Phimosis

Phimosis is a condition in which the foreskin of the penis cannot be pulled back past the glans. A balloon-like swelling under the foreskin may occur with urination. In teenagers and adults, it may result in pain during an erection, but is otherwise not painful. Those affected are at greater risk of inflammation of the glans, known as balanitis, and other complications.^[3]

In young children, it is normal to not be able to pull back the foreskin. In more than 90% of cases, this inability resolves by the age of seven, and in 99% of cases by age 16.^[4][5] Occasionally, phimosis may be caused by an underlying condition such as scarring due to balanitis or balanitis xerotica obliterans. This can typically be diagnosed by seeing scarring of the opening of the foreskin.^[5]

Typically, it resolves without treatment by the age of three. Efforts to pull back the foreskin during the early years of a boy's life should not be attempted. For those in whom the condition does not improve further time can be given or a steroid cream may be used to attempt to loosen the tight skin. If this method, combined with stretching exercises, is not effective then other treatments such as circumcision may be recommended.^[4] A potential complication of phimosis is paraphimosis, where the tight foreskin becomes trapped behind the glans.^[5] The word is from the Greek phimos (φῑμός), meaning "muzzle".^[6]

Signs and symptoms

At birth, the inner layer of the foreskin is sealed to the glans penis. The foreskin is usually non-retractable in early childhood, and can be as late as 18.^[7]

Medical associations advise not to retract the foreskin of an infant, in order to prevent scarring.^[8][9] Some argue that non-retractability may "be considered normal for males up to and including adolescence."^[10][11] Hill states that full retractability of the foreskin may not be achieved until late childhood or early adulthood.^[12] A Danish survey found that the mean age of first foreskin retraction is 10.4 years.^[13]

Rickwood, as well as other authors, has suggested that true phimosis is over-diagnosed due to failure to distinguish between normal developmental non-retractability and a pathological condition.^[14][15][16] Some authors use the terms "physiologic" and "pathologic" to distinguish between these types of phimosis;^[17] others use the term "non-retractile foreskin" to distinguish this developmental condition from pathologic phimosis.^[14]

In some cases a cause may not be clear, or it may be difficult to distinguish physiological phimosis from pathological if an infant appears to be in pain with urination or has obvious ballooning of the foreskin with urination or apparent discomfort. However, ballooning does not indicate urinary obstruction.^[18]

In women a comparable condition is known as "clitoral phimosis" whereby the clitoral hood cannot be retracted, limiting exposure of the glans clitoridis.^[19]

Severity

• Score 1: full retraction of foreskin, tight behind the glans.
• Score 2: partial exposure of glans, prepuce (not congenital adhesions) limiting factor.
• Score 3: partial retraction, meatus just visible.
• Score 4: slight retraction, but some distance between tip and glans, i.e. neither meatus nor glans can be exposed.
• Score 5: absolutely no retraction of the foreskin.^[20]

Cause

There are three mechanical conditions that prevent foreskin retraction:

1. The tip of the foreskin is too narrow to pass over the glans penis. This is normal in children and adolescents.^[21][22]

2. The inner surface of the foreskin is fused with the glans penis. This is normal in children and adolescents but abnormal in adults.^[22]

3. The frenulum is too short to allow complete retraction of the foreskin (a condition called frenulum breve).^[22]

Pathological phimosis (as opposed to the natural non-retractability of the foreskin in childhood) is rare and the causes are varied. Some cases may arise from balanitis (inflammation of the glans penis).^[23]

Lichen sclerosus et atrophicus (thought to be the same condition as balanitis xerotica obliterans) is regarded as a common (or even the main)^[24] cause of pathological phimosis.^[25] This is a skin condition of unknown origin that causes a whitish ring of indurated tissue (a cicatrix) to form near the tip of the prepuce. This inelastic tissue prevents retraction.

Phimosis may occur after other types of chronic inflammation (such as balanoposthitis), repeated catheterization, or forcible foreskin retraction.^[26]

Phimosis may also arise in untreated diabetics due to the presence of glucose in their urine giving rise to infection in the foreskin.^[27]

Phimosis in older children and adults can vary in severity, with some able to retract their foreskin partially (relative phimosis), and some completely unable to retract their foreskin even when the penis is in the flaccid state (full phimosis).

