Phimosis

Published Categorized as ORGAN SYSTEMS, Renal System

Inability to retract the prepuce/foreskin over the glans penis.


Aetiology

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)

Clinical features

  • 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.
Tight preputial orifice on retraction of foreskin: A) Skin at preputial outlet is healthy with no scarring, and the inner preputial mucosa is starting to evert through the outlet. With physiologic phimosis, the preputial outlet is always closed and one cannot see the glans unless the foreskin is retracted, as the examiner has done in the photograph. B) In many cases of pathologic phimosis, the glans and meatus are visible without any attempt at retraction, as the scarred ring holds the preputial outlet open. There is no inner mucosal eversion through the outlet. | McGregor TB, Pike JG, Leonard MP. Phimosis—a diagnostic dilemma. Can J Urol. 2005;12(2):2598–602.

Complications:

  • 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
Diagram illustrating paraphimosis | From the collection of Dr Ranjiv Mathews

Management

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)
Demonstration of the different steps to children and parents on how to apply the corticoid cream; it is emphasized after the resorption of the cream to attempt to fully retract the foreskin (mechanical physiotherapy of the foreskin). a Retracting the penile shaft skin to expose the non-elastic and unretractable foreskin. b Application of the topical corticoid cream. c Pulling forward of the foreskin and rubbing the cream to be resorbed. | Ghysel, C., Eeckt, K.V., & Bogaert, G. (2009). Long-Term Efficiency of Skin Stretching and a Topical Corticoid Cream Application for Unretractable Foreskin and Phimosis in Prepubertal Boys. Urologia Internationalis, 82, 81 – 88.

Circumcision:

Circumcision is the preferred treatment for pathological phimosis and represents the only absolute indication for this procedure in children.

2 comments

  1. I wanted to comment, there are some parts in the phimosis page which can lead to confussion and actually cause problems, the first being the advice to retract the foreskin of little boys when there’s increasing evidence that doing so can end forcing their foreskin and causing wounds, thus is not advisable, the second, using soap to wash the foreskin and glans, when most dermatologists advice against that, only slightly warm water should be used, since is a mucous tissue, the same as eyelids, and soaps can cause infection, the same way in which can harm the natural bacterial balance in the female vagina, and is the most common cause for balanitis; a lot of what is said seems coming from u.s. american textbooks which have no proper training on foreskins due to their practice of circumcising newborns and they go out of their way to promote that practice while neglecting providing proper advice; is time for these misconceptions to be updated.

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