Phimosis

Phimosis is a condition in which the foreskin of the penis cannot stretch to allow it to be pulled back past the glans. This condition can manifest as a balloon-like swelling under the foreskin during urination and may cause pain during erections in teenagers and adults. While not inherently painful otherwise, phimosis can increase the risk of complications such as balanitis, penile cancer, and urinary retention.

Signs and Symptoms

Phimosis is typically normal at birth and usually resolves by the age of 18. The foreskin of young boys is often non-retractable, with over 90% of cases resolving by age seven. Full retraction may be delayed by preputial adhesions. Medical guidance advises against attempting to retract the foreskin in infants to prevent scarring. Some reports suggest that true phimosis is over-diagnosed due to confusion with normal developmental non-retractability.

In some cases, distinguishing physiological phimosis from pathological phimosis can be challenging, especially if an infant shows discomfort while urinating or has a ballooning foreskin. Ballooning itself does not indicate urinary obstruction.

In women, a comparable condition is known as "clitoral phimosis," where the clitoral hood cannot be retracted, limiting exposure of the glans clitoridis.

Severity

Phimosis severity can be categorised as follows:

1. Full retraction of foreskin, tight behind the glans.
2. Partial exposure of glans, prepuce limiting factor.
3. Partial retraction, meatus just visible.
4. Slight retraction, but some distance between tip and glans.
5. Absolutely no retraction of the foreskin.

Causes and Risk Factors

Phimosis can be caused by several mechanical conditions, including a narrow foreskin tip, fusion of the inner foreskin with the glans, or a short frenulum (frenulum breve). Pathological phimosis may arise from balanitis, lichen sclerosus et atrophicus (also known as balanitis xerotica obliterans), chronic inflammation, repeated catheterisation, or forcible foreskin retraction. Diabetics may also develop phimosis due to glucose in their urine, which can lead to infections.

Unusual masturbation practices may exacerbate phimosis. Adjusting these practices has been shown to alleviate the condition without the need for circumcision.

Treatment

Treatment options for phimosis include both non-surgical and surgical methods.

Nonsurgical Treatment

Non-surgical measures are often effective for older boys and adults. These include:

• Advising patients to change masturbation techniques to mimic sexual intercourse more closely.
• Using topical steroid creams such as betamethasone or mometasone furoate to reduce inflammation and thin the skin.
• Gently stretching the foreskin manually or using specialised devices like foreskin tissue expander balloons or flesh tunnels. Studies report up to a 96% success rate when combining topical steroids with stretching exercises.

Surgical Treatment

Surgical methods range from minor procedures to complete removal of the foreskin:

• Dorsal slit: A single incision along the upper length of the foreskin.
• Ventral slit: An incision along the lower length of the foreskin, often used when frenulum breve is present.
• Preputioplasty: A limited dorsal slit with transverse closure to relieve tightness.
• Circumcision: Although effective, it has become less common as other methods are looked at.

Prognosis

The most acute complication of phimosis is paraphimosis, where the foreskin becomes trapped behind the glans, leading to swelling and pain. Phimosis has also been linked as a risk factor for urinary retention and penile carcinoma.

Epidemiology

Incidence reports of phimosis vary widely due to difficulties distinguishing between physiological and pathological forms. A commonly cited statistic is that pathological phimosis occurs in 1% of uncircumcised males. However, the incidence in adolescents and adults can be much higher, with some reports suggesting rates as high as 50%.

History

Historical accounts suggest that phimosis may have affected notable figures such as Louis XVI of France and Charles Guiteau, the assassin of US President James Garfield. However, these claims are often disputed and considered anecdotal.

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Self-assessment MCQs (single best answer)

What is phimosis?

Which of the following is a potential complication of phimosis?

At what age does phimosis typically resolve in most boys?

What is a non-surgical treatment option for phimosis?

Which condition can be confused with pathological phimosis due to similar symptoms?

What is a common risk factor for developing pathological phimosis?

Which surgical method involves making an incision along the upper length of the foreskin?

What is clitoral phimosis?

Which of the following is a sign of phimosis in infants?

Which historical figure is alleged to have had phimosis?