An error-prone study of penile problems

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The authors cite phimosis (tight foreskin) as a reason for circumcision, but exclude it for a technical rather than scientific reason, i.e., "because the procedure code did not indicate its severity", so skewing the the comparison. They also failed to take into account the fact that uncircumcised boys with phimosis are generally treated AFTER 5 years of age. They claim balanoposthitis (which circumcision protects against) was twice as high in circumcised boys. We point out that the reason for this anomalous finding was most likely because of circumcision to TREAT balanoposthitis. They ignore the protective effect of circumcision against urinary tract infections in infants, even though they cite my systematic and meta-analysis in J Urol. Their finding of higher percentage of "urethral stricture and/or meatal stenosis" based on data failed to realize the common misdiagnosis of the condition in uncircumcised boys when visual inspection is used, as is common, whereas overdiagnosis is common in circumcised boys. The finding by Federeski et al. of 2.9-fold higher rate of procedural complications from circumcision performed by surgeons (mostly urologists) than pediatricians was because boys requiring circumcision for medical reasons takes place later than "routine" (non-therapeutic) circumcision. Such treatment is more complex and higher risk than early circumcision by pediatricians, obstetricians, and family practitioners (mostly in the first week after birth). The authors nevertheless correctly find that complications during the first 28 days of life are low (0.5%), but after 90 days of age complications were higher (consistent with a study, not cited, by CDC researchers of 1.4 million US boys). Thus, the fact that risk of complications ramps up after after the neonatal pediod explains why the study by Federeski et al. found complications were much higher for later circumcisions.

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