Phimosis

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Phimosis
Classification and external resources

An erect penis with a case of phimosis
ICD-10 N47
ICD-9 605
DiseasesDB 10019
eMedicine emerg/423
MeSH D010688


Phimosis (/fɪˈmoʊsɨs/ or /faɪˈmoʊsɨs/[1][2]), from the Greek phimos (φῑμός ["muzzle"]), is a condition in males where the foreskin cannot be fully retracted over the glans penis. The term may also refer to clitoral phimosis in women, whereby the clitoral hood cannot be retracted, limiting exposure of the glans clitoridis.[3]

In the neonatal period, it is rare for the foreskin to be naturally retractable; Huntley et al. state that "non-retractability can be considered normal for males up to and including adolescence."[4] 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 (a condition deemed a problem).[5] Some authors use the terms "physiologic" and "pathologic" to distinguish between these types of phimosis;[6] others use the term "non-retractile foreskin" to distinguish this developmental condition from (pathologic) phimosis.[5]

There are three possible causes of non-retractile foreskin:

1. The tip of the foreskin is too narrow to pass over the glans penis. This is normal in children and adolescents.[7][8]
2. The inner surface of the foreskin is fused with the glans penis. This is normal in children and adolescents.[8]
3. The frenulum is too short to permit complete retraction of the foreskin (frenulum breve).

Pathological (acquired) phimosis has several causes. Lichen sclerosus et atrophicus (thought to be the same condition as balanitis xerotica obliterans) is regarded as a common (or even the main[9]) cause of pathological phimosis.[10] Other causes may include scarring caused by forcible retraction of the foreskin,[6] and balanitis.[11] Beaugé found that patients with phimosis had masturbation practices that differed from the usual pulling down of the foreskin that mimics sexual intercourse.[12] Some studies found phimosis to be a risk factor for urinary retention[13] and carcinoma of the penis.[14] Common treatments include steroid creams, manual stretching, preputioplasty, and circumcision.[15]

Normal development

At birth, the inner layer of the foreskin is sealed to the glans penis. This attachment forms "early in fetal development and provide[s] a protective cocoon for the delicate developing glans."[16] The foreskin is usually non-retractable in infancy and early childhood.[16]

The American Academy of Pediatrics and the Canadian Pediatric Society state that no attempt should be made to retract the foreskin of an infant.[17][18] Age is reportedly a factor in non-retractability: according to Huntley et al. the foreskin is reportedly retractable in approximately 50% of cases at 1 year of age, 90% by 3 years of age, and 99% by age 17. These authors argue that, unless scarring or other abnormality is present, non-retractibility may "be considered normal for males up to and including adolescence."[4] Hill states that full retractability of the foreskin may not be achieved until late childhood or early adulthood.[19] A Danish survey found that the mean age of first foreskin retraction is 10.4 years.[20]

Some pediatric urologists have argued that many physicians continue to have trouble distinguishing developmental non-retractility from pathological phimosis.[5][21][22]

Cause

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 retract an infant's 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, ballooning does not indicate urinary obstruction.[23]

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 in the flaccid state ('full phimosis').

When phimosis develops in an 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.

Beaugé noted that unusual masturbation practices, such as lying face down on a bed and rubbing the penis against the mattress, may cause phimosis. Patients are advised to stop exacerbating masturbation techniques and are encouraged to masturbate by moving the foreskin up and down so as to mimic more closely the action of sexual intercourse. After giving this advice Beaugé noted not once did he have to recommend circumcision.[12][24]

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. Infectious, inflammatory, and hormonal factors have all been implicated or proposed as contributing factors.[citation needed]

Phimosis may occur after other types of chronic inflammation (such as balanoposthitis), repeated catheterization, or forcible foreskin retraction.[25]

Phimosis may also arise in untreated diabetics due to the presence of glucose in their urine giving rise to infection in the foreskin.[26]

Management

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 adults, phimosis should be distinguished from frenulum breve, which more often requires surgery, though the two conditions can occur together.[citation needed]

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.[citation needed]

Nonsurgical

  • Topical steroid creams such as betamethasone, mometasone furoate and cortisone are effective in treating phimosis and may provide an alternative to circumcision.[27] It is theorized that the steroids work by reducing the body's inflammatory and immune responses, and also by thinning the skin.[27]
  • Stretching of the foreskin can be accomplished manually, with balloons[28] 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. Beaugé treated several hundred adolescents by advising them to change their masturbation habits to closing their hand over their penis and moving it back and forth. Retraction of the foreskin was generally achieved after four weeks and he stated that he never had to refer one for surgery.[12][24]

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 pathological 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[29][30] can be an effective alternative to circumcision.[22] 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 potential phimosis are inconsistent.[21][25][8][31][32][33]

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.

