Nila Munaya

Phemosis
Femur

Definition of Phimosis
Phimosis is a congenital or acquired narrowing of the prepuce [fig. phimosis], which
hinders (relative phimosis) or prevents (absolute phimosis) the retraction of the
prepuce. Natural adhesions (without scarring) during the first years of life between
the prepuce and the glans penis have to be distinguished from phimosis.

Erect penis with phimosis, the

retraction of the prepuce is not
possible. Public domain figure from
http://commons.wikimedia.org

Epidemiology of Phimosis
The prevalence of adhesions between prepuce and glans are age dependent: 58%
after 1 year of life, 1035% after 3 years of life. The prevalence of true phimosis
(with scarring) is 8% in 6-year old boys and 1% with 16 years of age.
Etiology (Causes) of phimosis
Natural adhesions:

The prepuce is formed by a fold of skin, which surrounds the glans by the fifth
month of fetal development. Initially, the inner sheet of the prepuce is connected to
the glans with adhesions. Penile growth, epithelial debris (smegma) and intermittent
erections lead to a separation of the prepuce from the glans: 50% after the first year
of life, 90% after third year of life.
Scarring of the Prepuce
Recurrent inflammation (balanitis) leads to scarring and narrowing of the prepuce,
which itself predisposes to recurrent balanitis.
Complications of Phimosis
Frequent complications are urinary tract infections, a paraphimosis or recurrent
balanitis. Obstructive voiding dysfunction and urinary retention are possible.
The risk of sexually transmitted diseases is higher in uncircumcised men.
Phimosis is a risk factor for penile cancer. With a good standard of hygiene care,
penis cancer is very rare. The risk for cervical cancer is increased in women with
uncircumcised men.
Signs and Symptoms

Difficult of missing retractability of the prepuce

Poor hygiene (smegma)

Obstructive voiding dysfunction, urinary retention

Complications like paraphimosis or balanitis

Treatment of Phimosis
Circumcision

Complete (radical) or incomplete (prepuce sparing) circumcision is the cornerstone

of phimosis treatment. Please see section circumcision: technique and complications.
Contraindications for circumcision are untreated balanitis, coagulation disorders or
hypospadias with possible repair in the future.
Newborn circumcision:
After local anesthesia of the penis, circumcision is performed using a Gomco clamp,
Mogen clamp or with the Plastibell technique. The complication rate for newborn
circumcision is 0.23%. Most complications are minor, but also devastating
complications like partial glans removal or ablative penile injury have occurred. See
below for arguments pro or contra prophylactic newborn circumcision.
Conservative Treatment of Phimosis
Local cortisone treatment for 612 weeks can lead to a healing of the phimosis, e.g.
betamethasone 0.06% cream. The glucocorticoid steroid cream is applied twice daily
for six weeks. With insufficient widening of the prepuce, the treatment can be
continuated for another 6 weeks. The success rate of conservative therapy
(avoidance of circumcision) is around 7590%. Contraindications to conservative
therapy are recurrent urinary tract infections and obstructive voiding dysfunction
due to phimosis.
Prophylactic Newborn Circumcision
Prophylactic newborn circumcision is the most common surgical procedure in the
United States. Controversies exist about the benefit and harm regarding the
prophylactic newborn circumcision, especially if the religious affiliation does not
mandate circumcision. Since the diseases, which can be reduced by prophylactic
circumcision are very rare, endorsement of routine circumcision is critical.
Arguments for a prophylactic newborn circumcision:

Avoidance the need for surgery of scarring phimosis in the phallic phase

Reduction of urinary tract infections

Reduced risk for transmission of sexually-transmitted diseases

Prevention of invasive penile cancer

Prevention of cervical cancer of future sexual partners

Arguments against prophylactic newborn circumcision:

Painful procedure with rare but potentially serious complications

Circumcision does not provide any reliable protection against sexuallytransmitted diseases

Incidence of penile cancer is very low with adequate hygiene care

Many circumcisions are not necessary (overtreatment), since preventable

diseases are rare.

http://en.wikipedia.org/wiki/Phimosis
Phimosis
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Phimosis
Classification and external resources

