Phimosis and paraphimosis

Disease Information

Overview

What is phimosis and paraphimosis?
Phimosis is a constriction of the opening of the foreskin so that it cannot be drawn back over the tip of the penis. This condition is a normal occurrence in the newborn boy, but over time, the skin that adheres to the tip of the penis can be retracted as the foreskin loosens. By age 17, 99 percent of males will be able to completely retract their foreskin.

• Phimosis can also occur if the foreskin is forced back before it’s ready. This can cause a fibrous scar to form, which may prevent future retraction of the foreskin.
• Paraphimosis occurs when the foreskin is retracted behind the corona (or crown) of the penis and cannot be returned to the unretracted position. This can cause entrapment of the penis, impairing the drainage of blood, and may be serious.

What are the symptoms of phimosis and paraphimosis?
The following are the most common symptoms of phimosis and paraphimosis. However, each child may experience symptoms differently. Symptoms may include:
Phimosis:

• bulging of the foreskin during urination
• inability to completely retract the foreskin by age 3 (in some children this process may take longer)

Paraphimosis:

• swelling of the tip of the penis as the foreskin is retracted or pulled back
• pain
• inability to pull the foreskin back over the tip of the penis
• discoloration, either dark red or bluish color of the tip of the penis

Phimosis and Paraphimosis

                                                             Phimosis and Paraphimosis
What Is It?

In an uncircumcised male, the head of the penis is covered by a sheath of skin known as the foreskin. Phimosis is a condition in which the foreskin is tightly stretched around the head of the penis and cannot be pulled back freely. Phimosis can occur naturally. For example, in boys younger than age 4, it is normally hard to pull back the foreskin. However, in older boys and men, phimosis often is triggered by an infection under the foreskin (balanitis) or by other medical conditions such as diabetes.

Paraphimosis occurs when a tight foreskin is pulled back behind the head of the penis and then becomes stuck. It cannot be placed forward again to its usual position covering the tip of the penis. This can cause swelling, pain and loss of blood flow to the tip of the penis. If the foreskin cannot be pushed back into its natural position, serious harm can occur.

Symptoms

Phimosis is usually painless. However, a very tight foreskin may interfere with urination or sexual function. In addition, phimosis may make it difficult for a man to clean under the foreskin, which can make infection of the skin more likely.

Paraphimosis usually results in painful swelling of the foreskin and head of the penis. Severe loss of blood flow to the head of the penis may be signaled by a deep purple color, which usually indicates a medical emergency.

Diagnosis

A doctor can diagnose phimosis and paraphimosis during a physical examination.

Expected Duration

Phimosis in a young child is likely to improve on its own. In adults, phimosis will not go away unless surgery is done or an infection is treated.

Prevention

Phimosis may be prevented by good hygiene. This includes fully pulling back the foreskin, so you can clean under it during bathing.

Paraphimosis can be prevented by carefully replacing the foreskin every time it is pulled back. If paraphimosis occurs, circumcision may be recommended to prevent it from happening again.

Treatment

Phimosis without any symptoms does not require treatment. This is especially true in children. If a boy does not outgrow phimosis or there are problems with urination or hygiene, treatment with certain medicated creams, such as hydrocortisone, may be effective.

In some older boys and men with phimosis, good hygiene and prompt treatment of infections may be all that is needed to prevent problems. In other men, persistent symptoms occur, and corrective surgery (circumcision) needs to be done.

It is an emergency if paraphimosis occurs and the foreskin cannot be pushed back into its normal position. A physician may need to do an emergency procedure to create a slit in the foreskin, or do circumcision.

When To Call a Professional

Call your doctor if you:

• Have difficulty pulling back or cleaning under your foreskin
• Develop an infection under the foreskin
• Pull back your foreskin and cannot push it back into its normal position

Prognosis

In most men, phimosis is not a serious problem and will not require treatment. However, it is not expected to improve on its own.

As noted above, paraphimosis is sometimes a medical emergency, and the penis may become permanently damaged if you do not seek immediate medical attention.

