Changing Trends in a Decade of Circumcision in Scotland

By O. Quaba and G.A. MacKinlay

Edinburgh, Scotland

Purpose: There has been a move toward conservative man- number of circumcisions performed between the first and
agement of foreskin problems. The aim of this study was to second halves of the study period. The fall in operations
examine overall trends for circumcision in Scotland to see if performed is almost solely attributable (94.5%) to a reduction
there has been a decrease in the number of operations in number of procedures carried out for phimosis. There was
performed. a corresponding increase in preputioplasties performed over
the study period.
Methods: Retrospective analysis looking at the number of
circumcisions performed each year over a 10-year period Conclusions: There has been a steady decrease in circumci-
(1990 to 2000), in the 0 to 13-year age group. The principal sion rates in Scotland. This is in keeping with greater appre-
indication for circumcision in each case was ascertained as ciation of pathologic phimosis as distinguished from a
were the number of preputioplasties performed over the healthy nonretractile foreskin, which does not require
corresponding period. circumcision.
J Pediatr Surg 39:1037-1039. © 2004 Elsevier Inc. All rights
Results: A total of 15,605 circumcisions were performed reserved.
during the 10-year period; 10,888 (69.8%) for phimosis, 2,724
(17.5%) for nonmedical/religious reasons, and 1993 (12.8%) INDEX WORDS: Circumcision, phimosis, incidence, preputio-
for all other indications. There was a 33.7% decrease in total plasty.

C IRCUMCISION is an old and widely practiced

procedure. There has been concern over the last
few years that many operations for circumcision are
agnosis of phimosis in England, despite a sustained
decrease in the number of circumcisions being
performed.6
performed unnecessarily. Several reports in the literature The introduction of topical steroids7 and the reemer-
have reappraised the indications for medical circumci- gence of preputioplasty8 in the 1990s, as alternatives to
sion, whereas others have highlighted alternatives to circumcision, for the treatment of tight nonretractile
circumcision. foreskin are also expected to have affected the number of
Balanitis, tight foreskin, and phimosis are the most circumcisions being performed.
common referral diagnoses for penile problems in chil- The aim of this study was to look at recent trends in
dren (excluding hypospadias).1 Regarding balanitis, it circumcision in Scotland. Scotland has the advantage of
has been suggested that circumcision should only be being a well-defined population with a comprehensive,
performed for recurrent and troublesome infection.2 standardized diagnostic coding system. In addition, reli-
Others have argued that circumcision for balanitis can gious circumcisions are routinely available within the
be avoided all together by separation of preputial National Health Service (NHS) throughout Scotland, and
adhesions using topical anesthetic in the outpatient we were able to examine trends in nonmedical circum-
department.3 cisions. Furthermore, we also looked at trends for pre-
Confusion still remains about the precise meaning of
putioplasty to see if there has been a significant increase
the term phimosis. The term in Greek simply means a
in the number performed.
muzzling of the glans. The foreskin is invariably nonre-
tractile at birth, but this state is transient and resolves in
nearly all boys as shown by Gairdner over 50 years ago.4
The foreskin in this case is unscarred with a pliant From the Department of Vascular Surgery, Basic Surgical
Training Scheme South East Scotland, Royal Infirmary of Edin-
preputial orifice, in contrast to pathologic phimosis, a
burgh and the Royal Hospital for Sick Children, Edinburgh,
condition in which the tip of the prepuce is scarred and Scotland.
indurated, usually owing to balanitis xerotica obliterans. Address reprint requests to O. Quaba, MRCS (Edin), SHO Vascular
In the late 1980s it was suggested that up to two thirds of Surgery, Basic Surgical Training Scheme South East Scotland, Royal
boys underwent unnecessary circumcision as a result of Infirmary of Edinburgh, Lauriston Place, EH3 9YW Edinburgh, United
Kingdom.
a misdiagnosis of phimosis when in reality they had a © 2004 Elsevier Inc. All rights reserved.
healthy nonretractile/adherent foreskin.5 More recently, 0022-3468/04/3907-0007$30.00/0
it has been shown that boys are still receiving a misdi- doi:10.1016/j.jpedsurg.2004.03.061

Journal of Pediatric Surgery, Vol 39, No 7 (July), 2004: pp 1037-1039 1037

1038 QUABA AND MACKINLAY

Table 1. Comparison of Overall Numbers of Circumcisions

Performed in First and Second Parts of the Study Period
1999-1995 1995-2000

All circumcisions 9383 (100%) 6222 (100%)

Phimosis 6937 (73.9%) 3951 (63.5%)
Nonmedical 1261 (13.4%) 1463 (23.5%)
Other 1185 (12.6%) 808 (13.0%)

