Phimosis is a condition where the foreskin of penis can’t be retracted back behind the glans penis. The condition is seen more commonly in children as compared to adults. In fact, at the time of birth 96% of male infants have what is known as physiological phimosis. This happens because of naturally occurring adhesions between prepuce and glans. The foreskin gradually becomes retractable over a variable period of time ranging from birth to 18 years of age or more. The retractiability of prepuce improves as the child grows in age. But in around 2% of otherwise normal males, the condition persists.
In uncircumcised grownup males, various reasons such as recurrent infections, local trauma etc can cause phimosis. This is known as pathological phimosis.
It is important to consult a trained urologist for such concerns because he can distinguish between the two and provide the suitable care and treatment plan.
Causes of pathological phimosis
● Balanitis xerotica obliterans (BXO).
● Repeated urinary tract infection.
● Foreskin infection.
● Repeated rough handling of the foreskin.
● Foreskin trauma.
Risk factors for phimosis
● Poor hygiene.
● Diabetes mellitus.
● Sexually transmitted infections.
● Psoriasis.
● Lichen planus.
● Lichen sclerosis.
Symptoms
Phimosis can be asymptomatic. But symptoms may present in form of redness, soreness or swelling of foreskin. Because of tight foreskin, there may be difficulty in micturition which varies in severity. During sexual intercourse, phimosis can result in pain, injury in form of skin splitting or lack of sensation. In latter cases, wearing a condom or lubrication can ease the pain.
Phimosis can also lead to inflammation of the glans penis which is known as balanitis. There can also be inflammation of glans as well as foreskin which is referred to as balanoposthitis. The aforementioned conditions are known to be caused by poor hygiene as well. Symptoms of balanitis and balanoposthitis can be itching, soreness, bad odour, redness, swelling, collection of fluid or painful micturition.
Evaluation and investigation
The diagnosis of phimosis is mainly clinical and usually no laboratory or radiological investigations are needed in such cases. But if there are associated conditions like urinary tract infections, simple urine or blood tests and sonography may be performed. It is important however that physiological be distinguished from pathological phimosis.
Also, pathological phimosis – when it is treated with surgery, the surgically excised skin should
be; sent for histopathology specially in cases where a doubt of malignancy is present.
Complications of phimosis
Although phimosis can be asymptomatic, timely intervention must be sought in case of any discomfort. Complications of phimosis include.
● Balanitis – inflammation of the glans of penis.
● Posthitis – inflammation of the foreskin.
● Paraphimosis – foreskin is retracted & swollen and stuck behind the head of penis.
● Voiding dysfunction – pain, discomfort during micturition.
● Penile carcinoma – there is an increased risk in uncircumcised males.
● Sexually transmitted disease.
Treatment / Management
When a patient is referred for non retractile foreskin, it is important to categories the condition as physiological or pathological. The plan of treatment will depend on the age of the patient, type of non retraction, cause, severity and associated morbid conditions.
For physiological phimosis in children, parents must be educated about the condition and further suggestions must be given regarding hygiene. This is referred to as the conservative treatment.
In children, indications where circumcision can be considered include recurrent balanitis, recurrent urinary tract infections (associated with condition like VUR, PUV, neuropathic bladder dysfunction), failed medical treatment or ballooning of prepuce during urination.
In adults, the mainstay treatment is circumcision. With recent development in technology, there are modern procedure available such as stapler circumcision which is gaining increased popularity among patient.
