 “phimosis” 2−
(269 men) (mean 28 y)
Yang et al (2009)35 China (10421 <28 days 665/667 99.7 “no retraction at all 2+
Chinese boys) . . . meatus and
glans . . . invisible”
≥1-<12 months 1139/1349 84.4
≥1-≥2 y 836/1737 48.1
≥3-<6 y 572/2109 27.1
≥7-≤10 y 282/2342 12.0
≥11-<18 y 151/2217 6.81
Dai et al (2011)36 China (9706 male Students in grades 767/9706 7.9 “phimosis” 2−
students) 1,5,7,10
Dubrovsky et al Canada (309 boys in ≥1.5-≤8.3 y (median 163/309 52.7 “nonvisible meatus” 2−
(2012)37 Montreal) 3.5 y)
Yamagishi et al Japan (188 men;171 18-89 y (median 2/171 1.1 “type 5, phimosis: 2+
(2012)38 uncirc’d) 40.5)
Romero et al Brazil, Curitiba (1731 ≥40 y (all) 8/1731 0.5 “phimosis” 2+
(2013)39 men, incl. 379
aged ≥60 y
≥60 y − 1.3
Budak et al (2014)40 Uzbekistan (1573 6-≤15 y 56/1573 3.6 “phimosis” 2−
Uzbek boys in
Sakura)
Wan et al (2014)41 China (2241 boys) 3-≤4 y: 622/1120 55.5 “phimosis” 2+
5-≤6 y: 466/1056 44.1
Irkilata et al (2016)42 Turkey (117 boys) 1-≤12 y 19/117 16.2 “complete phimosis” 2−
(median 5 y) (62% [72/117] had
partial phimosis)
Li et al (2016)43 China (176 boys) <28 days 11/13 92.3 “phimosis” based on 2+
attempt to gently
retract
1-<12 mo 37/45 82.2
1-≤2 y 19/42 45.2
3-≤6 y 30/76 38.7
Mukudu et al South Africa (2513 18-≤78 y 79/2513 3.0 “phimosis” 2+
(2016)44 men)
La Pera et al Italy (131 high school 18 y 17/131 12.9 “foreskin cannot be 2−
(2017)45 students) pulled back and
past the glans”
Oddo et al (2017)46 Swaziland (929 4-≤64 y 726/929 78 “phimosis” 2−
males) (age <4 = 3; age
6-12 = 627;age
13-19 = 268;age
≥20 = 31)
Yu et al (2017)47 South Korea (189 0-≤1 y 12/58 21 “phimosis”, urethral
boys) meatus and glans
penis were invisible
after retraction of
the foreskin”
2-≤5 y 16/83 19
6-≤9 y 1/22 5
10-≤13 y 14/26 54
Continued

128 UROLOGY 135, 2020


Table 1. Continued
Publication Country Age Cases/Total % Notes QR
De Rose et al Italy (4000 men) 15-30 y 4000 10.0 “phimosis”; the n 2+
(2019)48 value for each age
group was not
stated.
31-50 y 11.0
51-65 y 13.0
Gianfrilli et al Italy (3816 final year 18-19 y 133/1882 7.1 “phimosis” 2+
(2019)49 high school
students)
IQR, interquartile range; QR, quality rating of the study; y, years.
The “Notes” column shows phimosis definition stated in the publication; if only “phimosis” was stated then that is indicated.

