Physiologic phimosis:Pliant, unscarred preputial orifice. Physiologic phimosis is common in male patients up to 3 years of age, but often extends into older age groups. Physiologic phimosis is the rule in newborn males. The prepuce is adhered to glans and this separates over time.
Enthusiastic attempts to retract foreskin in physiological phimosis causes microtears, infection, and bleeding with secondary scarring and true phimosis.
True pathologic phimosis:Phimosis secondary to distal scarring of the prepuce. This scarring often appears as a contracted white fibrous ring around the preputial orifice.
- Poor hygiene
- Balanitis (infection of glans penis)
- Posthitis (inflammation of foreskin)
- Balanitisxerosisobliterans (BXO) (premalignant state): Genital form of lichen sclerosus et atrophicus
- Repeated catherization
- Diabetes mellitus (risk factor)
- Grade I: Fully retractable prepuce with stenotic ring in the shaft
- Grade II: Partial retractability with partial exposure of the glans
- Grade III: Partial retractability with exposure of the meatus only
- Grade IV—no retractability.
- Paraphimosis (M/acute complication): Glans is swollen and painful, and the foreskin is immobilized by the swelling in a partially retracted position
- Urinary retention
- Carcinoma of the penis
When a child is brought with history of inability to retract the foreskin, it is important to confirm whether it is physiologic or pathologic. Management depends on age of child, type of nonretraction, severity of phimosis, cause, and associated morbid conditions.
Proper preputial hygiene:Proper care for an uncircumcised penis is simple and helps prevent pathologic foreskin conditions. The foreskin can be cleansed with slightly warm water during routine bathing.
Physiologic phimosis:The best treatment for these patients is “tincture of time.” These patients require no more than reassurance of normalcy and reinforcement of proper preputial hygiene.
- Topical corticosteroids applied directly to the preputial outlet twice daily (help stretch the foreskin, if needed)
Circumcision:Circumcision is the preferred treatment for pathological phimosis and represents the only absolute indication for this procedure in children.