Phimosis – Diagnosis Conditions and Treatment Options

Posted on December 1, 2012 by phimosisadmin — No Comments ↓

Phimosis is a condition that occurs in all ages of men, where the foreskin does not fully retract over the head of the penis. The non retractable state can be considered normal for males up to adolescence. It is possible to acquired phimosis from damage or scarring to the penis, it can show as a white ring around the tip that is hardened non elastic skin. It can also be caused by narrowness.

Some men may have trouble during sex and masturbation, even pain. If this happens once, let it heal. If it happens continually you will want to take action. Seeking a doctor is always the best step, but here we go into depth on some home remedies that may work, or get your started.


Phimosis in older children and adults can vary in how severe the case is, with some men being able to retract partially and other unable to retract at all. There are two main practices of altering phimosis, surgery and non surgical. Curing is not mentioned because it is not an ailment, disease or sickness. Some women find phimosis attractive because of its uniqueness, men will either need to learn to accept their differences or change them to fit in. Phimosis is usually not a major health concern as in early stages of life it naturally can take place.

Non surgical practices of altering are:

•      Applying a topical cream such as hydrocortisone and betamethasone for a period of 2 months to the narrow part of the foreskin. It is the least costly and said to be the most effective. Success rates of up to 70% have been seen, but do not get discouraged if it does not work for you. You can combine this with stretching for even better results
•      Stretching. It can be manually accomplished with stretching balloon devices and surgical stainless steel hand stretchers. Skin that is under tension naturally tends to expand by growing more cells. This treatment is generally painless and non destructive. Also combine with a topical cream for faster results.

Surgical practices include:

•     Circumsision is performed, it is effective but some men shun at the idea.
•     Ventral slit, and dorsal slit. These are alternatives you may discuss with your doctor as they are very uncommon. These methods are more extreme and have more side effects and risks to the procedures. Take note that you will have stitches in your penis, and you may have a scar afterwards. Not the most pleasant or comforting thing to hear but you should know the truth of the matter.

Stretching techniques

•     The simplest method and easiest with an erection is to pull back on the skin so that the opening feels tight and stretched. This will be a difficult task to do at your home manually, their are stretching guides and tools that will inform you the proper way to do this and see results.
•     Grab each side of the opening of the foreskin and pull each side, or insert a finger if possible. Stretch the opening in this way until it feels slightly uncomfortably stretched. You should purchase one of the available tools or guides for this task to make it a safe procedure.

Without proper foreskin stretching education it is very possible to cause damage to your foreskin, requiring painful drastic surgery. When proper guide is followed, it could be a much easier process than going to a doctor in which case he will recommend circumcision. This is the last area men want to have surgery.

Without proper tight foreskin stretching instruction it is possible to damage the foreskin, requiring drastic surgery. When proper instructions are carefully followed, however, it is much more safe than going to the doctor in which case you are nearly guaranteed the total circumcision of your foreskin; obviously a body part most men consider quite important to their lives. Do not feel like you are alone if you have phimosis, there is help. Phimosis could be the one thing stopping you from being open with a women. It could be very embarrassing to have to explain it to a women, and you may not be socially accepted.
A tight foreskin can last throughout life and not cause any trouble at all. It’s always your decision which path to choose. If you have trouble urinating, get infection,  pain during erections or sexual intercourse it is best to see a doctor. Don’t be scared of visiting a doctor for something this personal, they have seen it before and they do not judge you.
Some Facts:

•     Most infants are born with a foreskin that does not retract and may even stay tight until after puberty
•     A retractable foreskin occurs in only 50% of twelve year olds, 90% of 16 and up to 99% of 18 year olds.
•     Most males are able to draw back the foreskin by age three
•     Phimosis is occasionally hereditary

It is suggested that any major decisions such as surgery not be decided until after puberty because the reaction to the over use of circumcision as the main treatment option. Many unnecessary circumcisions are made because of this. Many health professionals make the mistake of trying to forcibly stretch an infant or young boys foreskin and thereby damage it. The only person who should stretch and clean the foreskin is the boy himself. Bath products and chemical irritants can cause the foreskin to tighten and should be avoided.