Table 2. Prevalence of phimosis in uncircumcised adult A small Hong Kong study of men found 70% of phimosis
males cases were physiological and 30% were pathological.15
Publication Phimosis Total % Prevalence of pathological phimosis by age 15 years was
12
0.6% in a small study in Liverpool, UK, whereas physio-
Osmond (1953) 85 1095 7.8 logical phimosis was 8-fold higher.54
Scho€berlein (1967)14 263 3000 8.8
Chung (1971)15 17 3302 0.6 There is a wide variety of definitions, diagnostic criteria
Ishikawa and Kawakita 0 17 0 and classification schemes for phimosis. We propose the
(2004)25 following 4 categories for future studies: primary vs sec-
Daling et al (2005)4 21 276 7.6 ondary, and physiological vs pathological.
Li et al (2007)31 324 2409 13.5 One might expect that at least some older studies could
Uppal et al (2007)32 4 260 1.5
Shi (2009)34 11 269 4.1 provide estimates for phimosis prevalence that might approx-
Yamagishi et al (2012)38 2 171 1.1 imate values that would occur in the absence of medical
Romero et al (2013)39 8 1731 0.5 intervention. In this regard, a large study with low risk of
Mukudu et al (2016)44 79 155 51.0 bias found 85/718 (11.8%) of uncircumcised British
La Pera et al (2017)45 17 131 12.9 National Service men had phimosis.12 Prevalence of phimo-
Gianfrilli et al (2019)49 133 1882 7.1
Total 962 17,136 5.6 sis in a general population of men from early adulthood to
over age 65 years in western Washington State was 7.7%
Data for De Rose et al (2019)48 could not be included because
n values for males of different age groups were not disclosed. (21/276). A study in locations in and near Rome, Italy,
found that while 60.3% of 18-year-old high school students
had had sexual intercourse, there was a substantially higher
DISCUSSION prevalence of phimosis among those who had not experi-
The present study found that phimosis was virtually uni- enced sexual intercourse (21.1%), compared with those who
versal at birth, but gradually resolved with age in a major- had experienced sexual intercourse (7.5%; P = 0.023).45
ity of males. By adulthood, excluding 1 study involving The authors emphasized the role of physical genital patholo-
only 17 subjects in total,25 phimosis was still present in a gies, especially phimosis, as a cause of late onset of sexual
substantial percentage of males, although the percentage experience and possibly as a “trigger point of psychological
affected spanned a wide range. The reasons for the range fragility.” In a Canadian study of 202 men circumcised for
may be related to method of diagnosis of phimosis, defini- medical reasons, the most common indications were phimo-
tion used, racial factors, environmental factors, cultural sis (46.5%), dyspareunia (17.8%), balanitis (14.4%), and
factors (such as forced foreskin retraction), and prevalence concurrent phimosis and balanitis (8.9%).55 Older patients
of medical conditions that cause secondary phimosis. were more likely to undergo circumcision for concurrent phi-
These include inflammatory conditions such as balanopos- mosis and balanitis or cancer, whereas younger patients
thitis and lichen sclerosis. As well, smegma, diabetes, obe- sought circumcision for dyspareunia.55 Ballooning on urina-
sity, and possibly genetic and other factors, contribute to tion was recorded in 18/32 (56%) of boys aged 3-12 years
genital inflammation in different populations. Based on with phimosis.56
state of the foreskin, phimosis has been categorized in Phimosis is the strongest risk factor for penile cancer,4,5
order of increasing severity as normal, “cracking,” scarred, with a meta-analysis finding an odds ratio of 21.1 (95% CI
and lichen sclerosis.51 In secondary phimosis stemming 5.6−26.2).7 In a study in Washington state by Daling and
from lichen sclerosis, lichenoid changes are confined to coworkers, phimosis was associated with a significant 11.4-
the inner mucosal surface.52 A recent systematic review fold increase in risk of invasive penile cancer and 3.8-fold
found that prevalence of lichen sclerosis can be high increased risk of carcinoma in situ.4 It was suggested that
(mean 43%; range 10%-87%) in foreskin samples from the inflammation associated with phimosis represents a criti-
males aged ≤18 years circumcised for acquired phimosis.53 cal component of tumor development or progression since

UROLOGY 135, 2020 129


Figure 2. Forest plot of data from all studies for males aged ≥18 years. Shown as well is relative risk of phimosis calculated
by a fixed effects model and a random effects model. (Color version available online.)