An erect penis with a case of phimosis

Phimosis (/fmoss/ or /famoss/[1][2]), from the Greek phimos (

["muzzle"]), is a condition in males where the foreskin cannot be fully retracted over
the glans penis. The term may also refer to clitoral phimosis in women, whereby
the clitoral hood cannot be retracted, limiting exposure of the glans clitoridis.[3]
In the neonatal period, it is rare for the foreskin to be naturally retractable; Huntley
et al. state that "non-retractability can be considered normal for males up to and
including adolescence."[4] 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 (a condition deemed a
problem).[5] Some authors use the terms "physiologic" and "pathologic" to
distinguish between these types of phimosis;[6] others use the term "non-retractile
foreskin" to distinguish this developmental condition from (pathologic) phimosis.[5]

Pathological (acquired) phimosis has several causes. Lichen sclerosus et atrophicus

(thought to be the same condition as balanitis xerotica obliterans) is regarded as a
common (or even the main[7]) cause of pathological phimosis.[8] Other causes may
include scarring caused by forcible retraction of the foreskin,[6] and balanitis.[9]
Beaug found that patients with phimosis had masturbation practices that differed
from the usual pulling down of the foreskin that mimics sexual intercourse.[10] Some
studies found phimosis to be a risk factor for urinary retention[11] and carcinoma of
the penis.[12] Common treatments include steroid creams, manual stretching,
preputioplasty, and circumcision.[13]
Normal development
At birth, the inner layer of the foreskin is sealed to the glans penis. This attachment
forms "early in fetal development and provide[s] a protective cocoon for the delicate
developing glans."[14] The foreskin is usually non-retractable in infancy and early
childhood.[14]
The American Academy of Pediatrics and the Canadian Pediatric Society state that
no attempt should be made to retract the foreskin of an infant.[15][16] Age is reportedly
a factor in non-retractability: according to Huntley et al. the foreskin is reportedly
retractable in approximately 50% of cases at 1 year of age, 90% by 3 years of age,
and 99% by age 17. These authors argue that, unless scarring or other abnormality is
present, non-retractibility may "be considered normal for males up to and including
adolescence."[4] Hill states that full retractability of the foreskin may not be achieved
until late childhood or early adulthood.[17] A Danish survey found that the mean age
of first foreskin retraction is 10.4 years.[18]
Some pediatric urologists have argued that many physicians continue to have trouble
distinguishing developmental non-retractility from pathological phimosis.[5][19][20]
Cause

Pathological phimosis (as opposed to the natural non-retractability of the foreskin in

childhood) is rare and the causes are varied. Some cases may arise from balanitis
(inflammation of the glans penis), perhaps due in turn to inappropriate efforts to
retract an infant's foreskin. Other cases of non-retractile foreskin may be caused by
preputial stenosis or narrowness that prevents retraction, by fusion of the foreskin
with the glans penis in children, or by frenulum breve, which prevents retraction. In
some cases a cause may not be clear, or it may be difficult to distinguish
physiological phimosis from pathological 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.[21]
Phimosis in older children and adults can vary in severity, with some able to retract
their foreskin partially ('relative phimosis'), and some completely unable to retract
their foreskin even in the flaccid state ('full phimosis').
When phimosis develops in an adult who was previously able to retract his foreskin,
it is nearly always due to a pathological cause, and is far more likely to cause
problems for the man.
Beaug noted that unusual masturbation practices, such as lying face down on a bed
and rubbing the penis against the mattress, may cause phimosis. Patients are advised
to stop exacerbating masturbation techniques and are encouraged to masturbate by
moving the foreskin up and down so as to mimic more closely the action of sexual
intercourse. After giving this advice Beaug noted not once did he have to
recommend circumcision.[10][22]
One cause of acquired, pathological phimosis is chronic balanitis xerotica obliterans
(BXO), a skin condition of unknown origin that causes a whitish ring of indurated
tissue (a cicatrix) to form near the tip of the prepuce. This inelastic tissue prevents
retraction. Infectious, inflammatory, and hormonal factors have all been implicated
or proposed as contributing factors.[citation needed]

