Phimosis

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 (fī-mō'sĭs, fĭ-), from the Greek phimos (φῑμός ("muzzle")), is a condition where, in men, 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.^[1]

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."^[2] 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).^[3] Some authors use the terms "physiologic" and "pathologic" to distinguish between these types of phimosis;^[4] others use the term "non-retractile foreskin" to distinguish this developmental condition from (pathologic) phimosis.^[3]

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^[5]) cause of pathological phimosis.^[6] Other causes may include scarring caused by forcible retraction of the foreskin,^[4] and balanitis.^[7] Beauge found that patients with phimosis had masturbation practices that differed from the usual pulling down of the foreskin that mimics sexual intercourse.^[8] Some studies found phimosis to be a risk factor for urinary retention^[9] and carcinoma of the penis.^[10] Common treatments include steroid creams, preputioplasty, manual stretching, and circumcision.^[11]

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."^[12] The foreskin is usually non-retractable in infancy and early childhood.^[12]

During the 20th century, studies were released which furthered understanding of the normal development of the foreskin. For example, The fate of the foreskin, a study of circumcision,^[13] Further fate of the foreskin, Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys,^[14] and Analysis of shape and retractability of the prepuce in 603 Japanese boys.^[15]

The American Academy of Pediatrics and the Canadian Pediatric Society state that no attempt should be made to retract the foreskin of an infant.^[16][17] 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."^[2] Hill states that full retractability of the foreskin may not be achieved until late childhood or early adulthood.^[18]

Some pediatric urologists have argued that many physicians continue to have trouble distinguishing developmental non-retractility from pathological phimosis.^[3][19][20]

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, even ballooning does not always indicate urinary obstruction.^[21]

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').

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.^[8][22]

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. Some evidence suggests that BXO may be the same disease as lichen sclerosus et atrophicus of the vulva in females.^[23] Infectious, inflammatory, and hormonal factors have all been implicated or proposed as contributing factors.

Phimosis may occur after other types of chronic inflammation (such as balanoposthitis), repeated catheterization, or forcible foreskin retraction.^[24]

Phimosis may also arise in untreated diabetics due to the presence of glucose in their urine giving rise to infection in the foreskin.^[25]

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 men, 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 men with non-retractile foreskins have no difficulties and see no need for correction.

Non surgical methods include:

• Application of topical steroid cream, such as betamethasone, for 4–6 weeks to the narrow part of the foreskin is relatively simple, less expensive than surgical treatments and highly effective.^[20][26][27] It has replaced circumcision as the preferred treatment method for some physicians in the British National Health Service.^[28][29]
• Stretching of the foreskin can be accomplished manually, with balloons^[30] 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.^[8][22]

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^[31][32] can be an effective alternative to circumcision.^[20] It has the advantage of only limited pain and a short time of healing relative to circumcision, and avoids cosmetic effects.

Surgery

See also: Medical analysis of circumcision

Physicians often saw the natural unretractability of the foreskin in infancy as pathological and recommended circumcision. Sometimes circumcision was performed in infancy to prevent phimosis.^[33] "Many boys are circumcised for (pathological or physiological) phimosis before the age of five years, despite (pathological) phimosis being rare in this group".^[34]

However, there are dissenting views. Robert S. Van Howe has argued that choosing to skip nonsurgical treatments for phimosis and go straight to circumcision may be influenced by non-medical considerations;^[20] he has also suggested that an inaccurate diagnosis of phimosis is sometimes used as a justification for elective circumcision so that it will be covered by a national health system or insurance plan.^[20] Moreover, one study has shown that attempting nonsurgical treatment of pathologic phimosis when it occurs in infants and children costs 27.3% less than primary circumcision.^[35][36]

While circumcision prevents phimosis, studies of the incidence of healthy infants circumcised for each prevented case of potential phimosis are inconsistent.^{[14][19][24][37][38][39]}

Prognosis

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 sexual 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.^[40]

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.^{[24][37],[19]} When phimosis is simply equated with nonretractility of the foreskin after age 3 years, considerably higher incidence rates have been reported.^[14][38] 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.^[39]

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]}
• 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.^[41]
• Canadian prime minister Richard Bedford Bennett had phimosis.^[42]