many cancers arise from sites of infection, chronic irritation, application for a prolonged period, moderate efficacy, and
or injury. The study also noted significantly reduced penile risk of side effects. A recent RCT involving boys aged 3-
cancer risk among men circumcised early in life. Protection 13 years with grade 4-5 phimosis found 1% hydrocortisone
against phimosis, balanitis, smegma, high-risk HPV infec- cream had a 31%, 54%, and 61% success rate at 4, 8, and
tion, UTIs, and foreskin tears, which are all associated with 12 weeks, respectively; for 0.1% triamcinolone success
elevated penile cancer risk, may explain this. Phimosis is, rates were similar: 32%, 53%, and 68%, respectively.67
moreover, a risk for Fournier’s gangrene in rare cases.57 An earlier RCT concluded that although steroid creams
A study in the UK of 100 men aged 17-82 (mean 38 may be effective in the short term, in the long term, recur-
years) noted that 31% had a lifelong history of phimosis rence of phimosis is frequent, requiring retreatment or cir-
and 69% had a history of acquired phimosis.58 Of the men cumcision.68 Circumcision is the definitive cure and
with acquired phimosis, 32% had diabetes.58 Phimosis was conveys multiple other health benefits.69,70 It does, how-
6.7 times more common in men with a history of diabetes.39 ever, require a skilled practitioner and is more expensive.
Phimosis may be a warning sign of diabetes, since 12% of The present study has several limitations. In many stud-
the men with phimosis and who had no previous history of ies, the prevalence values for phimosis likely represent
a disorder of glucose metabolism or diabetes were found to underestimates. One reason is that the data do not capture
have diabetes (8%) or impaired fasting glycemia (4%), that males who had been circumcised to cure phimosis and who
is, diabetes prevalence was higher than the UK average for thus no longer qualified as being uncircumcised. Method of
diabetes of 3.6% at the time of the study.59 Balanitis is com- classification is another variable. Both the retractability and
mon in diabetes and recurrent infection and scarring is the shape of the prepuce lie within a spectrum that can
probably responsible for the phimosis that develops. sometimes be difficult to describe and there is no agreed
In infancy, it is not just the presence of the foreskin that classification system. Different studies have used their own
increases risk of UTI by trapping bacterial pathogens,60-62 it classifications for the purpose of their study, so possibly con-
is the nonretractile physiological phimosis that likely facili- tributing to variation in prevalence between some studies.
tates ascent of uropathogens up into the urinary tract.63,64 For example, Kayaba et al graded retractability according to
The amelioration of UTI risk with age65 mirrors the resolu- how much of the glans was visible after attempted prepuce
tion of phimosis with age evident in the present systematic retraction.3 Meuli et al designated severity of phimosis into
review. Steroid cream treatment leading to phimosis resolu- 4 grades: Grade I−fully retractable prepuce with stenotic
tion was associated with substantial reduction in recurrent ring in the shaft, Grade II−partial retractability with partial
UTI in uncircumcised Hispanic infants in Dallas.66 exposure of the glans, Grade III−partial retractability with
Thus, taken together, phimosis is a relatively minor exposure of the meatus only, and Grade IV−no retractabil-
condition that can have serious morbidity and potentially ity,71 which we would designate as phimosis. A classification
fatal consequences. system for phimosis severity used by others was: Grade 0
Steroid creams have become popular for treatment of −full retractability, Grade 1−full retraction but tight behind
phimosis, despite the need for at least twice-daily glans, Grade 2−partial exposure of glans, Grade 3−partial

130 UROLOGY 135, 2020


retraction with meatus just visible, Grade 4−slight retrac- 2. Oster J. Further fate of the foreskin: incidence of preputial adhe-
tion but neither meatus nor glans visible, and Grade 5 abso- sions, phimosis and smegma among Danish schoolboys. Arch Dis
Child. 1968;43:200–203.
lutely no retraction,3,72,73 which we would regard as
3. Kayaba H, Tamura H, Kitajima S, Fujiwara Y, Kato T, Kato T.
phimosis. All of these factors and differences in effectiveness Analysis of shape and retractability of the prepuce in 603 Japanese
of foreskin-retaining treatments likely contribute to the boys. J Urol. 1996;156:1813–1815.
large differences in prevalence of phimosis. The high het- 4. Daling JR, Madeleine MM, Johnson LG, et al. Penile cancer: impor-
erogeneity score we obtained was unsurprising and reflects tance of circumcision, human papillomavirus and smoking in in situ
the variability in data between studies. and invasive disease. Int J Cancer. 2005;116:606–616.
5. Morris BJ, Gray RH, Castellsague X, et al. The strong protective
The present systematic review also highlights gaps in effect of circumcision against cancer of the penis. Adv Urol.
current knowledge. Longitudinal studies over many years 2011;2011. article 812368.
are needed to better determine the natural history and 6. Harbour R, Miller J. A new system for grading recommendations in
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Vienna, Austria: R Foundation for Statistical Computing; 2016.
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privileged boys of New Haven. Yale J Biol Med. 1934;6:545–551.
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prevalence. Phimosis is present at birth and takes many J. 1949;2:1433–1437. illust.
years to resolve. A multitude of factors are at play. We 12. Osmond TE. Is routine circumcision advisable? J Roy Army Med
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