Phimosis

Phimosis is a medical term referring to a condition in which the foreskin of the penis of an uncircumcised male cannot be fully retracted. Phimosis is a Greek term, meaning "muzzled". The term is confusing because it is used to denote both a physiologic stage of development (i.e., not a disease), and a pathologic condition (i.e., a condition that causes problems for a person). There is some elasticity and ambiguity of use when referring to infants, as evidenced by conflicting incidence reports and widely varying post-neonatal circumcision rates, reflecting looseness in the diagnostic criteria 2,3. Phimosis has become a topic of contention in circumcision debates 14. For further discussion on this aspect see Medical analysis of circumcision.

Phimosis in history

Phimosis is a Greek word. The ancient medical writers were well acquainted with phimosis, wrote about it, and prescibed treatments.[1]

• Marie and Louis. Marie Antoinette was 14 and Louis, the future King, was only 15 when they married in 1770. Louis had frenulum breve which was corrected by minor surgery, but only after 7 years of marriage. Marie Antoinette finally gave birth to their first child the following year.

• President Garfield was assassinated by Charles Guiteau in 1881. The autopsy report for Guiteau 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.

Infantile or congenital phimosis

Phimosis in most but not all infants and children is physiologic rather than pathologic, whereas phimosis in adults is more often pathologic than physiologic. Some have suggested that physiologic infantile phimosis be referred to as developmental nonretractility of the foreskin to more clearly distinguish this normal stage of development from pathologic forms of phimosis 10. Different management is appropriate.

It has been widely recognized by the medical profession for most of the last century that most normal male infants have foreskins which are incompletely separated from the epithelium of the glans penis2. They cannot be easily retracted. There have been four types of medical responses and attitudes towards this "normal" infant phimosis:

1. Some physicians, especially in the first half of the twentieth century, recommended that the foreskin be repeatedly retracted, if necessary with some force, to free it from the glans. It was thought that ensuring separation early could prevent later (pathologic) phimosis and urinary problems in older boys, since it then permitted washing of the glans and foreskin. Poor hygiene has been thought to be a major causal factor in pathologic phimosis. This approach is now rarely recommended by physicians.

1. Some physicians, particularly in the middle of the twentieth century, used avoidance of phimosis as justification for routine neonatal circumcision.13 Circumcision does prevent phimosis, although by some incidence statistics, perhaps 10 to 20 infants must be circumcised to prevent each case of potential phimosis. If one believes even lower incidence estimates, far more must be circumcised for each case of phimosis prevented. Although there are proponents of this view, it is not considered a compelling argument for routine neonatal circumcision by most pediatricians.6
2. In the last three decades, as the circumcision rate in North America has fallen, the most common "official" recommendations and guidelines from medical societies, as well as infant care books written by "experts," have emphasized that it is normal not to be able to retract an infant's foreskin fully and that it need not be done. The American Academy of Pediatrics recommends gentle soap and water cleaning, but specifically recommends against forcible retraction.1 There is now some suspicion that forceful retraction that results in inflammation may actually contribute to pathologic phimosis at an older age.2 Although the rate of surgical treatment of phimosis (usually circumcision) is falling, some pediatric urologists have argued that many physicians continue to have trouble distinguishing developmental non-retractility from pathologic phimosis, and that the condition is overdiagnosed.101213
3. Finally, it should be noted that phimosis is sometimes used as a justification for circumcision so that it will be approved or covered by a national health system or private insurance plan313. The definition may be stretched by a physician as a favor to a family who wants to have an older child (e.g., 6 months or older) circumcised after declining or deferring it in the neonatal period. At least in North America, post-neonatal circumcisions are most often often performed as minor outpatient surgery by a surgeon, especially a pediatric urologist than by a child's pediatrician or primary care provider, making them much more expensive than the neonatal procedure and not always covered by insurance without a medical reason (such as phimosis) 13.

