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Phimosis

Phimoses

Phimosis refers to abnormal tightness of the foreskin, preventing its being retracted over the glans penis. Physiologic phimosis occurs naturally in males up to and including adolescence. Pathologic phimosis has several causes.


Presentation

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.
Enuresis
  • Enuresis A number of symptoms of obscure cause, such as enuresis, masturbation, habit spasm, night terrors, or even convulsions, have from time to time been attributed to phimosis, and circumcision has been advised.[cirp.org]
Long Arm
  • A transversal incision is made on the dorsal side of the ring of prepuce, like 3 contiguous Ts, the middle one inverted with the long arm on the preputial mucosa side.[ncbi.nlm.nih.gov]
Blurred Vision
  • Two months later, she had blurred vision in the right eye with the best-corrected visual acuity (BCVA) of 20/40.[ncbi.nlm.nih.gov]
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.com]
  • Symptoms of may include: Difficulty or pain during urination Painful erection Paraphimosis (A medical emergency where the foreskin can't return to it's normal location once retracted.)[medicinenet.com]

Workup

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.

Treatment

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.

Prognosis

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.

Etiology

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].

Epidemiology

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.

Sex distribution
Age distribution

Pathophysiology

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.

Prevention

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.

Summary

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.

Patient Information

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.

References

Article

  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.

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Last updated: 2019-07-11 22:43