Phimosis
Phimosis (fī-mō'sĭs, fĭ-), from the Greek phimos (φῑμός ("muzzle")), is a condition where, in men, 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.[1]In the neonatal period, it is rare for the foreskin to be naturally retractable; Huntley et al. state that "non-retractability can be considered normal for males up to and including adolescence."[2] 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 (a condition deemed a problem).[3] Some authors use the terms "physiologic" and "pathologic" to distinguish between these types of phimosis;[4] others use the term "non-retractile foreskin" to distinguish this developmental condition from (pathologic) phimosis.[3]
Pathological (acquired) phimosis has several causes. Lichen sclerosus et atrophicus (thought to be the same condition as balanitis xerotica obliterans) is regarded as a common (or even the main[5]) cause of pathological phimosis.[6] Other causes may include scarring caused by forcible retraction of the foreskin,[4] and balanitis.[7] Beauge found that patients with phimosis had masturbation practices that differed from the usual pulling down of the foreskin that mimics sexual intercourse.[8] Some studies found phimosis to be a risk factor for urinary retention[9] and carcinoma of the penis.[10] Common treatments include steroid creams, preputioplasty, manual stretching, and circumcision.[11]
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[edit] Normal development
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."[12] The foreskin is usually non-retractable in infancy and early childhood.[12]During the 20th century, studies were released which furthered understanding of the normal development of the foreskin. For example, The fate of the foreskin, a study of circumcision,[13] Further fate of the foreskin, Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys,[14] and Analysis of shape and retractability of the prepuce in 603 Japanese boys.[15]
The American Academy of Pediatrics and the Canadian Pediatric Society state that no attempt should be made to retract the foreskin of an infant.[16][17] Age is reportedly a factor in non-retractability: according to Huntley et al. the foreskin is reportedly retractable in approximately 50% of cases at 1 year of age, 90% by 3 years of age, and 99% by age 17. These authors argue that, unless scarring or other abnormality is present, non-retractibility may "be considered normal for males up to and including adolescence."[2] Hill states that full retractability of the foreskin may not be achieved until late childhood or early adulthood.[18]
Some pediatric urologists have argued that many physicians continue to have trouble distinguishing developmental non-retractility from pathological phimosis.[3][19][20]
[edit] Cause
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), perhaps due in turn to inappropriate efforts to retract an infant's 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 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, even ballooning does not always indicate urinary obstruction.[21]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').
When phimosis develops in an adult who was previously able to retract his foreskin, it is nearly always due to a pathological cause, and is far more likely to cause problems for the man.
Beaugé noted that unusual masturbation practices, such as lying face down on a bed and rubbing the penis against the mattress, may cause phimosis. Patients are advised to stop exacerbating masturbation techniques and are encouraged to masturbate by moving the foreskin up and down so as to mimic more closely the action of sexual intercourse. After giving this advice Beaugé noted not once did he have to recommend circumcision.[8][22]
One cause of acquired, pathological 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 sclerosus et atrophicus of the vulva in females.[23] Infectious, inflammatory, and hormonal factors have all been implicated or proposed as contributing factors.
Phimosis may occur after other types of chronic inflammation (such as balanoposthitis), repeated catheterization, or forcible foreskin retraction.[24]
Phimosis may also arise in untreated diabetics due to the presence of glucose in their urine giving rise to infection in the foreskin.[25]
[edit] Management
Phimosis in infancy is nearly always physiological, and needs to be treated only if it is causing obvious problems such as urinary discomfort or obstruction. In older children and men, 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 men with non-retractile foreskins have no difficulties and see no need for correction.
Non surgical methods include:
- Application of topical steroid cream, such as betamethasone, for 4–6 weeks to the narrow part of the foreskin is relatively simple, less expensive than surgical treatments and highly effective.[20][26][27] It has replaced circumcision as the preferred treatment method for some physicians in the British National Health Service.[28][29]
- Stretching of the foreskin can be accomplished manually, with balloons[30] 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. Beaugé treated several hundred adolescents by advising them to change their masturbation habits to closing their hand over their penis and moving it back and forth. Retraction of the foreskin was generally achieved after four weeks and he stated that he never had to refer one for surgery.[8][22]
- Circumcision is sometimes performed for pathological 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[31][32] can be an effective alternative to circumcision.[20] It has the advantage of only limited pain and a short time of healing relative to circumcision, and avoids cosmetic effects.
[edit] Surgery
See also: Medical analysis of circumcision
Physicians often saw the natural unretractability of the foreskin in infancy as pathological and recommended circumcision. Sometimes circumcision was performed in infancy to prevent phimosis.[33] "Many boys are circumcised for (pathological or physiological) phimosis before the age of five years, despite (pathological) phimosis being rare in this group".[34]However, there are dissenting views. Robert S. Van Howe has argued that choosing to skip nonsurgical treatments for phimosis and go straight to circumcision may be influenced by non-medical considerations;[20] he has also suggested that an inaccurate diagnosis of phimosis is sometimes used as a justification for elective circumcision so that it will be covered by a national health system or insurance plan.[20] Moreover, one study has shown that attempting nonsurgical treatment of pathologic phimosis when it occurs in infants and children costs 27.3% less than primary circumcision.[35][36]
While circumcision prevents phimosis, studies of the incidence of healthy infants circumcised for each prevented case of potential phimosis are inconsistent.[14][19][24][37][38][39]
[edit] Prognosis
Chronic complications of acquired (pathological) 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 sexual intercourse and chokes the glans penis. A totally non-retractable foreskin is rarely painful. There is some evidence that phimosis may be a risk factor for penile cancer.[40]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.