Treatment

Physiologic phimosis, common in males 10 years of age and younger, is normal, and does not require intervention.^[21][28][29] Non-retractile foreskin usually becomes retractable during the course of puberty.^[29]

If phimosis in older children or adults is not causing acute and severe problems, nonsurgical measures may be effective. Choice of treatment is often determined by whether circumcision is viewed as an option of last resort to be avoided or as the preferred course.

Nonsurgical

• Topical steroid creams such as betamethasone, mometasone furoate and cortisone are effective in treating phimosis and may provide an alternative to circumcision.^[28][30][31] It is theorized that the steroids work by reducing the body's inflammatory and immune responses, and also by thinning the skin.^[28]
• Stretching of the foreskin can be accomplished manually, with balloons or with other tools. Skin that is under tension expands by growing additional cells. A permanent increase in size occurs by gentle stretching over a period of time. The treatment is non-traumatic and non-destructive. Manual stretching may be carried out without the aid of a medical doctor. The tissue expansion promotes the growth of new skin cells to permanently expand the narrow preputial ring that prevents retraction. In a study, 86% of individuals were cured and could retract their foreskin in 6 weeks, by applying a cream and skin stretching twice daily.^[30][32]

Surgical

Preputioplasty:
Fig 1. Penis with tight phimotic ring making it difficult to retract the foreskin.
Fig 2. Foreskin retracted under anaesthetic with the phimotic ring or stenosis constricting the shaft of the penis and creating a “waist”.
Fig 3. Incision closed laterally.
Fig 4. Penis with the loosened foreskin replaced over the glans.

Surgical methods range from the complete removal of the foreskin to more minor operations to relieve foreskin tightness:

• Circumcision is sometimes performed for phimosis, and is effective.
• Dorsal slit (superincision) is a single incision along the upper length of the foreskin from the tip to the corona, exposing the glans without removing any tissue.
• Ventral slit (subterincision) is an incision along the lower length of the foreskin from the tip of the frenulum to the base of the glans, removing the frenulum in the process. Often used when frenulum breve occurs alongside the phimosis.
• Preputioplasty, in which a limited dorsal slit with transverse closure is made along the constricting band of skin^[33]< can be an effective alternative to circumcision.^[16] It has the advantage of only limited pain and a short time of healing relative to circumcision, and avoids cosmetic effects.

While circumcision prevents phimosis, studies of the incidence of healthy infants circumcised for each prevented case of phimosis are inconsistent.^[15][26]

Prognosis

The most acute complication is paraphimosis. In this condition, the glans is swollen and painful, and the foreskin is immobilized by the swelling in a partially retracted position. The proximal penis is flaccid. Some studies found phimosis to be a risk factor for urinary retention^[34] and carcinoma of the penis.^[35]

Epidemiology

A number of medical reports of phimosis incidence have been published over the years. They vary widely because of the difficulties of distinguishing physiological phimosis (developmental nonretractility) from pathological phimosis, definitional differences, ascertainment problems, and the multiple additional influences on post-neonatal circumcision rates in cultures where most newborn males are circumcised. A commonly cited incidence statistic for pathological phimosis is 1% of uncircumcised males.^{[26][36],[15]} When phimosis is simply equated with nonretractility of the foreskin after age 3 years, considerably higher incidence rates have been reported.^[29][37] Others have described incidences in adolescents and adults as high as 50%, though it is likely that many cases of physiological phimosis or partial nonretractility were included.^[38]

History

According to some accounts, phimosis prevented Louis XVI of France from impregnating his wife for the first seven years of their marriage. She was 14 and he was 15 when they married in 1770. However, the presence and nature of his genital anomaly is not considered certain, and some scholars (such as Vincent Cronin and Simone Bertiere) assert that surgical repair would have been mentioned in the records of his medical treatments if it had indeed occurred. It should be mentioned that non-retractile prepuce in adolescence is normal, common, and usually resolves with increasing maturity.^[29]

US president James Garfield was assassinated by Charles Guiteau in 1881. Guiteau's autopsy report indicated that he had phimosis. At the time, this led to the speculation that Guiteau's murderous behavior was due to phimosis-induced insanity.^[39]

References

External links

• Phimosis, by the University of California, San Francisco Urology department