Tight Foreskin (phimosis)

 

 How the foreskin develops in the first couple of years

The foreskin of a newborn boy is always closely contracted around the penis head (glans). Only a small passage allows the urine to pass through. In the first months the foreskin is stuck to the glans and cannot be pulled back and one should not attempt to do so.
During the first couple of years, the foreskin will become gradually looser and in many boys it can in time be pulled back without trouble. Half of all three-year-olds can pull back their foreskin.
It is not advisable to try pulling the foreskin back using force, since this may cause small cuts in the foreskin with scars, which could finally cause scarring of the foreskin.

Who can help?

A health visitor or GP will be able to give advice.
If the foreskin is very tight and stays so, causing recurrent infections and problems when urinating, then it may be necessary to operate.

Which problems may a tight foreskin cause?

A tight scarred foreskin – also called phimosis – can last throughout life and not cause any trouble at all.
It's a normally the patient’s decision whether to have an operation or not. If any problems do arise they usually happen after puberty when sexual activity begins.
The tightness may occur for the first time as an adult and usually requires an operation (circumcision).

• There might be trouble urinating.
• Infections may occur under the foreskin.
• At erection, a contracted foreskin may cause trouble by hurting when an attempt is made to pull the foreskin back. It may not go back over the glans before the penis is limp again. If the foreskin becomes inflamed in this position it may lead to paraphimosis, where the foreskin becomes inflamed and painful. This itself may require surgery to rectify.
• Pain during sexual intercourse.
• Very rarely, a malignant growth can occur in a long-standing phimosis.

How is a contracted foreskin treated?

Many boys can be treated with a cream that contains a weak corticosteroid.

• A GP can provide this treatment. The tip of the penis should be treated with the cream two to three times a day for two to three weeks at a time.
• The foreskin must be pulled as far back as possible without using force before the cream is put on.
• If this treatment does not work, an operation can help.

If treatment with creams has been unsuccessful, and signficicant symptoms remain, then a circumcision will be required in most cases to relieve the symptoms

How can Phimosis be Treated?

How can Phimosis be Treated?

 

 

Circumcision is the only permanent cure. This refers to the surgical removal of foreskin.

The normal non-retractile foreskin during childhood must be recognized and left alone. In such cases, patients and their parents should be advised against attempting forcible or premature retraction of the foreskin, and avoiding excessive washing of the penis with soap.

Once phimosis is diagnosed, the available treatments include-

Topical corticosteroids- Phimosis can be treated by the local application of topical steroids (betamethasone cream 0.05%) in 80-90% of cases. 

Manual stretching

Preputial plasty

Circumcision- Circumcision is the surgical procedure for removal of the foreskin.

Conservative treatments should be tried first and surgery should be used as a last resort.

 

