Regarding misconceptions that persist among practitioners regarding the foreskin, the Canadian Paediatric Society, in their most recent statement on circumcision (1996), goes as far as to question the applicability of the term “adhesions” to describe the synechia (the normal membrane between the glans and the foreskin prior to its spontaneous dissolution, over time). The CPS states:

In general, there is inadequate recognition of the long period before the natural separation of the prepuce and the glans is complete. Some authors still refer to the presence of “adhesions,” when, in fact, separation has not yet taken place; similarly, a nonretractile foreskin is sometimes incorrectly diagnosed as phimosis. [1]

The CPS prefers to term the normal non-retractability of the foreskin frequently observed in children, and even sometimes adolescents, developmental nonretractability of the prepuce. The CPS statement makes reference to a study of 420 boys conducted by Rickwood and Walker. In their study, Rickwood and Walker state:

non-retractile foreskin, where the prepuce is wholly or partially non-retractable due to persistence of developmental adherence between glans and foreskin (‘preputial adhesions’); this is often associated with a preputial orifice which, although somewhat narrow, is supple and unscarred (‘physiological phimosis’). [Rickwood’s italics and parentheses] [2]

The article by Rickwood and Walker presents very clearly the problems often found in connection with a diagnosis of phimosis:

The Greek derivation (f i m o s i V, muzzling) allows application whenever the foreskin cannot be fully retracted, but such all-embracing usage is misconceived as it implies the existence of pathology where very often there is none. In reality, there is a clear-cut distinction between true, pathological, phimosis...and partial or non-retractability of the foreskin caused by persistence of developmental adhesions between glans and prepuce. Almost 40 years ago, Gairdner demonstrated this state to be both normal and self-limiting in boys. Perhaps it was unfortunate that he followed his patients only to 5 years of age, at which time the foreskin is still wholly non-retractable in some boys while many more retain preputial adhesions. As a result, there remains misconception that persistence of either condition beyond this age requires action, be it ‘preputial stretching’, ‘freeing of adhesions’ or even circumcision. Oster’s study, involving almost 2000 schoolboys followed to physical maturity, showed otherwise: by the age of 17 years, and without any form of intervention, the foreskin had become fully retractable in all boys except 1% who had developed true phimosis as a secondary phenomenon. The non-retractile foreskin is asymptomatic except, on occasion, for ballooning during micturition, which is a harmless and transient phenomenon and, by virtue of its natural history, requires no treatment, least of all circumcision.[2] [Circumcison Information Resource Centre’s italics]

References

[1] Fetus and Newborn Committee, Canadian Paediatric Society. Neonatal circumcision revisited (clinical practice guidelines). Canadian Medical Association Journal 1996; 154(6): 769-780.

[2] Rickwood AMK et Walker J. Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence? Annals of the Royal College of Surgeons of England 1989;71(5):275-277.