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.[25][31],[21] When phimosis is simply equated with nonretractility of the foreskin after age 3 years, considerably higher incidence rates have been reported.[8][32] 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.[33]

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.[citation needed] It should be mentioned that non-retractile prepuce in adolescence is normal and common.[34]
  • U.S. 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 simplistic speculation that Guiteau's murderous behavior was due to phimosis-induced insanity.[35]

References

  1. ↑ OED 2nd edition, 1989 as /faɪˈməʊsɪs/.
  2. ↑ Entry "phimosis" in Merriam-Webster Online Dictionary.
  3. ↑ Munarriz R, Talakoub L, Kuohung W, et al. (2002). "The prevalence of phimosis of the clitoris in women presenting to the sexual dysfunction clinic: lack of correlation to disorders of desire, arousal and orgasm". J Sex Marital Ther 28 (Suppl 1): 181–5. doi:10.1080/00926230252851302. PMID 11898701. 
  4. ↑ 4.0 4.1 Huntley JS, Bourne MC, Munro FD, Wilson-Storey D (September 2003). "Troubles with the foreskin: one hundred consecutive referrals to paediatric surgeons". J R Soc Med 96 (9): 449–451. doi:10.1258/jrsm.96.9.449. PMC 539600. PMID 12949201. 
  5. ↑ 5.0 5.1 5.2 Rickwood AM, Walker J (1989). "Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence?". Ann R Coll Surg Engl 71 (5): 275–7. PMC 2499015. PMID 2802472. "Authors review English referral statistics and suggest phimosis is overdiagnosed, especially in boys under 5 years, because of confusion with developmentally nonretractile foreskin." 
  6. ↑ 6.0 6.1 McGregor TB, Pike JG, Leonard MP (March 2007). "Pathologic and physiologic phimosis: approach to the phimotic foreskin". Can Fam Physician 53 (3): 445–8. PMC 1949079. PMID 17872680. 
  7. ↑ Kayaba H, Tamura H, Kitajima S, et al.. Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol. 1996;156(5):1813-5.. PMID 8863623.
  8. ↑ 8.0 8.1 8.2 8.3 Øster J. Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child. 1968;43(228):200-3. PMID 5689532.
  9. ↑ Bolla G, Sartore G, Longo L, Rossi C (2005). "[The sclero-atrophic lichen as principal cause of acquired phimosis in pediatric age]". Pediatr Med Chir (in Italian) 27 (3–4): 91–3. PMID 16910457. 
  10. ↑ Buechner SA (September 2002). "Common skin disorders of the penis". BJU Int. 90 (5): 498–506. doi:10.1046/j.1464-410X.2002.02962.x. PMID 12175386. 
  11. ↑ Edwards S (June 1996). "Balanitis and balanoposthitis: a review". Genitourin Med 72 (3): 155–9. PMC 1195642. PMID 8707315. 
  12. ↑ 12.0 12.1 12.2 Beaugé M (1997). "The causes of adolescent phimosis". Br J Sex Med 26 (Sept/Oct). 
  13. ↑ Minagawa T, Murata Y (June 2008). "[A case of urinary retention caused by true phimosis]". Hinyokika Kiyo (in Japanese) 54 (6): 427–9. PMID 18634440. 
  14. ↑ Daling JR, Madeleine MM, Johnson LG et al. (September 2005). "Penile cancer: importance of circumcision, human papillomavirus and smoking in in situ and invasive disease". Int. J. Cancer 116 (4): 606–616. doi:10.1002/ijc.21009. PMID 15825185. 
  15. ↑ Steadman B, Ellsworth P (June 2006). "To circ or not to circ: indications, risks, and alternatives to circumcision in the pediatric population with phimosis". Urol Nurs 26 (3): 181–94. PMID 16800325. 
  16. ↑ 16.0 16.1 J.E. Wright (february 1994). "Further to 'the further fate of the foreskin'". The Medical Journal of Australia 160 (3): 134–5. PMID 8295581. 
  17. ↑ "Care of the Uncircumcised Penis". Guide for parents. American Academy of Pediatrics. September 2007. 
  18. ↑ "Caring for an uncircumcised penis". Information for parents. Canadian Paediatric Society. July 2012. 
  19. ↑ George Hill (2003). "Circumcision for phimosis and other medical indications in Western Australian boys". The Medical Journal of Australia 178 (11): 587; author reply 589–90. PMID 12765511. 