http://www.medindia.net/animation/Circumcision.asp 

Modern treatment of phimosis

Non-surgical methods now the standard approach

Much of the pressure for circumcision in the Victorian era and up until the 1960s was fear of phimosis - inability or difficulty in retracting the foreskin to expose the glans. In the nineteenth century this condition was wrongly believed to be the cause of a host of nervous and other diseases, leading many doctors to insist that unless the foreskin was fully mobile within a few weeks of birth, circumcision was essential. It was not until the 1940s that this error was corrected by Douglas Gairdner, though it persists in parts of the United States to this day. Research since the 1940s has established that it is perfectly normal for the foreskin not to become retractable until a boy reaches puberty, and that there is no need for any intervention unless he is experiencing discomfort, since most cases resolve spontaneously as he matures.
For cases of persistent phimosis, where there was discomfort, pain or other problems, it is true that there was probably no alternative to circumcision until the 1990s, when it was realised that the application of steroids caused the foreskin tissue to loosen and expand, thus permitting retraction. A host of articles in medical journals since the early 1990s has now established beyond any doubt that application of one or more of several different steroid creams to the foreskin is nearly always effective in resolving problem cases of phimosis. The notion that circumcision is the appropriate response to phimosis is now outdated and unscientific. The only situation where circumcision may still be necessary is in persistent cases of Balanitis xerotica obliterans (BXO or Lichen sclerosus - a very rare skin disease, possibly of fungal origin, but not yet fully understood) that do not respond to conservative treatment.
Most of these articles are available on CIRP, but an additional selection of articles is provided below. These show how assertions of the need for circumcision have decreased as understanding of normal penile development has improved. It is interesting to observe how allegations of the "need" for circumcision fade away as it is increasingly appreciated that, in most cases, the phimotic condition is normal and harmless, and that the foreskins of many healthy boys  do not become fully retractable until puberty or even later. In the first paper below (early 1990s) doctors are still circumcising quite young boys whose foreskins have not become retractable if they do not respond quickly to the steroid treatment. But as more experience is gained (and as false Victorian/Edwardian understanding dissipates) the anxiety recedes.  It comes to be appreciated that that it is quite normal for foreskins not to become retractable until puberty or after, and that in many cases they will do so naturally, even without treatment. What is particularly interesting about the results of many of the papers below is the number of boys in the control (non-treatment) group whose phimosis resolved quite naturally during the course of the study. The lesson here is to be patient and recall the old proverb: Fools rush in where angels fear to tread.
It is doubtful whether any boy needs treatment unless he is still phimotic after puberty and experiencing discomfort, but is is certainly better to undergo a harmless  course of steroid ointment than to suffer the risks and losses of amputating surgery. There is some evidence that extra testosterone can also held achieve foreskin mobility, suggesting that a low testosterone level may be connected with the phimotic condition in the first place.

Phimosis and Paraphimosis

When the foreskin won't retract

 

 

Phimosis, or preputial stenosis, is a term that usually means any condition where the foreskin of the penis cannot be retracted.

Most infants are born with a foreskin that cannot be retracted and the prepuce may be tight until after puberty.

A fully retractable foreskin occurs in 50% of ten year olds, 90% of 16 year olds and 98 to 99% of 18 year olds.

Causes of Phimosis
Phimosis can be caused by failure of foreskin to loosen during growth, infections such as balinitis, deformities caused by trauma and diseases of the genitals.
Symptoms of Phimosis
Phimosis is usually painless condition. Infection may result from an inability to carry out effective cleaning of the area in which case swelling, redness and discharge may all be present making the area tender and painful. A very tight foreskin can cause problems during intercourse, urination.
Paraphimosis
An inability to pull back the foreskin into position over the head of the penis can cause pain, swelling of the head of the penis and the foreskin. It may cause restricted blood flow, causing the head of the penis to become dark purple in color. If this should occur emergency treatment is required.
Deciding on treatment
Medical opinion differs on the condition and on treatment. It has been suggested that any radical or surgical treatments for phimosis should not be done until after puberty. This has partly come about because of the reaction to the over use of circumcision as a mainstream treatment for phimosis. It has also been reported by bodies such as CIRP that significant numbers of doctors are unable to recognise normal developmental tight prepuce and pathological phimosis. It is believed that many unnecessary circumcisions are performed because of current medical practice and misdiagnosis of phimosis. Balanitis xeroticia obliterans has been sited as one of the only causes of phimosis that should lead to a surgical circumcision.

 Treatment of Phimosis
If treatment is required there are three main types:

Tropical creams, steroidal and non steroidal, applied to the prepuce.

Gradual stretching of the opening of the prepuce to widen it.

Surgical reshaping of the prepuce to make it wider.

All these treatments tend to avoid the side effects associated with surgical circumcision, trauma, pain, side effects of removal of the foreskin such as friction and interference of the erogenous and sexual functions. Treatment of Paraphimosis
If the foreskin cannot be pulled back into place treatment should be sought. If the blood flow to the penis is restricted then emergency treatment is required and if the foreskin cannot be pulled back a surgical cut to the trapped foreskin may be required. Failure to seek treatment can result in permanent damage to the penis.

 Hygiene and the Foreskin
-

The American Academy of Pediatics recommends that the immature foreskin of intact boys is not forced back for cleaning.

The only person who should clean and retract the foreskin is the boy himself. Bubble bath products and other chemical irritants can cause the foreskin to tighten and it is recommended they should be avoided by intact males.