See also

• Paraphimosis
• Preputioplasty
• Medical analysis of circumcision
• Frenulum breve
• David Reimer
• Smegma

References

1. ^ 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
2. ^ ^{a b} 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. http://www.jrsm.org/cgi/pmidlookup?view=long&pmid=12949201. 
3. ^ ^{a b c} 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. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2499015. "Authors review English referral statistics and suggest phimosis is overdiagnosed, especially in boys under 5 years, because of confusion with developmentally nonretractile foreskin." 
4. ^ ^{a b} 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. http://www.cfp.ca/cgi/pmidlookup?view=long&pmid=17872680. 
5. ^ Bolla G, Sartore G, Longo L, Rossi C (2005). "[The sclero-atrophic lichen as principal cause of acquired phimosis in pediatric age]" (in Italian). Pediatr Med Chir 27 (3–4): 91–3. PMID 16910457. 
6. ^ 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. http://www3.interscience.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=1464-4096&date=2002&volume=90&issue=5&spage=498. 
7. ^ Edwards S (June 1996). "Balanitis and balanoposthitis: a review". Genitourin Med 72 (3): 155–9. PMC 1195642. PMID 8707315. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1195642. 
8. ^ ^{a b c} Beaugé M (1997). "The causes of adolescent phimosis". Br J Sex Med 26 (Sept/Oct). http://www.cirp.org/library/treatment/phimosis/beauge2/. 
9. ^ Minagawa T, Murata Y (June 2008). "[A case of urinary retention caused by true phimosis]" (in Japanese). Hinyokika Kiyo 54 (6): 427–9. PMID 18634440. 
10. ^ 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. 
11. ^ 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. 
12. ^ ^{a b} J.E. Wright (february 1949). "Further to 'the further fate of the foreskin'". The Medical Journal of Australia 160 (3): 134–5. PMID 8295581. http://www.cirp.org/library/normal/wright2/. 
13. ^ Gairdner D (1949). "The fate of the foreskin, a study of circumcision". Br Med J 2 (4642): 1433–1437. doi:10.1136/bmj.2.4642.1433. PMC 2051968. PMID 15408299. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2051968. 
14. ^ ^{a b c} Oster 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. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2019851. 
15. ^ Kabaya, Hiroyuki; Hiromi Tamura,Seiichi Kitajima, Yoshiyuki Fujiwara, Tetsuo Kato, Tetsuro Kato (November 1996). "Analysis of shape and retractability of the prepuce in 603 Japanese boys". Journal of urology 156 (5): 1813–1815. doi:10.1016/S0022-5347(01)65544-7. PMID 8863623. http://www.cirp.org/library/normal/kayaba/. 
16. ^ "Care of the Uncircumcised Penis". Guide for parents. American Academy of Pediatrics. September 2007. http://www.aap.org/publiced/br_uncircumcised.htm. 
17. ^ "Caring for an uncircumcised penis". Information for parents. Canadian Paediatric Society. November 2004. http://www.caringforkids.cps.ca/pregnancy&babies/Circumcision.htm. 
18. ^ 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. http://www.mja.com.au/public/issues/178_11_020603/matters_arising_020603-1.html. 
19. ^ ^{a b c} 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. http://www.mja.com.au/public/issues/178_04_170203/spi10278_fm.html. . Recent Australian statistics with good discussion of ascertainment problems arising from surgical statistics.
20. ^ ^{a b c d e} Van Howe RS (1998). "Cost-effective treatment of phimosis". Pediatrics 102 (4): e43–e43. doi:10.1542/peds.102.4.e43. PMID 9755280. http://pediatrics.aappublications.org/cgi/content/full/102/4/e43.  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.
21. ^ 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. 
22. ^ ^{a b} Beaugé, Michel (1991). "Conservative Treatment of Primary Phimosis in Adolescents". Faculty of Medicine, Saint-Antoine University. http://www.cirp.org/library/treatment/phimosis/beauge/. 
23. ^ Laymon CW, Freeman C (1944). "Relationship of Balanitis Xerotica Obliterans to Lichen Sclerosus et Atrophicus". Arch Dermat Syph 49: 57–9. http://www.cirp.org/library/treatment/BXO/laymon1/. 
