Phimosis

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The word phimosis originates from the Greek word phimos (φῑμός) which means "muzzle". In modern times, "phimosis" is a vague term used to describe a number of situations where the foreskin is not able retract to reveal glans, or the head of the penis. The term may also refer to clitoral phimosis in women, whereby the clitoral hood cannot be retracted, limiting exposure of the glans clitoridis.[1]

Contents

Correct Usage of the Term "Phimosis"

The word "phimosis" has become a vague term used to describe any condition where the foreskin has trouble retracting behind the glans, where the foreskin may be tight, retracting with difficulty, while in other cases, not retracting at all. It was from the 19th century onward that the usage of the word "phimosis" became vague and confused, but the original Greek word had a clinically precise definition.[2] In its earliest usage, the term "phimosis" was first used to indicate inflammatory strictures of various parts of the body. Galen, Heliodorus, and Andromachus, for example, used the term to refer to inflammatory strictures of the anus or the eyelid, but not the foreskin.[3][4][5]

The earliest etymological association between the term "phimosis" and the genitals was made by the Greek physician Dioscorides of Anazarbus, who flourished under the reigns of Claudius and Nero (41-68 AD), in his Materia Medica.[6] Dioscorides does not specifically refer to the foreskin, and he does not indicate the genitals of what sex. Furthermore, he used the Greek term phimos, which, in this case, could, with equal validity, refer to an imperforate anus or a urethral stricture of either sex.[7]

It is Aulus Cornelius Celsus who finally says that the Greeks associated genitals and the idea of stricture in his great work De Medicina.[8] Celsus specifically indicates that such a stricture is due to pathological inflammation.[9]

The second known use of the word phimosis is found in the extant writings of the Greek physician Antyllus, who lived in the second century AD.[10] Proceeding where Celsus left off, Antyllus further refines the medical conception of phimosis to include reference to inelastic scar tissue and pathological granulations as the cause of symptomatic preputial nonretractability.[11]

"Phimosis," then, strictly refers to a stricture of a part of the body, particularly one which is caused as a result of a pathological inflammation.

Incorrect Usage of the Term "Phimosis"

From the 19th century onward, the word "phimosis" has become convoluted. In their quest to make medical intervention indispensable, medical authors of the 19th century sought to pathologize natural attributes of male genital anatomy. To this end, they vilified defining characteristics of the developing juvenile penis, conflated them with actual medical conditions, and affixed the Greek term "phimosis" to them.[12] Thus, the word "phimosis" has been used inaccurately to describe a number of conditions where the foreskin is unable to retract behind the head of the penis, even stages in normal penile development.

To differentiate between phimosis and normal conditions of the penis today, a number of terms, such as "physiologic" and "pathologic phimosis" have been invented.[13] Other terms used to differentiate between physiologically normal and pathological non-retractability of the foreskin are "false" and "true phimosis." Still others use the term "non-retractile foreskin" to distinguish this developmental condition from pathologic phimosis.[14]

If we are to adhere to the specific condition that the Greek term indicates, the usage of the word "phimosis" to describe anything other than to the stricture of the foreskin, particularly when caused by a pathological inflammation, is inaccurate. Modern day authors continue to repeat the misuse of this term, and they need to be corrected.

Normal Development Vilified

Both the transitory narrowness and balanopreputial attachment characteristic of normal development in the juvenile penis are often improperly diagnosed as "phimosis," when in fact, these are normal stages of development. To confuse things further, the term "phimosis" is also used to denote the pathological, ulcerative balanopreputial adhesions of an adult suffering the dermatological effects of a sexually transmitted disease.[15] No Greek writer ever confused the developmental, physiological, and transitory balanopreputial attachment of the juvenile penis with pathological adhesions.

