Phimosis presents with the following characteristic clinical features.

• There is an inability to retract the foreskin of penis.
• A white constricting ring or band of prepuce may be seen over the glans.
• Redness of the prepuce may be seen.
• There is localized pain and tenderness in the penis.
• Urinary obstruction may be present and the urinary system may be weak. In addition, the prepuce may show swelling during urination.
• Hematuria (blood in urine) may also be seen in some cases.
• A purulent discharge may be present.
• Erection of the penis may be associated with moderate pain.
• These patients may suffer from recurrent infections of the urinary tract.
• Scarring may or may not be present.

• Pain

  Infection may result from an inability to carry out effective cleaning of the area, in which case swelling, redness, and discharge may all be present, making the area tender and painful. [menshealth.about.com]

  If the foreskin becomes inflamed in this position it may lead to paraphimosis, where the foreskin becomes inflamed and painful. This itself may require surgery to rectify. Pain during sexual intercourse. [netdoctor.co.uk]

  Complications of phimosis Phimosis can lead to complications such as: Pain and discomfort during urination Pain and discomfort during sexual intercourse Paraphimosis A risk factor for penile cancer Phimosis usually resolves itself in more than 90% of [medic8.com]

  Sometimes boys release it themselves or a doctors does this, often a painful experience. Occasionally the epithelium makes any movement of foreskin intensely painful or impossible. [male-initiation.net]

• Inflammation

  ICD-10-CM N47.1 is grouped within Diagnostic Related Group(s) (MS-DRG v 36.0): 727 Inflammation of the male reproductive system with mcc 728 Inflammation of the male reproductive system without mcc 795 Normal newborn Convert N47.1 to ICD-9-CM Code History [icd10data.com]

  The most frequent nuisance is increased spreading of the jet of urine (bother the cleaner more than the boy) and inflammation under the foreskin. [illchild.com]

  Pathological investigation carefully evaluated findings such as acute inflammation, chronic inflammation, increased pigmentation and atrophy in addition to findings of Lichen Sclerosus (LS) in all specimens. [ncbi.nlm.nih.gov]

  Inflammatory conditions like balanitis (inflammation of glans penis) and balanoposthitis (inflammation of prepuce and glans penis) can also lead to the development of pathological phimosis. Scarring of preputial orifices can cause phimosis. [symptoma.com]

  If a man or boy does not wash the area thoroughly and consistently, he may develop an infection, such as posthitis (inflammation of the foreskin) or balanitis (inflammation of the glans penis). Sometimes these two infections occur together. [issm.info]

• Gangrene

  We report a case of Fournier's gangrene in a 12-year-old boy from St. Boniface Hospital in Fond-des-Blancs, Haiti. [ncbi.nlm.nih.gov]

  As the swelling progresses, arterial supply is compromised, leading to penile infarction/necrosis, gangrene, and eventually, autoamputation. [emedicine.medscape.com]

• Severe Pain

  Forcing the foreskin to retract before it is ready can cause severe pain, bleeding, and tears in the skin. Smegma When the foreskin separates from the head of the penis, skin cells are shed. [web.archive.org]

  When this happens, it can result to severe painful conditions. [phimosis.ca]

  'I've never been able to have sex' Image copyright Getty Images Image caption Even washing his penis used to make Curtis sick (stock image) Curtis, 21, from Worcestershire, developed post-traumatic stress disorder due to the severe pain he experienced [bbc.co.uk]

• Enuresis

  As a result, the patient was freed from mechanical urethophraxis, frequent micturition and enuresis nocturna. Ureschesis and ureterohydronephrosis were significantly relieved. Case 2. [cirp.org]

  Occasionally, enuresis or urinary retention is noticed. The meatal opening is small and the tissue in front of the foreskin is white and fibrotic [29–31]. Phimosis due to BXO is severe with meatal stenosis, glanular lesions, or both [28]. [hindawi.com]

• Abdominal Distension

  After the bandage was removed the child voided a large volume of urine and the abdominal distension disappeared. The cause of systemic upset was an Escherichia coli urinary tract infection and subsequent septicaemia. [cirp.org]

• Sweating

  "I did have a girlfriend at one point, and when it started to go towards that sort of thing my heart rate would pick up and I would start to sweat and I just couldn't cope," he said. [bbc.co.uk]

