Phimosis

phimosis (from the Greek φῑμός, phimós, "snout") occurs when the foreskin hole is too narrow to allow the glans penis to come out. In other words, phimosis is a condition of the penis where the foreskin cannot be fully retracted over the glans. The term phimosis can also refer to phimosis of the clitoris, whereby the clitoral hood cannot be retracted, limiting exposure of the glans clitoris.

At birth, the foreskin is fused to the glans penis and cannot be retracted, that is, all newborn males have phimosis, but it gradually disappears during childhood and puberty. After puberty, around the age of 13 on average, the foreskin should be able to retract, exposing the glans penis, both when the penis is flaccid and when it is erect. If this is not possible, there is phimosis. Phimosis is considered pathological when it causes problems such as difficulty urinating or performing common sexual functions.

Phimosis can be resolved by circumcision, the use of tubes that take advantage of the progressive dilation of the phimotic ring, the use of steroid creams, and specific stretching exercises.

Epidemiology

Phimosis is common, especially in boys, before adolescence. It is estimated that less than 2% of 17-year-olds have phimosis. In 95% of newborns, preputial retraction is difficult. At 6 months only 20% of the foreskins are retractile, at one year 50% are retractable and at 3 years more than 90% are retractile.^{[citation needed]}

In recent years, a number of medical reports have been published on the incidence of phimosis. These reports vary widely, due to difficulties in distinguishing physiologic from pathologic phimosis, and multiple additional influences on postneonatal circumcision rates in cultures where most newborn males are circumcised. A commonly cited incidence statistic for pathologic phimosis is 1% of uncircumcised men. When phimosis is simply synonymous with non-retractability of the foreskin after 3 years of age, considerably higher incidence rates have been reported. Others have described incidences in adolescents and adults of up to 50%, although it is likely that many cases of physiologic phimosis or partial nonretractability were included.

Also, it is common for phimosis patients to suffer from large accumulations of smegma on the crown of the glans.

Etiology

There are three mechanical conditions that prevent retraction of the foreskin:

1. The tip of the foreskin is too narrow to pass over the gland. This is normal in prepuber children and adolescents.

2. The inner surface of the foreground merges with the penis gland. This is normal in children and adolescents, but abnormal in adults.

3. The penile braking is too short to allow complete retraction of the forehead (a condition called short branillo).

Pathological phimosis (as opposed to the natural non-retractility of the foreskin in childhood) is rare and the causes are varied. Some cases may arise from balanitis (inflammation of the glans penis).

Lichen sclerosus atrophic (believed to be the same condition as balanitis xerotica obliterans) is considered a common (or even leading) cause of pathologic phimosis. This is a skin condition of unknown origin that causes a whitish ring of hardened tissue near the tip of the foreskin. This tissue without elasticity prevents retraction.

Phimosis can occur after other types of chronic inflammation (such as balanoposthitis), repeated catheterization, or forceful retraction of the foreskin.

Phimosis can also arise in untreated diabetics, due to infection in the foreskin.

Phimosis in older boys and adults can vary in severity, with some being able to partially retract their foreskin (relative phimosis), and some totally unable to retract their foreskin, even when the penis is in a flaccid state (complete phimosis).

The cause of phimosis is thought to be congenital, but it can also be due to forced retractions of the foreskin of babies during grooming by parents, which creates fibrous rings on the foreskin and balanopreputial adhesions.

In adults, the causes of phimosis are usually varied: chronic or recurrent balanoposthitis, especially in diabetics, balanitis xerotica obliterans, and trauma (direct, violent sexual acts, urological manipulations).

Pathophysiology

The foreskin develops as a small layer of epithelium that surrounds the glans penis, from the twelfth week of gestation. By the time of birth, it completely hides the glans penis and is strongly adhered to its epithelium. Over the course of the first four to five years of age, gradual separation of the foreskin occurs, through intermittent erections and the accumulation of desquamation cells, which should not be confused with smegma.

Patient with fimosis and mega-prep

If you can't fully retract the foreskin behind the glans, then you have phimosis. Not all foreskins automatically retract when experiencing a penile erection. If it can be done manually without pain, it is not considered phimosis, since it is possible in this case to have full sexual intercourse without difficulty.

The foreskin is usually non-retractile in infancy. Some argue that non-retractility can be considered normal for males until puberty, which is when a male technically becomes potentially sexually active. Hill states that full retractability of the foreskin cannot be achieved until late childhood or early adulthood. A Danish study found the median age of first foreskin retraction to be 10.4 years.

Rickwood, as well as other authors, has suggested that true phimosis is over-diagnosed due to the inability to distinguish between normal developmental non-retractility and a pathological state. Some authors use the terms "physiological" and "pathological" to distinguish between these types of phimosis; others use the term "non-retractile foreskin" to distinguish this condition from the development of pathological phimosis.