  20. ↑ Thorvaldsen MA, Meyhoff H.. Patologisk eller fysiologisk fimose?. Ugeskr Læger. 2005;167(16):1852-62.
  21. ↑ 21.0 21.1 21.2 Spilsbury K, Semmens JB, Wisniewski ZS, Holman CD (2003). "Circumcision for phimosis and other medical indications in Western Australian boys". Med. J. Aust. 178 (4): 155–8. PMID 12580740. . Recent Australian statistics with good discussion of ascertainment problems arising from surgical statistics.
  22. ↑ 22.0 22.1 Van Howe RS (1998). "Cost-effective treatment of phimosis". Pediatrics 102 (4): e43–e43. doi:10.1542/peds.102.4.e43. PMID 9755280.  A review of estimated costs and complications of 3 phimosis treatments (topical steroids, praeputioplasty, and surgical circumcision). The review concludes that topical steroids should be tried first, and praeputioplasty has advantages over surgical circumcision. This article also provides a good discussion of the difficulty distinguishing pathological from physiological phimosis in young children and alleges inflation of phimosis statistics for purposes of securing insurance coverage for post-neonatal circumcision in the United States.
  23. ↑ Babu R, Harrison SK, Hutton KA (2004). "Ballooning of the foreskin and physiological phimosis: is there any objective evidence of obstructed voiding?". BJU Int. 94 (3): 384–387. doi:10.1111/j.1464-410X.2004.04935.x. PMID 15291873. 
  24. ↑ 24.0 24.1 Beaugé, Michel (1991). "Conservative Treatment of Primary Phimosis in Adolescents". Faculty of Medicine, Saint-Antoine University. 
  25. ↑ 25.0 25.1 25.2 Cantu Jr. S. Phimosis and paraphimosis at eMedicine
  26. ↑ Bromage, Stephen J.; Anne Crump and Ian Pearce (2008). "Phimosis as a presenting feature of diabetes". BJU International 101 (3): 338–340. doi:10.1111/j.1464-410X.2007.07274.x. PMID 18005214. 
  27. ↑ 27.0 27.1 Hayashi, Y.; Kojima, Y.; Mizuno, K.; Kohri, K. (2011). "Prepuce: phimosis, paraphimosis, and circumcision.". ScientificWorldJournal 11: 289–301. doi:10.1100/tsw.2011.31. PMID 21298220. 
  28. ↑ He Y, Zhou XH (1991). "Balloon dilation treatment of phimosis in boys. Report of 512 cases". Chin. Med. J. 104 (6): 491–3. PMID 1874025. 
  29. ↑ Cuckow PM, Rix G, Mouriquand PD (1994). "Preputial plasty: a good alternative to circumcision". J. Pediatr. Surg. 29 (4): 561–563. doi:10.1016/0022-3468(94)90092-2. PMID 8014816. 
  30. ↑ Saxena AK, Schaarschmidt K, Reich A, Willital GH (2000). "Non-retractile foreskin: a single center 13-year experience". Int Surg 85 (2): 180–3. PMID 11071339. 
  31. ↑ 31.0 31.1 Shankar KR, Rickwood AM (1999). "The incidence of phimosis in boys". BJU Int. 84 (1): 101–102. doi:10.1046/j.1464-410x.1999.00147.x. PMID 10444134.  This study gives a low incidence of pathological phimosis (0.6% of uncircumcised boys by age 15 years) by asserting that balanitis xerotica obliterans is the only indisputable type of pathological phimosis and anything else should be assumed "physiological". Restrictiveness of definition and circularity of reasoning have been criticized.
  32. ↑ 32.0 32.1 Imamura E (1997). "Phimosis of infants and young children in Japan". Acta Paediatr Jpn 39 (4): 403–5. PMID 9316279.  A study of phimosis prevalence in over 4,500 Japanese children reporting that over a third of uncircumcised had a nonretractile foreskin by age 3 years.
  33. ↑ 33.0 33.1 Ohjimi T, Ohjimi H (1981). "Special surgical techniques for relief of phimosis". J Dermatol Surg Oncol 7 (4): 326–30. PMID 7240535. 
  34. ↑ Øster J (1968). "Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys". Arch. Dis. Child. 43 (228): 200–203. doi:10.1136/adc.43.228.200. PMC 2019851. PMID 5689532. 
  35. ↑ Hodges FM (1999). "The history of phimosis from antiquity to the present". In Milos, Marilyn Fayre; Denniston, George C.; Hodges, Frederick Mansfield. Male and female circumcision: medical, legal, and ethical considerations in pediatric practice. New York: Kluwer Academic/Plenum Publishers. pp. 37–62. ISBN 0-306-46131-5. 

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