Phimosis

Phimosis is a condition where the male foreskin cannot be fully retracted from the head of the penis. The word derives from the Greek phimos (φῑμός, "muzzle"). As most boys are born with a non-retracting foreskin, the term is confusing because it denotes both a normal stage of development, and a pathological condition (i.e. a condition that causes problems for a person). This confusion is particularly pronounced in regard to infants. Conflicting incidence reports and widely varying post-neonatal circumcision rates reflect looseness in the diagnostic criteria.^[1][2] Phimosis has become a topic of contention in circumcision debates.^[3]

It is normal for a baby's foreskin not to retract, but as the child grows the foreskin is expected to become retractable. Some have suggested that physiological infantile phimosis be referred to as developmental nonretractility of the foreskin to more clearly distinguish this normal stage of development from pathological forms of phimosis.^[4] Different management is appropriate. In other words, there are different degrees of phimosis, and treatment may vary on the degree of phimosis.

Women can suffer from clitoral phimosis.^[5]

Natural development of the foreskin

For most of the Twentieth Century, most of the medical profession has recognized that most male infants have foreskins which are still attached to the epithelium of the glans penis ^[1] and cannot easily be retracted. There have been four types of medical responses and attitudes toward this fact:

1. In the first half of the Twentieth Century, some physicians recommended that the foreskin be repeatedly retracted, if necessary with some force, to free it from the glans. It was thought that this could prevent later (pathological) phimosis and urinary problems in older boys by permitting washing of the glans and foreskin. Poor hygiene was thought to predispose to pathological phimosis. This approach has not been recommended by physicians for many decades.
2. Particularly in the middle of the Twentieth Century, some physicians promoted routine neonatal circumcision to avoid phimosis.^[3] While circumcision prevents phimosis, at least 10 to 20 healthy infants must be circumcised for each prevented case of potential phimosis according to some incidence statistics. If one believes even lower phimosis incidence estimates, far more must be circumcised to prevent each case of phimosis. While some still promote this view, most pediatricians do not consider it a compelling argument for routine neonatal circumcision.^[6]
3. In the last three decades, as the circumcision rate in North America has declined, the most common official recommendations and guidelines from medical societies, as well as infant care books written by experts, have emphasized that it is normal not to be able to retract an infant's foreskin fully and that it need not be done. The American Academy of Pediatrics recommends gentle soap and water cleaning, but specifically recommends against forcible retraction.^[6] There is now some suspicion that forceful retraction that results in inflammation may actually contribute to pathological phimosis at an older age.^[1] Although the rate of surgical treatment of phimosis (usually circumcision) is falling, some pediatric urologists have argued that many physicians continue to have trouble distinguishing developmental non-retractility from pathological phimosis, and that phimosis is overdiagnosed.^[7][8][9]
4. Phimosis is sometimes used as a justification for circumcision,^[2][9] so that it will be covered by a national health system or insurance plan. The definition may be stretched by a physician for an older child; particularly where (as in North America), post-neonatal circumcision is usually outpatient surgery by a pediatric urologist, more expensive than the neonatal procedure.^[9]

Pathological phimosis in childhood

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), perhaps due in turn to inappropriate efforts to separate and retract an infant foreskin. Other cases of non-retractile foreskin may be caused by preputial stenosis or narrowness that prevents retraction, by fusion of the foreskin with the glans penis in children, or by frenulum breve, which prevents retraction. 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, even ballooning does not always indicate urinary obstruction.^[10]

Acquired phimosis

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

Because of the "elasticity" of the diagnostic criteria, there has been considerable variation in the reported prevalence of pathological phimosis. An incidence rate of 1% to 2% of the uncircumcised adult male population is often cited, though some studies of older children or adolescents have reported higher rates.^[1] Relative phimosis is more common, with estimates of its frequency at approximately 8% of uncircumcised men.^[11]

When phimosis develops in an uncircumcised adult who was previously able to retract his foreskin, it is nearly always due to a pathological cause, and is far more likely to cause problems for the man.

One cause of acquired, pathological phimosis is chronic balanitis xerotica obliterans (BXO), 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. Some evidence suggests that BXO may be the same disease as lichen sclerosus et atrophicus of the vulva in females.^[12] Infectious, inflammatory, and hormonal factors have all been implicated or proposed as contributing factors. Circumcision is usually recommended though alternatives have been advocated.

