Phimosis

Overview
Phimosis is a medical condition in which the foreskin of the penis of a male cannot be fully retracted. The word derives from the Greek phimos (, "muzzle"). The term is confusing because it is used to denote both a physiological stage of development (i.e. not a disease), and a pathological condition (i.e. a condition that causes problems for a person). Elasticity and ambiguity of definition are especially common when referring to infants. Conflicting incidence reports and widely varying post-neonatal circumcision rates reflect looseness in the diagnostic criteria. Phimosis has become a topic of contention in circumcision debates

Phimosis in most but not all infants is physiological rather than pathological, whereas phimosis in older children and adults is more often pathological than physiological. 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. Different management is appropriate.

Note that women can suffer from clitoral phimosis.

Infantile or congenital phimosis
It has been widely recognized by the medical profession for most of the last century that normal male infants have foreskins which are incompletely separated from the epithelium of the glans penis. They cannot be easily retracted. There have been four types of medical responses and attitudes toward this "normal" infant phimosis:


 * 1) Some physicians, especially in the first half of the twentieth century, recommended that the foreskin be repeatedly retracted, if necessary with some force, to free it from the glans. It was thought that ensuring separation early could prevent later (pathological) phimosis and urinary problems in older boys, since it permitted 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) Some physicians, particularly in the middle of the twentieth century, used avoidance of phimosis as justification for routine neonatal circumcision. Circumcision does prevent phimosis, although by some incidence statistics, at least 10 to 20 infants must be circumcised to prevent each case of potential phimosis. If one believes even lower phimosis incidence estimates, far more must be circumcised to prevent each case of phimosis. Although there are proponents of this view, it is not considered a compelling argument for routine neonatal circumcision by most pediatricians.
 * 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. There is now some suspicion that forceful retraction that results in inflammation may actually contribute to pathological phimosis at an older age. 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.
 * 4) Phimosis is sometimes used as a justification for circumcision, 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.

Not all infantile phimosis is simply physiological. Though uncommon, phimosis can occasionally lead to urinary obstruction or pain. Causes of pathological phimosis in infancy 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.

There are several management approaches to infant phimosis. Most cases of simple physiological phimosis need no "management" but will disappear with time or simple stretching of the foreskin. Various topical steroid ointments have been effective at hastening separation without surgery. Several surgical techniques have been devised, which range from simple slitting of a segment of the foreskin to removal of it (circumcision).

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. Relative phimosis is more common, with estimates of its frequency at approximately 8% of uncircumcised men.

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.

An important 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. 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.

Images of phimosis.

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.

The worst acute complication is 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. Paraphimosis is considered an emergency.

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 adults 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 adults 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, though others quote higher rates.


 * Preputioplasty, in which a limited dorsal slit with transverse closure is made along the constricting band of skin can be an effective alternative to full circumcision. 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.

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. It has replaced circumcision as the preferred treatment method for some physicians in the U.K. National Health Service.

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. Stretching of the foreskin can be accomplished manually, sometimes with masturbation, also known as the Beaugé method. The stretching can also be accomplished with balloons placed under the foreskin skin under anaesthesia, or with a tool. The tissue expansion promotes the growth of new skin cells to permanently expand the narrow preputial ring that prevents retraction.

Dilation and Stretching

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 treatment is inexpensive. Relief of phimosis by a stretching technique has the advantage of preserving all foreskin tissue and the sexual pleasure nerves. The Beaugé Method has proved successful for many.

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. , When phimosis is simply equated with nonretractility of the foreskin after age 3 years, considerably higher incidence rates have been reported. 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.Ohjimi T, Ohjimi H. surgical techniques for relief of phimosis J Dermatol Surg Oncol 7:326-30, 1981. Almost half of Japanese adolescent and adult men suffer from some degree of phimosis.

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.

Other

 * Gairdner D. The fate of the foreskin, a study of circumcision Brit Med J 2:1433-7, 1949. 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. Adult circumcision American Family Physician 1999;59(6): 1514. Technique for circumcision with some discussion of phimosis as most common indication for adult circumcision.