  On the non-genital skin, the disease may manifest as porcelain-white spots with small visible plugs inside the orifices of hair follicles or sweat glands on the surface. [en.wikipedia.org]

• Visual Impairment

  A randomised trial of povidone-iodine to reduce visual impairment from corneal ulcers in rural Nepal. Br J Ophthalmol. 2004;88(12):1487-1492. 55972 Raczynska, K., Kokot, W., Krajka-Lauer, J., and Iwaszkiewicz-Bilikiewicz, B. [sohf.nl]

• Forgetful

  Patients with phimosis, both physiologic and pathologic, are at risk for developing paraphimosis when the foreskin is forcibly retracted past the glans and/or the patient or caretaker forgets to replace the foreskin after retraction. [emedicine.medscape.com]

• Painful Erection

  Pathologic phimosis may be detected in males who report painful erections, hematuria, recurrent urinary tract infections, preputial pain, or a weakened urinary stream. (See below.) Physiologic phimosis versus pathologic phimosis. [emedicine.medscape.com]

  Complications of phimosis include bleeding, infections, difficult or painful urination, and painful erections. Sometimes paraphimosis, a condition in which the foreskin stays retracted and can’t be pulled forward, occurs as well. [issm.info]

  If you experience painful erections while you have phimosis, see a doctor as soon as possible. Painful erections, especially with symptoms like swelling and discharge, can be signs of an infection or sexually transmitted disease (STD). [healthline.com]

• Dysuria

  Pathologic phimosis that does not resolve naturally or causes other complications, including; penile irritation or bleeding, ballooning of the foreskin with urination resulting in forceful/difficult urination, urinary retention, painful urination (dysuria [urology.ucsf.edu]

  Phimosis that does not resolve naturally or causes other complications, including penile irritation or bleeding, ballooning of the foreskin with urination resulting in forceful/difficult urination, urinary retention, painful urination (dysuria), painful [ohsu.edu]

  Tags: dysuria Phimosis Sean M. Fox I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. [pedemmorsels.com]

In case of phimosis, there is no role of investigations in the diagnosis. The diagnosis can be made exclusively by proper history and physical examination of the patient.

Physiologic phimosis resolves itself by the time a child reaches puberty and requires no medical or surgical intervention for its correction.

For pathological phimosis, the conservative treatment consists of stretching the foreskin over the glans either manually or with tools under the guidance of a physician which can resolve the problem by widening the preputial ring. But this can also lead to permanent swelling and although a non-invasive procedure, it is avoided.

Medical treatment of phimosis consists of steroids. Topical steroids (like cortisone) application on the preputial orifice can help soften the skin [3] [4] [5].

The surgical treatment can be done by the following [6] [7].

• Circumcision: It is the surgical removal of the foreskin of the penis. It is one of the most effective therapies for phimosis [8][9] [10].

• Manual reduction of the prepuce over the glans with procedures to minimize the edema of the glans like osmotic method, puncture technique, hyaluronidase method and aspiration.
• Dorsal slit procedure
• Ventral slit procedure: the restricting band is incised for about 1 to 2 cm in the 12 o’clock position.
• Preputioplasty: It consists of separation of the foreskin from glans. It is less traumatic as compared to circumcision and provides the advantage of rapid healing and less pain.

Treatment of concurring infections like urinary tract infection, balanitis and balanoposthitis should also be done.

Pathological phimosis is more likely to occur in case of repeated manual attempts to cause retraction of foreskin in congenital phimosis.

With proper care and treatment, complete resolution of the condition can occur. 80 to 90 % of the cases respond to corticosteroid therapy. 75% of the cases can be corrected with manual reduction method.

However, 2 % of the cases are related with gross morbidities like swelling and inflammation, necrosis, gangrene and auto amputation of the penis.

Phimosis can be either by physiological or pathological [1].

Physiological

At the time of birth, the foreskin is firmly attached to glans penis. This persists through early childhood till puberty and resolves thereafter.

Pathological

Inability of the foreskin to retract after attaining puberty constitutes pathological type of phimosis.

Pathological phimosis can have a number of causes.

• Poor hygiene is a contributing factor in the development of pathological phimosis.
• Inflammatory conditions like balanitis (inflammation of glans penis) and balanoposthitis (inflammation of prepuce and glans penis) can also lead to the development of pathological phimosis.
• Scarring of preputial orifices can cause phimosis.
• Pathological phimosis may also occur as a result of trauma.
• The patients who have short frenulum and narrow preputial ring are predisposed to the development of phimosis.
• Pathological phimosis may also be iatrogenic. It can result from catheterization of the penis.
• Infection secondary to other diseases like diabetes may also lead to phimosis. Phimosis may sometimes even be the presenting complaint of the patients with diabetes [2].