A number of reports in the medical literature of the United Kingdom indicate that medical doctors are not trained to distinguish between normal developmental tight prepuce in boys and pathological phimosis.[16][17][18][19][20] This results in cases of misdiagnosis of normal developmental preputial tightness as pathological phimosis in the UK.[21][22][23][24][25]

Hypertrophic Phimosis: AKA "Redundant Foreskin"

One common misuse of the word phimosis by medical writers of the nineteenth-century as well as present concerns the length of the foreskin. Penises were and are frequently diagnosed with phimosis because the foreskin has arbitrarily been determined to be "too long", "redundant", or "hypertrophic". The Greeks, however, recognized no such disease. In antiquity, the problem was not having too much foreskin, but having too little. Consequently, classical medical writers were concerned with a deformity called lipodermos, a condition in which the foreskin was not long enough to cover the glans penis completely. Galen, Soranus, Dioscorides, and Antyllus, among others, published lengthy descriptions of lipodermus and made detailed recommendations for its correction.[26][27][28][29]

"Congenital Phimosis"

Authors of the 19th century perpetuated the mistaken belief that the foreskin was supposed to be retractable at the time of birth of the infant, which led to a characterization of the genitalia of most infant males as defective at birth.[30] Doctors could then diagnose a child with "congenital phimosis" and prescribe circumcision, when, in fact, the foreskin is developmentally normal, and no intervention is necessary.

The idea that the foreskin should be retractable at birth and that it should be forced back for hygiene is mistaken and dangerous misinformation. This is an old, outdated idea that, unfortunately, is still stubbornly being repeated today. The American Academy of Pediatrics cautions parents not to retract their son's foreskin, but suggests that once he reaches puberty, he should retract and gently wash with soap and water.[31] The Royal Australasian College of Physicians as well as the Canadian Paediatric Society emphasize that the infant foreskin should be left alone and requires no special care. [32] [33]

For more information, see Retraction of the foreskin.

"Phimosis" in Children and Adolescents

The first data on development of retractile foreskin were provided in 1949 by the famous British paediatrician, Douglas Gairdner.[34] According to Gairdner, 80 percent of boys should have a retractable foreskin by the age of two years, and 90 percent of boys should have a retractable prepuce by the age of three years.[35] Gairdner's research was groundbreaking at the time, as it destroyed the myth that a child's foreskin should be retractable at birth. However, inaccuracies in Gairdner's data would spawn new ones. Gairdner had collected no data on children beyond age 5, for example, which led some authors improperly to assume that children whose foreskin was not retractable by that age were suffering from "phimosis," and that circumcision was necessary.

Gairdner's figures on percentage of retractability are now known to be too high.[36][37][38][39] Later studies have indicated that only about 40-50 percent of boys have fully retractable foreskins at age ten.[40][41][42][43]

Unfortunately, Gairdner's data have been incorporated into many textbooks and are still being repeated in medical literature today. Most medical curriculum still uses Gairdner's inaccurate data, so most healthcare providers are still being taught inaccurate data.[44] These outmoded figures are being used by many doctors to erroneously diagnosis phimosis in normal, healthy boys, leading to false indications of circumcision.

For further reading, see Retraction of the foreskin.

"Phimosis" in Adults

Occasionally, a male reaches adulthood with a non-retractile foreskin. The non-retractability is not caused by any pathogen or adhesion, and is merely a failure of the preputial opening to dilate to allow passage of the glans. The term for a narrowing of the foreskin which is not caused by any pathogen is "preputial stenosis," and should not be confused with true phimosis, which is actually caused by a disease.

Unlike phimosis, which is pathological, preputial stenosis is a true narrowing of the foreskin which is caused by a lack of hormones in the body.[citation needed] Of these 2%, 85-95% will respond to topical steroids. Of those who fail this, at least 75% will respond to stretching under local anesthesia, either manually or with a balloon. The arithmetic is simple: At the very most 7 boys in 10,000 may need surgery for preputial stenosis.

Non-retractability in Children

The rare condition of difficulty in retracting the foreskin in adult men must not be confused with the natural state of the penis in neonates and pre-pubecent boys. In newborns and young children, the foreskin is adhered to the glans by means of a membrane called synechia, also known as the balano-preputial membrane or balano-preputial lamina and will not retract.[45] Forcibly retracting the foreskin of a child can cause damage to a child's penis. (Please see article on forced retraction.)

For more information regarding the normal development of the intact penis through childhood, see the article on the Retraction of the Foreskin.