Phimosis may occur after other types of chronic inflammation (e.g., balanoposthitis), repeated catheterization, or forceful foreskin retraction.^[1]

Phimosis may also sometimes be brought on by diabetes, due to high levels of sugar being present in the urine of some diabetics, which creates the right conditions for bacteria to breed, under the foreskin.

Potential complications of acquired phimosis

Chronic complications of acquired (pathological) phimosis can include discomfort or pain during urination or sexual intercourse. The urinary stream can be impeded, resulting in dribbling and wetness after urination. Harmful urinary obstruction is possible but uncommon. Pain may occur when a partially retractable foreskin retracts during intercourse and chokes the glans penis. A totally non-retractable foreskin is rarely painful. There is some evidence that phimosis may be a risk factor for penile cancer.^[13]

The most acute complication is paraphimosis (Paraphimosis image). In this acute 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.

Treatment of phimosis

Phimosis in infancy is nearly always physiological, and needs to be treated only if it is causing obvious problems such as urinary discomfort or obstruction. In older children and men phimosis should be distinguished from frenulum breve, which more often requires surgery, though the two conditions can occur together.

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 the patient (or doctor) views circumcision as an option of last resort to be avoided or as the preferred course. Some men with nonretractile foreskins have no difficulties and see no need for correction.

• Circumcision is the traditional surgical solution for pathological phimosis, and is effective. Serious complications from circumcision are very rare, but minor complication rates (e.g., having to perform a second procedure or meatotomy to revise the first or to re-open the urethra) have been reported in about 0.2-0.6% in most reported series,^[6] though others quote higher rates.^[9]
• Preputioplasty, in which a limited dorsal slit with transverse closure is made along the constricting band of skin^[14][15] can be an effective alternative to full circumcision.^[9] It has the advantage of only extremely limited pain and a very short time of healing relative to the rather more traumatic circumcision, together with no cosmetic effects.

There is a school of opinion among the medical profession that advocates and promotes a number of alternative methods where surgery, with all the attendant risks, can be avoided.

High rates of success have been reported with several nonsurgical measures:

• Application of topical steroid cream for 4-6 weeks to the narrow part of the foreskin is relatively simple and less expensive than surgical treatments.^[9] It has replaced circumcision as the preferred treatment method for some physicians in the U.K. National Health Service.^[16][17]
• Stretching of the foreskin can be accomplished manually. 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 stretching can also be accomplished with balloons placed under the foreskin skin under anaesthesia,^[18]or with a tool.^[19] The tissue expansion promotes the growth of new skin cells to permanently expand the narrow preputial ring that prevents retraction.

Incidence

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.^[1][4],[8] When phimosis is simply equated with nonretractility of the foreskin after age 3 years, considerably higher incidence rates have been reported.^[20][21] 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.^[22]

Phimosis in history

• According to some accounts, phimosis prevented Louis XVI of France from impregnating his wife, Marie Antoinette, 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 (Vincent Cronin and Simone Bertiere) assert that surgical repair would have been mentioned in the records of his medical treatments if it had occurred.
• US President James Garfield was assassinated by Charles Guiteau in 1881. The autopsy report for Guiteau indicated that he had phimosis. At the time, this led to the simplistic speculation that Guiteau's murderous behavior was due to phimosis-induced insanity.^[23]

See also

• paraphimosis
• Medical analysis of circumcision
• frenulum breve
• David Reimer

References

Further reading

• Gairdner D (1949). "The fate of the foreskin, a study of circumcision". Br Med J 2 (4642): 1433–7, illust. PMID 15408299.  This study was one of the first attempts to determine incidence and is still cited by both advocates and opponents of circumcision. He reported both a high rate (92%) of retractability by age 5 years (though the report is criticised because he "ran a probe around to loosen the adherence of foreskin to glans") and a high rate (20%) of boys older than 5 without full retractability.
• Holman JR, Stuessi KA (1999). "Adult circumcision". Am Fam Physician 59 (6): 1514–8. PMID 10193593. http://www.aafp.org/afp/990315ap/1514.html.  Technique for circumcision with some discussion of phimosis as most common indication for adult circumcision.

External links

The following links are provided by advocates against circumcision and provide a discussion of alternative treatments.

• Male Initiation and the Phimosis Taboos
• Encyclopedia of Phimosis Statistics
• Anti-Circumcision Opinion: Conservative Treatment of Phimosis: Alternatives to Radical Circumcision
• NORM-UK: Information about conservative treatment of phimosis

Pictures

• Picture of a penis with phimosis
• Pictures of a penis with fully retracted foreskin after successful treatment of phimosis