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Phimosis--a diagnostic dilemma?

INTRODUCTION: Phimosis is defined as the inability to retract the foreskin. Differentiating between physiological phimosis and pathological phimosis is important, as the former is managed conservatively and the latter requires surgical intervention. Referrals of patients with physiological phimosis to urology clinics may create anxiety regarding the need for surgery amongst patients and parents, while unnecessarily expanding the waiting list for specialty assessment.

OBJECTIVES: To determine the ability of referring physicians to differentiate physiological from pathological phimosis, and to see whether there is any difference in this ability between generalists versus specialists.

MATERIALS AND METHODS: A retrospective chart review of 284 consecutive referrals for phimosis to the Children's Hospital of Eastern Ontario (CHEO) Urology Clinic during November 2000 - April 2003 was conducted. Referral sources included family physicians (FP), pediatricians (PD), emergency physicians (ER), and other subspecialists (SS). Data for this study were obtained from the original referral letters and cross-referenced with the impressions of the pediatric urologist following the initial patient encounter. The accuracy in diagnosing phimosis was evaluated among the various types of referring physicians.

RESULTS: A total of 284 phimosis referrals were reviewed of patients ranging from 2 months to 16 years of age (mean = 6.6 years). The referral sources consisted of 222-GP, 33-PD, 23-ER, and 6-SS. The majority of referred cases were diagnosed by the attending pediatric urologist as physiological phimosis across all referral sources, with the exception of subspecialists (FP = 75.2%, PD = 81.8%, ER = 56.5%, SS = 33.3%). Second to this was the diagnosis of pathological phimosis across all referral sources except SS (FP = 14.9%, PD = 12%, ER = 34.8%, SS = 50%). Overall, the circumcision rate for the 284 phimosis referrals reviewed was 14.4%.

CONCLUSIONS: Our findings reveal that many physicians continue to face difficulties in distinguishing physiological phimosis from the pathological. As a result, many unnecessary referrals are made for phimosis . We suggest the implementation of improved educational measures regarding preputial pathophysiology in the medical curriculum. Such measures would serve two purposes: first, to reduce the number of unnecessary specialty referrals and secondly, to aid primary care physicians in recognizing the presence of physiological phimosis so that patients and families may be reassured of normalcy.

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