24. ^ ^{a b c} Cantu Jr. S. Phimosis and paraphimosis at eMedicine
25. ^ 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. http://www3.interscience.wiley.com/journal/118508219/abstract?CRETRY=1&SRETRY=0. 
26. ^ Topical steroid application versus circumcision in pediatric patients with phimosis: a prospective randomized placebo controlled clinical trial, World Journal of Urology, 2008, 26, pp.187-190
27. ^ Phimosis and topical steroids: new clinical findings, Pediatric Surgery International, 2007, 23, pp.331-335
28. ^ Berdeu D, Sauze L, Ha-Vinh P, Blum-Boisgard C (2001). "Cost-effectiveness analysis of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect". BJU Int. 87 (3): 239–244. doi:10.1046/j.1464-410x.2001.02033.x. PMID 11167650. http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=1464-4096&date=2001&volume=87&issue=3&spage=239. 
29. ^ Chu CC, Chen KC, Diau GY (1999). "Topical steroid treatment of phimosis in boys". J. Urol. 162 (3 Pt 1): 861–863. doi:10.1097/00005392-199909010-00078. PMID 10458396. 
30. ^ 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. http://www.cirp.org/library/treatment/phimosis/he-zhou/. 
31. ^ 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. http://linkinghub.elsevier.com/retrieve/pii/0022-3468(94)90092-2. 
32. ^ 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. http://www.cirp.org/library/treatment/phimosis/saxena1/. 
33. ^ J.E. Wright (february 1994). "Further to 'the further fate of the foreskin'". The Medical Journal of Australia 160 (3): 134–5. PMID 8295581. http://www.cirp.org/library/normal/wright2/. 
34. ^ Dewan PA (2003). "Treating phimosis". Med. J. Aust. 178 (4): 148–50. PMID 12580737. http://www.mja.com.au/public/issues/178_04_170203/dew10610_fm.html. 
35. ^ Hina Z Ghory; Rahul Sharma (April 28, 2010). "Phimosis and Paraphimosis". eMedicine. http://emedicine.medscape.com/article/777539-treatment. "An initial attempt at medical intervention has been shown to reduce costs by 27.3% in comparison with primary circumcision as a treatment of phimosis in infants and children." 
36. ^ Nobre, YD; Freitas, RG; Felizardo, MJ; Ortiz, V; MacEdo Jr, A (January 2010). "To circ or not to circ: clinical and pharmacoeconomic outcomes of a prospective trial of topical steroid versus primary circumcision". International Braz J Urol 36 (1): 75–85. doi:10.1590/S1677-553820100000100012. PMID 20202239. http://www.brazjurol.com.br/january_february_2010/Nobre_75_85.htm. "As a first-line treatment for [pathologic] phimosis, topical corticosteroid administration reduced costs by 27.3% in comparison with circumcision, even when we included the costs of the circumcisions eventually performed in the clinical treatment group." 
37. ^ ^{a b} 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. http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=1464-4096&date=1999&volume=84&issue=1&spage=101.  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.
38. ^ ^{a b} 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.
39. ^ ^{a b} Ohjimi T, Ohjimi H (1981). "Special surgical techniques for relief of phimosis". J Dermatol Surg Oncol 7 (4): 326–30. PMID 7240535. 
40. ^ Willcourt RJ. Discussion of Rickwood et al. (2000) BMJ.com e-letters, 30 June 2005.
41. ^ 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. http://www.circumstitions.com/Absurd.html#assassin. 
42. ^ http://www.nndb.com/people/500/000111167/

External links

• Our son is not circumcised. When will his foreskin retract? by American Academy of Pediatrics
• Normal development of the foreskin: Birth through age 18 by CIRP
• Conservative Treatment of Phimosis: Alternatives to Radical Circumcision by CIRP
• Male Initiation and the Phimosis Taboos
• Encyclopedia of Phimosis Statistics
• NORM-UK: Information about conservative treatment of phimosis
• Phimosis treatment information
• The Manitoban article on phimosis and frenulum breve

Pictures

• Picture of a penis with phimosis
• Pictures of a penis with fully retracted foreskin after successful treatment of phimosis