Physiologic phimosis is common in about 10% of the males by the age of 3 and in about 5% by the age of 16. The incidence of phimosis is more among the uncircumcised as compared to the uncircumcised males. Phimosis rarely affects the females.

The normal penis is composed of the shaft, the glans penis and the prepuce. The inner surface of prepuce is firmly adherent to the glans in infancy and early childhood (physiological phimosis). These adhesions later on breakdown and form pearly white beads called “smegma” under the foreskin.

In uncircumcised males, inflammation of prepuce or glans results in scar tissue formation as a result of which the foreskin loses its elasticity and cannot be retracted over the glans.

It is not possible to prevent the congenital (physiological) form of phimosis. However, pathological phimosis can be prevented by the use of the following preventive measures.

• Observing proper hygiene can help reduce the likelihood of developing the pathological form of phimosis.
• Forcible retraction of the foreskin should be avoided as it can lead to permanent trauma in addition to infections.
• Children as well as the patients of pathological phimosis should be educated about the importance of reducing the foreskin every time after cleaning.
• Children should be taught the importance of cleaning and drying properly under the foreskin every time.
• If the foreskin cannot be retracted even after the age of 14, expert help should be sought.
• If not taken proper care of, phimosis can lead to paraphimosis and even penile carcinoma.

Phimosis is a penile disorder in which the foreskin of the penis is attached to the underlying penile tissue and cannot be retracted over it. The disease is common in the males who have not been circumcised.

Difficulty while urinating or while performing normal sexual activity are common complaints associated with phimosis.
The condition may also be found in females to a lesser extent (clitoral phimosis). Closely related to phimosis is another disease, paraphimosis, in which the skin of penis is retracted beyond the corona and cannot be returned back to the unretracted position.

Phimosis is the condition in which the foreskin of the penis is attached to the underlying skin and cannot be retracted over the head of the penis. This can lead to painful erection and difficulty while urinating and during intercourse. Erection is also painful.

The attachment of foreskin to glans penis (head of the penis) is normal in childhood and it detaches itself at puberty. If the condition persists even after puberty, it is known as phimosis. Non-invasive procedure of treating phimosis consists of retracting the foreskin over the head manually. Ointments are also available for this purpose. Observing proper hygienic measures can help avoid phimosis in adults.

1. Thorvaldsen MA, Meyhoff HH. [Pathological or physiological phimosis?]. Ugeskrift for laeger. Apr 25 2005;167(17):1858-1862.
2. Skoglund RW. Diabetes presenting with phimosis. Lancet. Dec 25 1971;2(7739):1431.
3. Moreno G, Corbalan J, Penaloza B, Pantoja T. Topical corticosteroids for treating phimosis in boys. The Cochrane database of systematic reviews. 2014;9:CD008973.
4. Lee JW, Cho SJ, Park EA, Lee SJ. Topical hydrocortisone and physiotherapy for nonretractile physiologic phimosis in infants. Pediatric nephrology. Aug 2006;21(8):1127-1130.
5. Esposito C, Centonze A, Alicchio F, Savanelli A, Settimi A. Topical steroid application versus circumcision in pediatric patients with phimosis: a prospective randomized placebo controlled clinical trial. World journal of urology. Apr 2008;26(2):187-190.
6. Tofukuji H. [Surgery of phimosis]. Shujutsu. Operation. Jun 1970;24(6):739-743.
7. Falkowski J. [Surgical treatment of phimosis]. Polski tygodnik lekarski. Nov 3 1952;7(44):1413-1419.
8. Bailis SA. Circumcision for phimosis and other medical indications in Western Australian boys. The Medical journal of Australia. Jun 2 2003;178(11):587-588; author reply 589-590.
9. Stenram A, Malmfors G, Okmian L. Circumcision for phimosis: a follow-up study. Scandinavian journal of urology and nephrology. 1986;20(2):89-92.
10. Stenram A, Malmfors G, Okmian L. Circumcision for phimosis--indications and results. Acta paediatrica Scandinavica. Mar 1986;75(2):321-323.