What Is Phimosis?
Phimosis is a medical condition in which the foreskin of the penis of an uncircumcised male cannot be fully retracted. Phimosis is usually referred to as a male problem, but can also happen to women: women suffer from clitoral phimosis [1] (in this article we will discuss phimosis in men only). Phimosis can occur at any age, but the highest incidence is seen in infancy and adolescence — a study from the seventies claims that approximately 1% of males older than 16 years have problems with phimosis. [2]
The term phimosis denotes both the physiological stage of development (which is not referred to as a disease), and a pathological condition when phimosis can cause problems for a person. In most but not all infants, phimosis is physiological rather than pathological, whereas phimosis in older children and adults is more often pathological than physiological. [3]
- Congenital or primary phimosis: A condition when the subject had phimosis ever since he can remember. Treatment in this case usually includes gentle stretching, since there is a reason to believe that gentle stretching will mobilize the elastic capacity of the skin tissue.
- Acquired or secondary phimosis (or secondary phimosis of a lichenoid or fibrous type): Secondary phimosis of a lichenoid or fibrous type is a phimosis when the subject can remember developing a phimotic ring. In these cases, such types of phimosis are prone to degeneration and are generally difficult to stretch. In some cases, steroids may help, but recurrent problems require surgery.
Both terms denote the inability to retract the distal prepuce over the glans penis; however once the foreskin can be retracted so that the glans penis partially appears, phimosis is no longer present. Phimosis is not a disease; phimosis is a condition.
A report classified phimosis after using steroid creams into 5 types according to retractability of the foreskin after one or more treatments [5]:
- Type 0 – Full retraction, not tight behind glans, or easy retraction, limited only by congenital adhesions to the glans
- Type 1 – Full retraction of the foreskin, tight behind the glans
- Type 2 – Partial exposure of glans, prepuce (not congenital adhesions) limiting factor
- Type 3 – Partial retraction, the meatus just visible
- Type 4 – Slight retraction, but some distance remains between the tip and glans, that is neither meatus nor glans can be exposed
- Type 5 – Absolutely no retraction is possible
There is one more term we have to define: paraphimosis. Paraphimosis is the entrapment of a retracted foreskin behind the coronal sulcus, and the condition occurs in the incorrectly circumcised or uncircumcised penis. Paraphimosis is a urological emergency in which the retracted foreskin of an uncircumcised male cannot be returned to its normal anatomic position. [6]
While primary and secondary phimosis denotes aggravated or impossible retraction of foreskin over the glans penis, typical of paraphimosis is edema, tenderness, and erythema of the glans or of the distal foreskin.
Causes
Primary or congenital phimosis occurs in young children — infants and it is normal to have it into the teenage years. Primary or congenital phimosis is physiological but does not cause any side problems, such as urinary obstruction, hematuria, or preputial pain. It is possible child suffers from congenital phimosis because of a history of recent catheterization or of parents forcibly retracting the foreskin in an attempt to clean the glans.
Secondary or acquired phimosis also has several possible causes: it most often occurs because of a history of poor hygiene, chronic balanoposthitis, but forceful retraction of a primary phimosis is also possible. This is why parents should never try to force the foreskin back as it can be very painful for their son and can also lead to small injuries, causing scarring which can make it even harder to pull the foreskin back. This type of phimosis is known as acquired or pathological phimosis. Secondary or acquired phimosis is often followed by hematuria or preputial pain. Acquired phimosis is typical for both children and adults.
Secondary or acquired phimosis, caused by poor hygiene and/or chronic balanoposthitis can eventually lead to paraphimosis. Typical of paraphimosis is pain and edema of the uncircumcised or improperly circumcised penis. Even vigorous sexual activity has been reported to predispose one to paraphimosis. Paraphimosis is a urological emergency in which the retracted foreskin of an uncircumcised male cannot be returned to its normal anatomic position. Clinicians must recognize paraphimosis promptly, as it can result in gangrene and amputation of the glans penis.
Care Of The Uncircumcised Penis
No special care is required for the foreskin in infancy — the foreskin should not be forcibly retracted, however gentle retraction is acceptable. The main goal of gentle retraction is cleansing underneath the foreskin during diaper changes or bathing. This type of gentle retraction will result in progressive retraction over time. After the retraction, the foreskin should be pulled back over the head of the penis and returned to the normal position. The foreskin doesn’t have to be pulled back completely to be able to keep the penis clean. Washing it from the outside is enough. Under no circumstances should objects such as cotton swabs be used to clean the space between the foreskin and the glans. [7]
Treatment
The need for treatment will depend on the child’s age, the extent of the problem, and what is causing it [7]:
- If phimosis persists but doesn’t cause any problems, you can wait until after about the age of three before going to see a doctor about it.
- After the age of three there are three treatment options available:
- “Wait and see” if the phimosis will go away on its own.
- Use a steroid cream to help stretch the foreskin.
- Have surgery to partially or completely remove the foreskin (circumcision).
The main aim of treatment is to enable the boy to wash his penis properly and urinate without any difficulties or pain. Erections shouldn't be painful either.
Some men simply accept the chronic irritation and the red, swollen foreskin. They sometimes complain of phimosis and visit the doctor only when there is pain or an odorous discharge. However, the treatment of phimosis depends on the type of phimosis.
Congenital phimosis should be left alone: only the usual cleaning without any forceful retraction is recommended. Proper foreskin hygiene is also suggested to patients with acquired phimosis. Use of steroid creams as a noninvasive effective treatment for acquired phimosis is recommended (treatment for repeated phimosis may involve application of a steroid cream to the foreskin up to three times a day for about a month to loosen the adhesive ring) or the use of nonsteroidal ointments has also been reported to be of benefit in the treatment of acquired phimosis.
If phimosis is causing urinary obstruction, seek medical attention from a specialist (urologist). In cases like this, it is often necessary to perform circumcision or other plastic surgical technique to enlarge the opening without actually removing tissue. As said, either antibiotics may control the infection, sometimes hot soaks may help separate the foreskin from the glans, but if they fail, a small incision is made to release it.
In some cases, circumcision is advised, which is done when the inflammation clears [8]. Circumcision is performed under general anesthesia. The foreskin is pulled back as far as it will go: it is slit along its upper surface and then all around so that it can be removed.
The raw edges of the inner and outer layers are stitched, and then a dressing is applied. The patient usually goes home the same day. Pain is present until the healing is complete, but it can be controlled with painkillers. After the circumcision, the patient may find that the appearance of the penis has changed considerably.
All causes of potential infection must be kept away (for example urine). Urination may also be painful.
For a couple of days, a patient should avoid tight clothes or any excessive movement, especially sexual activity. After few days there should be no more pain and stitches should be healing.
In paraphimosis, after emergent reduction, referral to a urologist for eventual circumcision is obligatory since the condition is likely to recur. Treatment for paraphimosis may involve lubricating the foreskin and tip of the penis and then gently squeeze the tip of the penis while pulling the foreskin forward. If this shows to be ineffective, a small incision to relieve the tension may be performed. However, generally, circumcision is performed. Of course, complications (gangrene of the glans, inflammation of the prepuce) are possible, but if appropriate treatment is followed they are not likely to occur.