Not all infantile phimosis is simply physiologic. Though uncommon, phimosis can occasionally lead to urinary obstruction or pain. Causes of pathologic phimosis in infancy are varied. Some cases may arise from balanitis (inflammation of the glans penis) due to inappropriate efforts to separate and retract an infant 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 not always be easy to distinguish physiologic phimosis from pathologic if an infant appears to be in pain with urination or has obvious ballooning of the foreskin with urination or apparent discomfort.

There are several management approaches to infant phimosis.3 Most cases of simple physiologic phimosis need no "management" but will disappear with time or simple stretching of the foreskin. Various topical steroid ointments have been effective at hastening separation without surgery.713 Several surgical techniques have been devised, which range from simple slitting of a segment of the foreskin to removal of it (circumcision).

When phimosis persists into later childhood or adolescence, it is less likely to resolve with maturation, and incurs a higher risk of causing problems. However, even in adolescents and adults, some non-retractile foreskins can fairly be termed "physiologic," in the sense of being a developmental variation that does not necessarily cause trouble.

Acquired phimosis

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").[4]

Because of the "elasticity" of the diagnostic criteria, there has been considerable variation in the reported prevalence of pathologic phimosis. An incidence rate of 1% to 2% of the uncircumcised adult male population is often cited, though some studies of older children or adolescents have reported higher rates.2 Relative phimosis is more common, with estimates of its frequency at approximately 8% of uncircumcised men 7.

When phimosis develops in an uncircumcised adult who was previously able to retract his foreskin, it is nearly always due to a pathologic cause, and is far more likely to cause problems for the man.

An important cause of acquired, pathologic 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 sclerosis et atrophicus of the vulva in females.[2] Infectious, inflammatory, and hormonal factors have all been implicated or proposed as contributing factors. Circumcision is usually recommended though alternatives have been advocated.

Phimosis may occur after other types of chronic inflammation (e.g., balanoposthitis), repeated catheterization, or forceful foreskin retraction 2.

Images of phimosis.[3][4][5]

Potential complications of acquired phimosis

Chronic complications of acquired (pathologic 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 intercourse and chokes the glans penis. A totally non-retractable foreskin is rarely painful.

The worst acute complication is paraphimosis [6]. In this acute 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. Paraphimosis is considered an emergency.

Treatment of phimosis

Phimosis in infancy is nearly always physiologic, and needs to be treated only if it is causing obvious problems such as urinary discomfort or obstruction. In older children and adults 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 adults with nonretractile foreskins have no difficulties and see no need for correction.

High rates of success have been reported with several nonsurgical measures. Application of topical steroid cream for 4-6 weeks to the narrow part of the foreskin is relatively simple and less expensive than surgical treatments.13 It has replaced circumcision as the preferred treatment method in the NHS of the U.K.[7] [8][9]. When the phimosis is partial,especially in children, repeated gentle forward stretching (not retraction), may promote separation.

Preputioplasty, in which a limited dorsal slit with transverse closure is made along the constricting band of skin [10][11] can be an effective alternative to full circumcision 13.

Circumcision is the traditional surgical solution for pathologic phimosis, and is effective.[12] Serious complications from circumcision are very rare, but minor complication rates (e.g., having to perform a second procedure or meatotomy to revise the first or to re-open the urethra) have been reported in about 5-10% in most reported series.13

There is a school of opinion amoung the medical profession that advocates and promotes a number of alternative methods where surgery, with all the attendant risks, can be avoided. Stretching of the foreskin can be accomplished manually, sometimes with masturbation, also known as the Beaugé method[13]. The stretching can also be accomplished with balloons placed under the foreskin skin under anaesthesia,[14] or with a tool [15]. The tissue expansion promotes the growth of new skin cells to permanently expand the narrow preputial ring that prevents retraction.