Adhesions

There are three types of adhesions that occur between the foreskin in the glans. The first are, natural, transitory adhesions that occur as part of normal development. The second are iatrogenic adhesions that occur as a result of external tampering of a developing child's penis, such as the forced, premature retraction of the foreskin; forcibly tearing away the synechia causes wounds, whereby actual adhesions are caused to grow between the foreskin and glans. The third are pathological, ulcerative balanopreputial adhesions of an adult suffering the dermatological effects of a sexually transmitted disease.[46]

Adhesions that occur as a normal part of a child's development will begin to disappear by themselves as the child nears puberty. Adhesions that were iatrogenically induced, however, may require surgical intervention later on. Adhesions that occur as a symptom of a sexually transmitted disease may also require surgical intervention. Surgical intervention to alleviate adhesions may or may not entail circumcision.

It is a mistake to classify the non-retractability of the foreskin caused by adhesions (be they the transitory adhesions a developing child encounters, or pathological adhesions that occur as part of a sexually transmitted disease) as "phimosis," however, as phimosis refers strictly to stricture, or muzzling at the end of the foreskin caused by BXO.

Phimosis Caused by Circumcision

Phimosis can actually be caused by circumcision. Phimosis with a trapped penis is an infrequent but important complication of circumcision. This condition is more likely to occur in older infants and those with poor attachment of the penile skin to the shaft.

Stages of Normal Development

Typically, when a baby boy is born, the prepuce is long with a narrow tip.[47][48] Retraction is not possible in the majority of infants because the narrow tip will not pass over the glans penis. Moreover, it is normal for the inner mucosal surface of the prepuce to be fused with the underlying mucosal surface of the glans penis,[49][50][51][52] further preventing retraction. This attachment forms "early in fetal development and provide[s] a protective cocoon for the delicate developing glans."[53] The foreskin is usually non-retractable in infancy and early childhood.[53]

In normal development, the foreskin usually separates from the glans and becomes retractable with age.[54] In normal development, the foreskin usually separates from the glans and becomes retractable with age.[55] As the infant matures into a boy and the boy into a man, the tip of the prepuce becomes wider, and the shaft of the penis grows, making the tip of the prepuce appear shorter. The membrane that bonds the inner surface of the prepuce with the glans penis spontaneously disintegrates and releases the prepuce to separate from the glans. The prepuce spontaneously becomes retractable.

The prepuce of boys may be tight until after puberty.[56][57][58] This is an entirely normal condition and it is not phimosis.

According to the experience in cultures where circumcision is uncommon, this tightness rarely requires treatment. Spontaneous loosening usually occurs with increasing maturity.[59][60][61] One may expect 50 percent of ten-year-old boys; 90 percent of 16-year-old boys; and 98-99 percent of 18 year-old males to have full retractable foreskin. Treatment is seldom necessary. If treatment should be necessary, it should not be done until after puberty and the male can weigh the therapeutic options and give informed consent.[62]

Medical associations advise not to forcibly retract the foreskin of an infant, as this interferes with normal penile development, and may result in scarring or injury.[63][64] Some argue that non-retractability may "be considered normal for males up to and including adolescence,"[65][66] though there is much uncertainty among health care workers about when the foreskin of a boy should become retractable.[67] Hill states that full retractability of the foreskin may not be achieved until late childhood or early adulthood.[68] A Danish survey found that the mean age of first foreskin retraction is 10.4 years.[69]

"Pathological" or "True" Phimosis and False Diagnoses of Phimosis

The only condition that can be accurately described as "true phimosis," is a condition where ‘‘the tip of the foreskin is scarred and indurated and has the histological features of Balanitis xerotica obliterans’’.[70] It should not be confused with normal developmental stages of the penis, or with other conditions where the foreskin is narrow or adhered to the glans. In Britain, Rickwood et al. have successfully argued that the definition of phimosis should be divested of any notions of preputial non-retractability, physiological balanopreputial attachment, or preputial length.[71] Rickwood has refined this to the formulas: ‘‘Phimosis = BXO’’, and ‘‘No BXO = No Phimosis’’.[72]

The mistaken belief that the foreskin was supposed to be retractable at the time of birth of the infant has led to a characterization of the genitalia of most infant males as defective at birth. This has led to many false diagnoses of phimosis, followed by unnecessary circumcision, when, in fact, the foreskin is developmentally normal. Rickwood, as well as other authors, has suggested that true phimosis is over-diagnosed due to failure to distinguish between normal developmental non-retractability and a pathological condition.[14][73][74]

