Although it is in generally regarded as a common condition, not too many people have heard about phimosis. What exactly is this condition?
Phimosis is defined as the inability of the prepuce, also called the foreskin, to be retracted behind the glans. Of course, we are talking about uncircumcised males.
What is also interesting, a great majority of all males are born with congenital phimosis, but this represents a benign condition that does not need any treatment and resolves on its own in the majority of infants in their early childhood. Phimosis in infants is termed pathologic when nonretractability is associated with local or urinary complaints attributed to the phimotic prepuce. 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.[1] Although it is mostly a condition that affects the males, women can also suffer from a similar condition called clitoral phimosis.
As already mentioned phimosis in male babies is completely normal — in this case, phimosis protects the sensitive head of the penis from rubbing against things, becoming too dry and coming into contact with germs like viruses or bacteria. 90% of male babies are born with their foreskins tight or stuck to the head of their penis. This normal condition resolves within the first three years of their life. However, phimosis demands treatment when the foreskin can’t be pulled back in older boys or adult men.[2]
- About one-half of one-year-old boys are affected by phimosis.
- About one in 10 three-year-old boys still have phimosis.
- And by the age of 16, only 1 out of 100 teenage boys are still affected.
The most common symptoms of phimosis are [2]:
- inability to retract a foreskin
- straining during urination
- a thin stream of urine
- recurrent urinary infections
Uncomplicated pathologic phimosis is usually responsive to conservative medical treatment, but patients should know that every failure of medical treatment leaves only surgical intervention as the alternative, usually in the traditional form of a circumcision, or preputioplasty, where a narrow non-retractile foreskin is widened.[2]
Relevant anatomy
The foreskin or prepuce is an integral 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 remain fully functional. As said earlier, development of the prepuce is incomplete in the newborn male child. Separation from the glans, and consequently foreskin retractability, usually occurs by the age of three or by the teenage years.
Incidence of the condition
A commonly quoted incidence statistic for pathological phimosis is 1% of uncircumcised males. Others have described incidences in adolescents and adults as high as 50%.[2]
Several types of research done in the fifties of the previous century have shown that only 4% of infants had a fully retractable foreskin at birth, but 90% did by age 3.[3] This means that this condition could be, on certain occasions and age, considered to be physiological. Besides this primary type, experts believe that secondary adult phimosis may also occur due to poor hygiene or an underlying medical condition. Balanitis can occur in babies and is a consequence of poor hygiene — a common occurrence among boys still wearing diapers.[4]
Types of phimosis and possible treatments
1. Infantile or congenital phimosis
As already mentioned, infantile phimosis has been widely recognized by the general practitioners for most of the last century. The foreskin cannot be easily retracted. There are several approaches to this type of phimosis, and the most commonly used is the one where the foreskin is being repeatedly and very gently retracted to free it from the glans. If this isn’t being done, a boy could experience pathological phimosis and urinary problems later in life. Opposing 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. Forceful retraction creats microtears at the preputial orifice, which may lead to scarring that might eventually cause formation of a phimotic ring. [4]
Another approach presented by some physicians is based on routine neonatal circumcision. Circumcision is known to prevent phimosis, although by some incidence statistics, at least 10 to 20 percent of all infants would have to be circumcised to prevent every case of potential phimosis. So far, infantile phimosis is mentioned only as physiological, but not all cases of congenital phimosis are simply physiological.
Although prior statements from the American Academy of Pediatrics recommended against circumcision, the most recent recommendation states that circumcision outweigh the risk and the procedure’s benefits justify it for families who want it. The greatest benefits included prevention of urinary tract infections, transmission of sexually transmitted infections such as human papilloma virus (HPV), and penile cancer. However, with improvements in daily hygiene and prevention strategies in sexually transmitted diseases, neonatal circumcision may not be critical for the prevention of penile cancer, especially in western countries.[5]
Possible causes of pathological congenital phimosis are:
- balanitis (inflammation of the glans penis)
- preputial stenosis or narrowness that prevents retraction
- a condition called Frenulum breve
There are several management approaches to infant phimosis: topical steroid ointments are commonly used, as well as several different surgical techniques.
2. Acquired phimosis
It stands to reason that not all phimosis are equal. They can vary in severity:
- some men are able to retract their foreskin partially (a condition called relative phimosis),
- some men are completely unable to retract the foreskin (full phimosis).
The former type is more common, with estimates of its frequency at approximately 8% of uncircumcised men.
Exact medical graduation is as follows:
- Grade I - Fully retractable prepuce with stenotic ring in the shaft
- Grade II - Partial retractability with partial exposure of the glans
- Grade III - Partial retractability with exposure of the meatus only
- Grade IV - No retractability
Stretching methods
Patients should know that stretching techniques could be particularly useful for the treatment of the non-retractile foreskin, and can be an addition to using topical steroids [6,7]:
Tips for stretching
- Use baby oil or Vaseline intensively 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 per day.
- Insert your thumb (or smaller finger if necessary) into the foreskin, gripping 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.
Potential complications of acquired phimosis
Acquired phimosis, if left untreated, can lead to several complications. Chronic complications include discomfort or pain during urination or sexual intercourse. The urinary stream can be impeded, resulting in dribbling and wetness after urination. During sexual intercourse, or even during a simple erection, the patient could experience strong pain because of overextension of the foreskin. Pain may occur when a partially retractable foreskin retracts during intercourse and chokes the glans penis.
Since HPV is related to penile cancer and phimosis is related to HPV, evidence claims that phimosis is a risk factor for penile cancer, with up to 90% of cases of penile cancer being related to phimosis.[8]
Of course, all patients should know that the worst acute complication is paraphimosis. Paraphimosis is an 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 in an adult, and usually requires an operation (circumcision).
Review of possible complications:
- Problems urinating
- Problems and pain during intercourse
- Infections 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
- A small chance of malignant growth in a long-standing foreskin contraction
Paraphimosis can be avoided by [9]:
- after you have sex, cleaning yourself, and pull your foreskin back down to its natural position.
- do not leave your foreskin behind the head of your penis for any longer than you need to.
- if a catheter is put into your bladder, check afterward to be sure that your foreskin is covering the head of your penis.
Circumcision – health benefits
Urinary tract infections: One of the most beneficial things about 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 types of research have proven that the risk in circumcised kids is approximately 1 in 1000, while the risk in uncircumcised kids is about 1 in 100.[10]
Sexually transmitted diseases: Another very serious vote in favor of circumcision is a prevention of STDs, particularly HPV infection. A large number of case-control studies concerning the relationship between the foreskin and HIV infection have confirmed the presence, but not a definite link. Oddly enough, USA has one of the highest rates of STDs, HIV infection, but male circumcision as well.
Penile cancer: Timing of circumcision could also be extremely important. Although it may sound impossible, infant circumcision seems to decrease the risk of penile cancer, while the same procedure done later does not. Fortunately, penile cancer is a rare disease in the United States, with an incidence of 1.5 per 100,000 people. Direct proof of the connection is the fact that the lowest incidence has been reported in Muslims and Jews, and both of these groups have high rates of neonatal circumcision.
Diabetes mellitus: Experts claim that phimosis may be a presenting symptom of early diabetes mellitus. Where is the connection between these two conditions? Well, 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 cause phimosis complications.[11]
Circumcision and sex: 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 has also been proven that circumcised men have to deal with discomfort and a dry glans. The foreskin has many needed functions: protective, erogenous, sensory, and physiologic.