Phymosis Related Complications

 

 

Although it is in generally- a common condition- not too many people have heard about the condition called phimosis. What exactly is phimosis? Well, it is defined as the inability of the prepuce, also called -the foreskin, to be retracted behind the glans penis. Of course- we are talking about uncircumcised males. What’s also interesting-a great majority of all males are born with congenital phimosis but this represents a benign condition that resolves in the great percentage of infants in their early childhood. It is also extremely important to point out that the phimosis in most infants is physiological rather than pathological, whereas phimosis in older children and adults is more often pathological than physiological. Although, it is mostly a condition that affects the males, women can also suffer from a similar condition called the clitoral phimosis. The most common symptoms are:

·          inability to retract foreskin

·          straining during urination

·          thin stream of urine

·          recurrent urinary infections

Good thing is that uncomplicated pathologic phimosis is usually acceptable to conservative medical treatment but patients should know that every failure of medical treatment is a secure indication for surgical intervention, usually in the traditional form of a circumcision or preputioplasty. 

Everyone should know that the foreskin or prepuce is an integral, normal part of the penis. It normally forms an anatomical covering over the glans. It is interesting that the sensory receptors of the ridged band of the preputial mucosa may form part of the afferent limb of the ejaculatory reflex and that’s why it is important that all of these structures are fully functional. Like it was been told- the development of the prepuce is incomplete in the newborn male child. Separation from the glans and foreskin retractability occurs at a variable age.  

Important thing to point out is that a commonly incidence statistic for pathological phimosis is 1% of uncircumcised males. Others have described incidences in adolescents and adults as high as 50%. Several researches done in the past have showed that only 4% of infants had a fully retractable foreskin at birth but that 90% did by age 3 years. This means that this condition could be, in certain occasions and age, considered to be physiological. Beside this, primary type- experts are saying that adult phimosis may also occur secondary to poor hygiene or an underlying medical condition.

Like it was already mentioned- this infantile phimosis has been widely recognized by the general practitioners for most of the last century. It is extremely important to point out that this foreskin cannot be easily retracted. There are several approaches to this type of phimosis and the most famous one where foreskin is being repeatedly retracted to free it from the glans. If this isn’t being done- later in life, a boy could experience pathological phimosis and urinary problems. Poor hygiene was thought to predispose to pathological phimosis. Oppositely to this approach- there are some experts that claim that forceful retraction that results in inflammation may actually contribute to pathological phimosis at an older age.

Another approach is presented in some physicians is based on routine neonatal circumcision. How come? Well, the fact is that circumcision really does prevent phimosis, although by some incidence statistics, at least 10 to 20 infants must be circumcised to prevent each case of potential phimosis. Although, so far, this infantile phimosis is mentioned only as physiological, the thing is that this isn’t the only case because not all infantile phimosis is simply physiological. Possible causes of these, pathological congenital phimosis, are:

There are several management approaches to infant phimosis and some of the most common are topical steroid ointments and several other surgical techniques.

Reasonably- not all phimosis are the same! They can vary in severity, with some men able to retract their foreskin partially, condition called relative phimosis, and some completely unable to retract foreskin, condition called full phimosis. Of course- this first type- relative phimosis is more common, with estimates of its frequency at approximately 8% of uncircumcised men.  Exact medical graduation is next:

Patients should know that stretching techniques could be particularly useful for treatment of the non-retractile foreskin. Here are some good advices:

·          Use baby oil or simple Vaseline intensive as a lubricant

·          Pull the foreskin forward away from the body several times then pull it back and hold it in the stretched position for several minutes twice daily

·          Then you could insert your thumb or smaller finger if necessary, into the foreskin and grip the glans between finger and thumb and then roll the foreskin over the thumb until the tight ring is white with stretching

·          Hold it in this position as long as you can at a time

It is reasonable that acquired phimosis, if left untreated, can lead to several complications! Chronic complications of acquired (pathological phimosis) include: discomfort or pain during urination or sexual intercourse. How come? Well, it is simple- the urinary stream can be impeded, resulting in dribbling and wetness after urination. During sexual intercourse, or even during simple erection, patient could experience strong pain because of over-extension of the foreskin! Pain may occur when a partially retractable foreskin retracts during intercourse and chokes the glans penis. Although nothing of this is proven –the fact is that there is some evidence that phimosis may be a risk factor for penile cancer. Of course, all patients should know that the worst acute complication is paraphimosis. Paraphimosis is one acute condition characterized by the glans swollenness and strong pain. During this condition the foreskin is immobilized by the swelling in a partially retracted position. The contraction may occur for the first time as an adult and usually requires an operation (circumcision).

Review of possible complications:

·          There might be trouble urinating

·          Problems and pain during intercourse

·          Infections may occur under the foreskin

·          Frequent and recurrent infections under the foreskin which can be avoided by cleaning regularly under the foreskin with lukewarm water

·          At erection, a contracted foreskin may cause trouble by hurting when an attempt is made to pull the foreskin back

·          Although very rarely, there is a chance that a malignant growth can occur in a long-standing foreskin contraction.

One of the most beneficial things about the circumcision is the fact that it has been promoted as a means of reducing the risk of urinary tract infections, which are more common in uncircumcised males younger than 6 months. Several researches have proven that the risk in circumcised kids is approximately 1 in 1000, while the risk in uncircumcised kids is about 1 in 100.

Another very serious indication for circumcision is prevention of STDs. Although not too many people know about this- the fact is that a large number of case-control studies concerning the relationship between the foreskin and HIV infection have confirmed the present but not definite link. Another fact is that the United States has one of the highest rates of STDs, HIV infection, and male circumcision. Strange!

Timing of circumcision could also be amazingly important! Although it may sound impossible- the fact is that infant circumcision seems to decrease the risk of penile cancer, while the same thing but only -done later does not. Good thing is that penile cancer is a rare disease in the United States, with an incidence of 1.5 per 100,000 people. Direct proof of this the fact that the lowest incidence has been reported in Muslims and Jews and we all know that both of these groups have high rates of neonatal circumcision.

Experts are claiming that this condition may be a presenting symptom of early diabetes mellitus. Where is the connection between these two conditions? Well, it is simple- when the residual urine of a patient with diabetes mellitus becomes trapped under the foreskin, the combination of a moist environment and glucose in the urine may lead to a proliferation of bacteria which can then progress to phimosis.

Experts today know that the presence of the foreskin actually enhances the sexual experience for men because it constantly moves over the head of the penis causing more friction and pleasure. Therefore, it is logical to assume that men will also lose much sensitivity to the glans if circumcised. Not only that- it is also proven that circumcised men will have to deal with discomfort and dry glans. The foreskin has many needed functions: protective, erogenous, sensory, and sexual physiologic.