Phimosis (
/fɪˈmoʊsəs/ or
/faɪˈmoʊsəs/[1][2]), 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.
[3]
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."
[4]
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).
[5] Some authors use the terms "physiologic" and "pathologic" to distinguish between these types of phimosis;
[6] others use the term "non-retractile foreskin" to distinguish this developmental condition from (pathologic) phimosis.
[5]
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
[7]) cause of pathological phimosis.
[8] Other causes may include
scarring caused by forcible retraction of the foreskin,
[6] and
balanitis.
[9] Beaugé found that patients with phimosis had
masturbation practices that differed from the usual pulling down of the foreskin that mimics
sexual intercourse.
[10] Some studies found phimosis to be a risk factor for
urinary retention[11] and
carcinoma of the penis.
[12] Common treatments include
steroid creams, manual stretching,
preputioplasty, and
circumcision.
[13]
Contents
- 1 Normal development
- 2 Cause
- 3 Management
- 4 Prognosis
- 5 Epidemiology
- 6 History
- 7 See also
- 8 References
- 9 External links
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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."
[14] The foreskin is usually non-retractable in infancy and early childhood.
[14]
The
American Academy of Pediatrics and the
Canadian Pediatric Society state that no attempt should be made to retract the foreskin of an infant.
[15][16] 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."
[4] Hill states that full retractability of the foreskin may not be achieved until late childhood or early adulthood.
[17] A Danish survey found that the mean age of first foreskin retraction is 10.4 years.
[18]
Some
pediatric urologists
have argued that many physicians continue to have trouble
distinguishing developmental non-retractility from pathological
phimosis.
[5][19][20]
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, ballooning does not 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.
[10][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. Infectious, inflammatory, and hormonal factors have all been
implicated or proposed as contributing factors.
[citation needed]
Phimosis may occur after other types of chronic inflammation (such as
balanoposthitis), repeated
catheterization, or forcible foreskin retraction.
[23]
Phimosis may also arise in untreated diabetics due to the presence of
glucose in their urine giving rise to infection in the foreskin.
[24]
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.[25][26] It has replaced circumcision as the preferred treatment method for some physicians in the British National Health Service.[27][28]
- Recently, a trial of treatment with betamethasone dipropionate
(0.05%) for 2 weeks is advocated in all children with phimosis before
undertaking surgery. This steroid therapy demonstrated a success rate of
77%.[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.[10][22]
Surgical methods range from the complete removal of the foreskin to more minor operations to relieve foreskin tightness:
- 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.
Surgery
Physicians often saw the natural, normal 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]
A 2010 study from Brazil found that treatment of young boys with a
topical steroid cream was more cost-effective than circumcision within
the Brazilian public health system.
[35]
While circumcision prevents phimosis, studies of the incidence of
healthy infants circumcised for each prevented case of potential
phimosis are inconsistent.
[36][19][23][37][38][39]
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.
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.
[23][37],[19]
When phimosis is simply equated with nonretractility of the foreskin
after age 3 years, considerably higher incidence rates have been
reported.
[36][38]
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.
[39]
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]
- U.S. 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 simplistic speculation that Guiteau's
murderous behavior was due to phimosis-induced insanity.[40]
Topical corticosteroids- Phimosis can be treated by the local application of topical steroids (betamethasone cream 0.05%) in 80-90% of cases. 