In some cases, it may be difficult to distinguish normal non-retractability and pathological phimosis, if an infant appears to be in pain with urination or has obvious ballooning of the foreskin with urination or apparent discomfort. However, ballooning does not indicate urinary obstruction.[75]

Diagnosis of Phimosis, AKA "True Phimosis"

To determine whether or not a person is suffering a case of "true phimosis," the doctor should order that the proper analyses be conducted to determine whether or not the narrowing of the foreskin has been caused by BXO. Once a legitimate case of phimosis has been confirmed, treatment options can be considered. "True phimosis," where a stricture of the preputial opening is a result of BXO, is a rare disease, occurring in less than 1% of males. [76]

Treatment

Preputioplasty:
Fig 1. Penis with tight phimotic ring making it difficult to retract the foreskin.
Fig 2. Foreskin retracted under anaesthetic with the phimotic ring or stenosis constricting the shaft of the penis and creating a “waist”.
Fig 3. Incision closed laterally.
Fig 4. Penis with the loosened foreskin replaced over the glans.

True phimosis may be the only legitimate indication for surgical intervention. Surgical methods range from the complete removal of the foreskin to more minor operations to relieve foreskin tightness:

  • Circumcision is sometimes performed for pathological phimosis, and is effective.
  • Dorsal slit (superincision) is a single incision along the upper length of the foreskin from the tip to the corona, exposing the glans without removing any tissue.
  • Ventral slit (subterincision) is an incision along the lower length of the foreskin from the tip of the frenulum to the base of the glans, removing the frenulum in the process. Often used when frenulum breve occurs alongside the phimosis.
  • Preputioplasty, in which a limited dorsal slit with transverse closure is made along the constricting band of skin[77][78] can be an effective alternative to circumcision.[74] It has the advantage of only limited pain and a short time of healing relative to circumcision, and avoids cosmetic effects.

Circumcision as Phimosis Prophylaxis

While circumcision prevents phimosis, studies of the incidence of healthy infants circumcised for each prevented case of potential phimosis are inconsistent.[73][79][80][81][82][83]


Prognosis

The most acute complication is paraphimosis. In this condition, the glans is swollen and painful, and the foreskin is immobilized by the swelling in a partially retracted position. The proximal penis is flaccid. Some studies claim phimosis to be a risk factor for urinary retention[84] and carcinoma of the penis.[85] though neither the American Cancer Society, nor any other respected medical organization in the world recommends circumcision as prophylaxis for any of these conditions.


References

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  68. George Hill (2003). "Circumcision for phimosis and other medical indications in Western Australian boys". The Medical Journal of Australia 178 (11): 587; author reply 589–90. PMID 12765511. http://www.mja.com.au/public/issues/178_11_020603/matters_arising_020603-1.html. 
  69. Thorvaldsen MA, Meyhoff H.. Patologisk eller fysiologisk fimose?. Ugeskr Læger. 2005;167(16):1852-62.
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  71. Rickwood AMK, Hemalatha V, Batcup G, Spitz L (1980) Phimosis in boys. Br J Urol 52:147-150
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  73. 73.0 73.1 Spilsbury K, Semmens JB, Wisniewski ZS, Holman CD (2003). "Circumcision for phimosis and other medical indications in Western Australian boys". Med. J. Aust. 178 (4): 155–8. PMID 12580740. http://www.mja.com.au/public/issues/178_04_170203/spi10278_fm.html.  . Recent Australian statistics provide good discussion of ascertainment problems arising from surgical statistics.
  74. 74.0 74.1 Van Howe RS (1998). "Cost-effective treatment of phimosis". Pediatrics 102 (4): e43–e43. doi:10.1542/peds.102.4.e43. PMID 9755280. http://pediatrics.aappublications.org/cgi/content/full/102/4/e43.  A review of estimated costs and complications of 3 phimosis treatments (topical steroids, praeputioplasty, and surgical circumcision). The review concludes that topical steroids should be tried first, and praeputioplasty has advantages over surgical circumcision. This article also provides a good discussion of the difficulty distinguishing pathological from physiological phimosis in young children and alleges inflation of phimosis statistics for purposes of securing insurance coverage for post-neonatal circumcision in the United States.
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