Objective: To assess the importance of identifying physiological preputial adhesion and pathological phimosis as different clinical entities in children. Methods: A prospective study was done on 40 patients of presumed phimosis, referred to the paediatric surgery department, for circumcision. Patients were examined for their symptoms and classified as either having symptomatic physiological preputial adhesions or pathological phimosis. Patients in the former group underwent adhesiolysis and those in the later group underwent circumcision. They were followed up and results obtained were analysed. Results: Out of the 40 patients referred with a presumed diagnosis of phimosis, only 5 (12.5%) patients had pathological phimosis and among these 3 were found to have balanitis xerotica obliterans. Pathological phimosis patients presented late at a mean age of 60 months. They underwent circumcision. 35 (87.5%) patients were found to have symptomatic physiological preputial adhesions and presented earlier at a mean age of 28 months. 33 (94.3%) of these could be managed by simple adhesiolysis as outdoor patients while 2 patients were non-responders and needed circumcision. Among responders to adhesiolysis, majority of the patients (29 out of 33) needed a single attempt while 4 patients needed multiple attempts at adhesiolysis. Conclusion: Most of the patients referred for circumcision for phimosis actually had symptomatic preputial adhesions which could be managed by simple adhesiolysis. Only few patients had pathological phimosis needing circumcision. Balanitis xerotica obliterans was found to be an important cause of pathological phimosis. Proper diagnosis could prevent unnecessary surgical intervention under anaesthesia and keep the prepuce intact preserving its vital functions.