Incidence

A number of medical reports of phimosis incidence have been published over the years. They vary widely because of the difficulties of distinguishing physiologic phimosis (developmental nonretractility) from pathologic 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 pathologic phimosis is 1% of uncircumcised males.21112 When phimosis is simply equated with nonretractility of the foreskin after age 3 years, considerably higher incidence rates have been reported.[4]59 Others have described incidences in adolescents and adults as high as 50%, though it is likely that many cases of physiologic phimosis or partial nonretractility were included.8

External links

Medical articles

1. American Academy of Pediatrics. Circumcision: frequently asked questions. AAP recommendations on care of uncircumcised foreskin.
2. Cantu Jr. S. Phimosis and paraphimosis. Excellent Emedicine overview.
3. Dewan PA. Treating phimosis. Med J Aust 2003;178:148-150. Discussion of physiologic and pathologic phimosis in childhood and use of diagnosis to justify surgery for parents' sake. Pictures of infant penises with and without phimosis.
4. Gairdner D: The fate of the foreskin, a study of circumcision. Brit Med J 2:1433-7, 1949. This study was one of the first attempts to determine incidence and is still cited by both advocates and opponents of circumcision. He reported both a high rate (92%) of retractability by age 5 years (though the report is criticised because he "ran a probe around to loosen the adherence of foreskin to glans")[16] and a high rate (20%) of boys older than 5 without full retractability.
5. Imamura E. Phimosis of infants and young children in Japan. Acta Paediatr Jpn 39:403-5, 1997. A study of phimosis prevalence in over 4,500 Japanese children reporting that over a third of uncircumcised retained a nonretractile foreskin a age 3 years.
6. Lannon CM, Bailey AGD, Fleischman AR, Kaplan GW, Shoemaker CT, Swanson JT, Coustan D. Circumcision Policy Statement. Pediatrics 103:686-693, 1999. Although not directly focusing on phimosis, this American Academy of Pediatrics report provides a synopsis of circumcision statistics and benefits, with noncommittal final recommendation. "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision, in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child."
7. Monsour MA, Rabinovitch HH, Dean GE. Medical management of phimosis in children: our experience with topical steroids. J Urol 1999 162:1162–4. Good description of topical steroid use as alternative to surgery.
8. Ohjimi T, Ohjimi H. Special surgical techniques for relief of phimosis. J Dermatol Surg Oncol 7:326–30, 1981. Almost half of Japanese adolescent and adult men suffer from some degree of phimosis according to Ohjimi.
9. Øster J: Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child 43(228):200–3,1968.
10. Rickwood AM, Walker J. Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence? Ann R Coll Surg Engl 71:275–7, 1989. Authors review English referral statistics and suggest phimosis is overdiagnosed, especially in boys under 5 years, because of confusion with developmentally nonretractile foreskin.
11. Shankar KR, Rickwood AM. The incidence of phimosis in boys. BJU Int 1999; 84:101–2. This study gives a low incidence of pathologic phimosis (0.6% of uncircumcised boys by age 15 years) by asserting that balanitis xerotica obliterans is the only indisputable type of pathologic phimosis and anything else should be assumed "physiologic". Restrictiveness of definition and circularity of reasoning have been criticized.
12. Spilsbury K, Semmens JB, Wisniewski ZS, Holman CDJ. Circumcision for phimosis and other medical indications in Western Australian boys. Med J Aust 2003; 178:155-158. Recent Australian statistics with good discussion of ascertainment problems arising from surgical statistics.
13. Van Howe RS. Cost-effective treatment of phimosis. Pediatrics 1998 102: p. e43. A urologist reviews estimated costs and complications of 3 phimosis treatments (topical steroids, praeputioplasty, and surgical circumcision) and 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 pathologic from physiologic phimosis in young children and acknowledges the distortion of statistical justification for surgery by insurance policies in the United States.
14. Multiple authors. Matters arising. Med J Aust 178:587–90, 2003.] Letters to the Med J Aust debating the phimosis statistics of Spilsbury and the treatment recommendations of Dewan from both proponents and opponents of circumcision.
15. Holman JR, Stuessi KA. Adult circumcision. American Family Physician 1999;59(6): 1514.

Other material

The following links are provided by advocates against circumcision and provide a discussion of alternative treatments.

• A Picture of a penis with phimosis
• B Pictures of a penis with fully retracted foreskin after successful treatment of phimosis
• C Summary of Phimosis Statistics
• D Anti-Circumcision Opinion: Conservative Treatment of Phimosis: Alternatives to Radical Circumcision