MATERIALS AND METHODS

Data were obtained from the Information and Statistics Division of
the NHS in Scotland. Records were examined for all circumcisions Fig 1. Circumcision rates in Scotland over the 10-year study pe-
performed in Scotland in the 0 to 13-year age group between April riod.
1990 and March 2000. The principal indication for circumcision based
on the International Classification of Diseases (ICD) was available for
all operations performed. by 1993 to 1994 there was a steady increase in the
It is important to note that the ICD classification does not distinguish
between (1) phimosis, (2) adherent prepuce, and (3) tight foreskin, all
number of preputioplasties performed, peaking at 318
of which are considered under the same diagnostic code. This subgroup procedures in the year 1996 to 1997. Subsequently,
of patients was classified as the “phimosis” group bearing in mind that preputioplasty rates have decreased. The slight rise again
some of the patients will have had pathologic phimosis, whereas others in 2000 may indicate that the graph will plateau. Pre-
will have had a healthy but nonretractile foreskin. The other major sumably, some surgeons believe that preputioplasty is of
subgroup in the ICD classification is defined as “procedures for pur-
poses other than remedying health states,” ie, nonmedical indications
benefit. The senior author performs short radial prepu-
for circumcision. Other subgroups of the ICD classification, such as tioplasties in a few selected patients who do not respond
hypospadias, accounted for less than 13% of the total number of to conservative measures and in whom there remains a
circumcisions performed, and, hence, we did not consider these specific tight constriction band.
indications in further detail. Figure 3 summarizes the trend in circumcision rates
Analysis was carried out on the total number of circumcisions: the
number performed for “phimosis” versus nonmedical indications, as
for phimosis and the rate for preputioplasties over the
well as the trend over the 10-year period. corresponding period.
In addition, the total number of preputioplasties in the same age
group over the corresponding period was also examined. DISCUSSION
Many reports have been written in recent years indi-
RESULTS
cating that, in most cases, childhood circumcision is
A total of 15,605 circumcisions were performed over performed unnecessarily. The British Medical Associa-
the 10-year period, 10,888 (69.8%) for the phimosis tion and the American Academy of Paediatrics recom-
group, 2,724 (17.5%) for nonmedical/religious reasons, mend that circumcision should only be performed for
and 1,993 (12.8%) for all other indications including medical reasons, something that is rarely necessary.
hypospadias. Table 1 shows that there has been a marked Routine neonatal circumcision should not be performed.
decrease in the overall number of circumcisions per- It has been recorded that the neonatal circumcision rate
formed over the 10-year period. Comparing the first and in Finland is zero and the risk of needing a late circum-
second 5 years of the study period there has been a cision in Finland is 1 in 16,667.9 It would, therefore,
33.7% decrease in overall numbers of circumcisions appear that the continued practice of routine neonatal
performed. This fall in circumcision rates is largely circumcision in many parts of North America is ill
attributable (94.5%) to a reduction in procedures carried founded.
out for phimosis. Figure 1 illustrates the overall decrease
in all circumcisions performed with just less than 2,000
operations a year in the early 1990s to less than 1,000 in
the year 1999 to 2000. What is striking from the graph is
the fact that the decrease in overall numbers is almost
exactly mirrored by the decrease in procedures carried
out for phimosis. The number of procedures performed
for nonmedical indications has remained relatively
constant.
Figure 2 shows the trend for preputioplasties over the
study period. It can be seen that few procedures were Fig 2. Preputioplasty rates in Scotland over the 10-year study
carried out in the early part of the study period. However, period.
CIRCUMCISION TRENDS IN SCOTLAND 1039

Fig 3. Circumcision and preputio-

plasty rates.

Rickwood et al6 state that an attainable target of 2% of compares with more than 5% (5.3%) based on circum-
boys being circumcised for medical reasons would be cision rates for the early 1990s in Scotland.
consistent with evidence-based circumcision.6 Our study Circumcision for religious/nonmedical purposes is of-
confirms that this target has already been achieved in fered routinely under the NHS throughout Scotland, and
Scotland as a whole compared with the estimated 3.8% our study confirms that the number of circumcisions for
of boys circumcised in England.6 this indication has remained relatively constant. How-
The number of male live births in Scotland in the year ever, because of the decrease in circumcisions for phi-
1999 to 2000 was just less than 28,000. If the most recent mosis, an increasing proportion of boys in Scotland are
circumcision rate in our study for phimosis (550 proce- being circumcized for nonmedical reasons: 13.4% in the
dures for the year 1999 to 2000) remained unchanged, first 5 years of the study period compared with 23.5% in
then less than 2% (1.98%) of boys in Scotland would be the last 5 years (44.5% in the last year of our study
circumcised for ’phimosis’ by their 13th birthday. This period).

REFERENCES
1. Williams N, Chell J, Kapila L: Why are children referred for 6. Rickwood AMK, Kenny SE, Donnell SC: Towards evidence
circumcision? BMJ 306:28, 1993 based circumcision of English boys: Survey of trends in practice. BMJ
2. Escala JM, Rickwood AMK: Balanitis. Br J Urol 63:196-197, 1989 321:792-793, 2000
3. MacKinlay GA: Save the prepuce. Painless separation of prepu- 7. Wright JE: The treatment of childhood phimosis with topical
tial adhesions in the outpatient clinic. BMJ 297:590-591, 1988 steroid. Aust N Z J Surg 64:327-328, 1994
4. Gairdner DM: The fate of the foreskin. BMJ 2:1433-1437, 1949 8. Cuckow PM, Rix G, Mouriquand PD: Preputial plasty: A good
5. Rickwood AMK, Walker J: Is phimosis over diagnosed in boys alternative to circumcision. J Pediatr Surg 29:561-563, 1994
and are too many circumcisions performed in consequence? Ann R 9. Dennistoun GC: Circumcision and the code of ethics. Humane
Coll Surg Engl 71:275-277, 1989 Health Care International 12:78-80, 1996