Phimosis

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Phimosis
Phimosis.jpg
An erect penis with a case of phimosis
Classification and external resources
Specialty Urology
ICD-10 N47
ICD-9-CM 605
DiseasesDB 10019
eMedicine emerg/423
Patient UK Phimosis
MeSH D010688
[[[d:Lua error in Module:Wikidata at line 863: attempt to index field 'wikibase' (a nil value).|edit on Wikidata]]]

Phimosis (/fɪˈmoʊsᵻs/ or /faɪˈmoʊsᵻs/[1][2]), from the Greek phimos (φῑμός ["muzzle"]), is a condition of the penis where 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.[3]

At birth, the foreskin is fused to the glans and is not retractable. Huntley et al. state that "non-retractability can be considered normal for males up to and including adolescence."[4]

Normal developmental non-retractability does not cause any problems. Phimosis is deemed pathological when it causes problems, such as difficulty urinating or performing common sexual functions. There are numerous causes of so-called pathological phimosis. Nonsurgical treatment involves the stretching of the foreskin, steroid creams and changing masturbation habits. Surgical treatments include preputioplasty and circumcision.

Signs and symptoms

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."[5] The foreskin is usually non-retractable in infancy and early childhood,[5] and can be as late as 18.[6]

Medical associations advise not to retract the foreskin of an infant, in order to prevent scarring.[7][8] Some argue that non-retractability may "be considered normal for males up to and including adolescence."[4][9] Hill states that full retractability of the foreskin may not be achieved until late childhood or early adulthood.[10] A Danish survey found that the mean age of first foreskin retraction is 10.4 years.[11]

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.[12][13][14] Some authors use the terms "physiologic" and "pathologic" to distinguish between these types of phimosis;[15] others use the term "non-retractile foreskin" to distinguish this developmental condition from pathologic phimosis.[12]

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, ballooning does not indicate urinary obstruction.[16]

Cause

There are three mechanical conditions that prevent foreskin retraction:

1. The tip of the foreskin is too narrow to pass over the glans penis. This is normal in children and adolescents.[17][18]
2. The inner surface of the foreskin is fused with the glans penis. This is normal in children and adolescents but abnormal in adults.[18]
3. The frenulum is too short to allow complete retraction of the foreskin (a condition called frenulum breve).[18]

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).[19]

Lichen sclerosus et atrophicus (thought to be the same condition as balanitis xerotica obliterans) is regarded as a common (or even the main)[20] cause of pathological phimosis.[21] This is 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.

Phimosis may occur after other types of chronic inflammation (such as balanoposthitis), repeated catheterization, or forcible foreskin retraction.[22]

Phimosis may also arise in untreated diabetics due to the presence of glucose in their urine giving rise to infection in the foreskin.[23]

Phimosis in older children and adults can vary in severity, with some able to retract their foreskin partially (relative phimosis), and some completely unable to retract their foreskin even when the penis is in the flaccid state (full phimosis).

Treatment

Physiologic phimosis, common in males 10 years of age and younger, is normal, and does not require intervention.[17][24][25] Non-retractile foreskin usually becomes retractable during the course of puberty.[25]

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 circumcision is viewed as an option of last resort to be avoided or as the preferred course.[citation needed]

Nonsurgical

  • Topical steroid creams such as betamethasone, mometasone furoate and cortisone are effective in treating phimosis and may provide an alternative to circumcision.[24][26] It is theorized that the steroids work by reducing the body's inflammatory and immune responses, and also by thinning the skin.[24]
  • Stretching of the foreskin can be accomplished manually, with balloons[27] 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. In a study, 86% of individuals were cured and could retract their foreskin in 6 weeks, by applying a cream and skin stretching twice daily.[28]

Surgical

File:Preputioplasty png conv.png
Preputioplasty:
Fig 1. Penis with tight phimotic ring making it difficult to retract the foreskin.
Fig 2. Foreskin retracted under anaesthetic with the phimotic ring or stenosis constricting the shaft of the penis and creating a “waist”.
Fig 3. Incision closed laterally.
Fig 4. Penis with the loosened foreskin replaced over the glans.

Surgical methods range from the complete removal of the foreskin to more minor operations to relieve foreskin tightness:

  • Circumcision is sometimes performed for 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[29][30] can be an effective alternative to circumcision.[14] It has the advantage of only limited pain and a short time of healing relative to circumcision, and avoids cosmetic effects.

While circumcision prevents phimosis, studies of the incidence of healthy infants circumcised for each prevented case of phimosis are inconsistent.[13][22]

Prognosis

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. Some studies found phimosis to be a risk factor for urinary retention[31] and carcinoma of the penis.[32]

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.[22][33],[13] When phimosis is simply equated with nonretractility of the foreskin after age 3 years, considerably higher incidence rates have been reported.[25][34] 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.[35]

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] It should be mentioned that non-retractile prepuce in adolescence is normal and common.[25]

US 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 speculation that Guiteau's murderous behavior was due to phimosis-induced insanity.[36]

References

  1. ↑ OED 2nd edition, 1989 as /faɪˈməʊsɪs/.
  2. ↑ Entry "phimosis" in Merriam-Webster Online Dictionary.
  3. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  4. ↑ 4.0 4.1 Lua error in package.lua at line 80: module 'strict' not found.
  5. ↑ 5.0 5.1 Lua error in package.lua at line 80: module 'strict' not found.
  6. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  7. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  8. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  9. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  10. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  11. ↑ Thorvaldsen MA, Meyhoff H.. Patologisk eller fysiologisk fimose?. Ugeskr Læger. 2005;167(16):1852-62.
  12. ↑ 12.0 12.1 Lua error in package.lua at line 80: module 'strict' not found.
  13. ↑ 13.0 13.1 13.2 Lua error in package.lua at line 80: module 'strict' not found.. Recent Australian statistics with good discussion of ascertainment problems arising from surgical statistics.
  14. ↑ 14.0 14.1 Lua error in package.lua at line 80: module 'strict' not found. 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.
  15. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  16. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  17. ↑ 17.0 17.1 Kayaba H, Tamura H, Kitajima S, et al.. Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol. 1996;156(5):1813-5.. doi:10.1016/S0022-5347(01)65544-7. PMID 8863623.
  18. ↑ 18.0 18.1 18.2 Øster J. Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child. 1968;43(228):200-3. doi:10.1136/adc.43.228.200. PMID 5689532.
  19. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  20. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  21. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  22. ↑ 22.0 22.1 22.2 Cantu Jr. S. Phimosis and paraphimosis at eMedicine
  23. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  24. ↑ 24.0 24.1 24.2 Lua error in package.lua at line 80: module 'strict' not found.
  25. ↑ 25.0 25.1 25.2 25.3 Lua error in package.lua at line 80: module 'strict' not found.
  26. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  27. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  28. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  29. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  30. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  31. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  32. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  33. ↑ Lua error in package.lua at line 80: module 'strict' not found. 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.
  34. ↑ Lua error in package.lua at line 80: module 'strict' not found. 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.
  35. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  36. ↑ Lua error in package.lua at line 80: module 'strict' not found.

External links

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