Phimosis may occur after other types of chronic inflammation (such as

balanoposthitis), repeated catheterization, or forcible foreskin retraction.[23]
Phimosis may also arise in untreated diabetics due to the presence of glucose in their
urine giving rise to infection in the foreskin.[24]
Management
Phimosis in infancy is nearly always physiological, and needs to be treated only if it
is causing obvious problems such as urinary discomfort or obstruction. In older
children and adults, phimosis should be distinguished from frenulum breve, which
more often requires surgery, though the two conditions can occur together.
If phimosis in older children or adults is not causing acute and severe problems,
nonsurgical measures may be effective. Choice of treatment is often determined by
whether the patient (or doctor) views circumcision as an option of last resort to be
avoided or as the preferred course.
Non surgical methods include:

Application of topical steroid cream, such as betamethasone, for 46 weeks

to the narrow part of the foreskin is relatively simple, less expensive than
surgical treatments and highly effective.[25][26] It has replaced circumcision as
the preferred treatment method for some physicians in the British National
Health Service.[27][28]

Recently, a trial of treatment with betamethasone dipropionate (0.05%) for 2

weeks is advocated in all children with phimosis before undertaking surgery.
This steroid therapy demonstrated a success rate of 77%.[29]

Stretching of the foreskin can be accomplished manually, with balloons[30] or

with other tools. Skin that is under tension expands by growing additional
cells. A permanent increase in size occurs by gentle stretching over a period
of time. The treatment is non-traumatic and non-destructive. Manual
stretching may be carried out without the aid of a medical doctor. The tissue

expansion promotes the growth of new skin cells to permanently expand the
narrow preputial ring that prevents retraction. Beaug treated several
hundred adolescents by advising them to change their masturbation habits to
closing their hand over their penis and moving it back and forth. Retraction
of the foreskin was generally achieved after four weeks and he stated that he
never had to refer one for surgery.[10][22]

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.
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[31][32] can be an effective alternative to
circumcision.[20] It has the advantage of only limited pain and a short time of
healing relative to circumcision, and avoids cosmetic effects.

Surgery
Physicians often saw the natural, normal unretractability of the foreskin in infancy as
pathological and recommended circumcision. Sometimes circumcision was
performed in infancy to prevent phimosis.[33] "Many boys are circumcised for
(pathological or physiological) phimosis before the age of five years, despite
(pathological) phimosis being rare in this group".[34]
A 2010 study from Brazil found that treatment of young boys with a topical steroid
cream was more cost-effective than circumcision within the Brazilian public health
system.[35]
While circumcision prevents phimosis, studies of the incidence of healthy infants
circumcised for each prevented case of potential phimosis are inconsistent.[19][23][36][37]
[38][39]

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.
Epidemiology

A number of medical reports of phimosis incidence have been published over the
years. They vary widely because of the difficulties of distinguishing physiological
phimosis (developmental nonretractility) from pathological phimosis, definitional
differences, ascertainment problems, and the multiple additional influences on postneonatal circumcision rates in cultures where most newborn males are circumcised.
A commonly cited incidence statistic for pathological phimosis is 1% of
uncircumcised males.[23][37],[19] When phimosis is simply equated with nonretractility
of the foreskin after age 3 years, considerably higher incidence rates have been
reported.[36][38] Others have described incidences in adolescents and adults as high as
50%, though it is likely that many cases of physiological phimosis or partial
nonretractility were included.[39]
History

According to some accounts, phimosis prevented Louis XVI of France from

impregnating his wife for the first seven years of their marriage. She was 14
and he was 15 when they married in 1770. However, the presence and nature
of his genital anomaly is not considered certain, and some scholars (such as
Vincent Cronin and Simone Bertiere) assert that surgical repair would have
been mentioned in the records of his medical treatments if it had indeed
occurred.[citation needed]

U.S. president James Garfield was assassinated by Charles Guiteau in 1881.

Guiteau's autopsy report indicated that he had phimosis. At the time, this led
to the simplistic speculation that Guiteau's murderous behavior was due to
phimosis-induced insanity.