Clinical picture

Complication of the fimosis, called parafimosis

Basically there are two types of phimosis depending on the degree of retraction of the foreskin:

• Relative Fimosis: when the foreskin is partially withdrawn
• Fimosis complete: when the foreskin is not removed, even when the penis is flaccid.

Depending on the degree of foreskin stenosis, there are three categories:

• Fimosis puntiforme: the one in which the prepucial hole is of a minimum diameter, barely appreciable, with the surrounding skin of normal appearance and thickness.

• Cycatricial or non-retractable annul: that in which the skin surrounding the prepucial orifice is indurated or thickened, usually by previous balnopostitis.

• Annular fimosis: those cases that cannot be included in either of the previous two groups, the prepucio being narrowed to a greater or lesser extent and by some circumstances there are complications or failure to retraction.

Phimosis must be differentiated from paraphimosis (urological emergency caused by inflammation or edema of the foreskin) that prevents the covering of the glans penis after its forced retraction and that produces a constriction or strangulation of the glans penis due to a ring of the foreskin that has become retracted, with risk of necrosis of the glans penis, which can cause its loss. It is relatively frequent in adults with urinary catheterization and in children after their first penile manipulations.

Complications

• Painful intercourse: due to the lack of slide of the prep on the gland and penis.

• Balanitis: is the infection of the penis, due to the accumulation of smegma in the balno-prepucial space.

• Urine infections: if the smegma infection rises by the urethra.

• Miction problems: ranging from disuria, to acute repetition urine retentions and requiring urinary probe.

• Balano-prepucial adherences: it is the binding of the foreskin with the gland, which complicates the fimosis more and which may be present in the absence of fimosis.

• Parafimosis: it occurs when the gland passes through a narrow fimotic ring, then it is edematized, inflamed, and cannot return to normal position. Inflammatory changes progress in the part held under pressure (glande) and will not stop until manual or surgical reduction. Paraphysis is considered an emergency.

• Penis cancer: it is a very rare complication, with an incidence less than 1/100.000 males a year, which can be due to the persistence of fimosis after puberty.

Treatment

Physiologic phimosis, common in males 10 years of age and younger, is normal and does not require intervention. The non-retractile foreskin normally becomes retractable during puberty.

If phimosis in older children or adults is not causing acute and severe problems, non-surgical measures may be effective.

As a general rule, except in exceptional cases, circumcision should be considered an option of last resort.

Non-surgical

• The stretching of the foreskin can be achieved manually, with balloons or with other tools. The skin that is under tension expands by the growth of additional cells. A permanent increase in size occurs due to soft stretching over a period of time. Treatment is neither traumatic nor destructive. Manual stretching can be done without the help of a doctor. The expansion of tissue promotes the growth of new skin cells to permanently expand the narrow prepucial ring that prevents retraction. In a study, 86% of people were cured and could retract their foreskin in 6 weeks, by applying a cream and stretching the skin twice a day. Beaugé advises patients to masturbate by moving the foreskin up and down to correct the fimosis.

• Topical steroid creams such as betamethasone, mummetasone and cortisone furoate are effective in treating fimosis and can provide an alternative to circumcision. It is theorized that steroids work by reducing inflammatory and immune responses from the body, and also by skin thinning. Treatment with topical corticosteroids, such as betametasone, indicated by the pediatrician from the age of three for about two or three months and with the help of soft retractions, can fix the fimosis.
• Tuboids: A valid non-surgical approach for the treatment of fimosis is the progressive expansion of the fimotic ring thanks to medical ergonomic design devices called "tuboids". These, applying the well established principle of skin dilation, allow the formation of new elastic cells, resulting in the recovery of the elasticity of the foreskin and the disappearance of the fimosis.[1]

Surgical

Surgical methods range from complete removal of the foreskin to much simpler operations:

• Frenuloplasty. At times, the fimosis is caused by a too short brawn, in these situations a frenuloplasty can solve the problem by keeping the foreskin. Frenuloplasty consists of making an incision in the mill.

• Dorsal cleft (superincision) is a single incision along the upper length of the foreskin from the tip to the crown, exposing the gland without removing any tissue.

• Ventral yeast (subterincision) is an incision along the lower length of the prep from the tip of the branillo to the base of the gland, eliminating the branillo in the process. It is often used when short brawn occurs along with the fimosis.

• Prepucioplasty: a small incision is made along the constriction band. It can be an effective alternative to circumcision. It has the advantage of being much less painful and with less healing time than circumcision, and avoids cosmetic effects. Prepucioplasty is an alternative operation to circumcision, not mutilating, which leaves the prepucio intact.

• Circumcision is the total or partial removal of the foreskin, leaving the gland permanently uncovered.