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.

• 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]

• Chronic Infection

  This is often the result of chronic infection caused by poor hygiene. Poor hygiene and enthusiastic attempts to correct congenital phimosis increase the risk of developing pathological phimosis. [patient.info]

  For instance, the penis may develop chronic infection or bleeding. Or the phimosis may come back. [aboutkidshealth.ca]

  HPV infection is common. In most men, the body clears the infection on its own. But in some, the infection doesn't go away and becomes chronic. [cancer.org]

  Chronic infection may lead to skin maceration and more scar contracture, further aggravating the problem. In many children, this condition is self-limited. [emedicine.medscape.com]

• 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]

• Recurrent Inflammation

  Intervention may be undertaken if there are issues with any of the following hygeine issues recurrent inflammation or infection of the foreskin (balanoposthitis) recurrent urinary tract infection difficulty with urination In deciding on the most appropriate [metrovanurology.com]

  […] of the glans penis Posthitis is an inflammation of the foreskin. [unboundmedicine.com]

  Scarring of the Prepuce Recurrent inflammation (balanitis) leads to scarring and narrowing of the prepuce, which itself predisposes to recurrent balanitis. [urology-textbook.com]

• 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]

• Dermatitis

  Dermat. & Syph. 42: 755 (Nov.) 1940. Nomland, R.: Lichen Sclerosus et Atrophicus (Hallopeau) and Related Cutaneous Atrophies, Arch. Dermat. & Syph. 21: 575 (April) 1930. [cirp.org]

  One child had an untoward effect (candidal dermatitis, TID regimen). There was an 84.5% response rate (moderate to no phimosis) with the BID regimen and an 87% response rate with the TID regimen (P = nonsignificant). [ncbi.nlm.nih.gov]

  Katerina Yale, Olabola Awosika, Monica Rengifo-Pardo and Alison Ehrlich, Genital Allergic Contact Dermatitis, Dermatitis, 10.1097/DER.0000000000000371, 29, 3, (112-119), (2018). Andrew T. Gabrielson, Tan V. [www3.interscience.wiley.com]

  Causes Physiologic Phimosis Newborn: Phimosis is normal in infants School age: 90% of boys can fully retract foreskin Puberty : Nearly 100% of boys fully retract foreskin Pathologic Causes Trauma Dermatitis Balanitis IV. [fpnotebook.com]

• Eczema

  As a steroid cream alternative, it has been shown to be beneficial to inflammatory skin conditions such as eczema (9) Do’s and Don’ts of Phimosis Do Conduct phimosis exercises regularly. Always use an anti-inflammatory cream. [homeremedyhacks.com]

  Phimosis may be caused by a skin condition, such as: Eczema: A long-term condition that causes the skin to become itchy, red, dry, and cracked. Psoriasis: This skin condition leads to patches of skin becoming red, flaky, and crusty. [medicalnewstoday.com]

• Skin Disease

  Summary Diseases of the male genitalia range from infectious lesions to inflammatory and neoplastic conditions, including many genital manifestations of more general skin diseases. [www3.interscience.wiley.com]

  UV light treatment of psoriasis Men who have a skin disease called psoriasis are sometimes treated with drugs called psoralens and then an ultraviolet A (UVA) light source. This is called PUVA therapy. [cancer.org]

  The patient should minimize or preferably stop scratching LS-affected skin.[25] Any scratching, stress or damage to the skin can worsen the disease. [en.wikipedia.org]

• Erythema

  Infection and cellulitis Secondary bacterial infection can occur, with erythema or lymphangitis tracking proximally down the penile shaft. Associated dysuria is common. [rch.org.au]

  Topisch wordt jodium gebruikt voor dermatitis, erythema nodosum, erythema multiforme, eczeem, psoriasis, als antisepticum, ter voorkoming van mucositis, wondgenezing en voor diabetische voet- en veneuze beenulcera. [sohf.nl]

• Irritability

  In adults, phimosis may result from balanoposthitis or prolonged irritation. Risk of UTI, penile cancer, HIV, and sexually transmitted diseases is increased. The usual treatment is circumcision. [merckmanuals.com]

  Remember, soaps and body washes are very irritating to the mucosal tissue of the glans and foreskin. Their pH is too alkaline while fragrances and surfactants found in them can irritate your penile tissue and even make your phimosis worse. [amazon.com]

  Bubble bath products and other chemical irritants can cause the foreskin to tighten and it is recommended they should be avoided by intact males. Thanks for your feedback! Article Sources Foreskin Hygiene Guidelines. American Academy of Pediatrics [menshealth.about.com]

  Commonly it may also lead to infection of the head of the penis, causing irritation and discharge. The tightening of the foreskin is caused by a tight preputial ring, a band of fibrous tissue at the end of the foreskin. [glansie.com]

  Traces of urine that remain under the foreskin can irritate it, so make sure you pull back the foreskin to wash the skin underneath. Sometimes balanoposthitis is the result of a bacterial or fungal infection. [metro.co.uk]

• 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]

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.