Phimosis is a condition where the male foreskin cannot be fully retracted from the head of the penis. The word derives from the Greek phimos (φῑμός, "muzzle"). As most boys are born with a non-retracting foreskin, the term is confusing because it denotes both a normal stage of development, and a pathological condition (i.e. a condition that causes problems for a person). This confusion is particularly pronounced in regard to infants. Conflicting incidence reports and widely varying post-neonatal circumcision rates reflect looseness in the diagnostic criteria.
Phimosis has become a topic of contention in circumcision debates.
It is normal for a baby's foreskin not to retract, but as the child grows the foreskin is expected to become retractable. Some have suggested that physiological infantile phimosis be referred to as developmental nonretractility of the foreskin to more clearly distinguish this normal stage of development from pathological forms of phimosis. Different management is appropriate.
For most of the Twentieth Century, most of the medical profession has recognized that most male infants have foreskins which are still attached to the epithelium of the glans penis. and cannot easily be retracted. There have been four types of medical responses and attitudes toward this fact:
In the first half of the Twentieth Century, some physicians recommended that the foreskin be repeatedly retracted, if necessary with some force, to free it from the glans. It was thought that this could prevent later (pathological) phimosis and urinary problems in older boys by permitting washing of the glans and foreskin. Poor hygiene was thought to predispose to pathological phimosis. This approach has not been recommended by physicians for many decades.
Particularly in the middle of the Twentieth Century, some physicians promoted routine neonatal circumcision to avoid phimosis. While circumcision prevents phimosis, at least 10 to 20 infants must be circumcised to prevent each case of potential phimosis according to some incidence statistics. If one believes even lower phimosis incidence estimates, far more must be circumcised to prevent each case of phimosis. While some still promote this view, most pediatricians do not considered it a compelling argument for routine neonatal circumcision.
In the last three decades, as the circumcision rate in North America has declined, the most common official recommendations and guidelines from medical societies, as well as infant care books written by experts, have emphasized that it is normal not to be able to retract an infant's foreskin fully and that it need not be done. The American Academy of Pediatrics recommends gentle soap and water cleaning, but specifically recommends against forcible retraction. There is now some suspicion that forceful retraction that results in inflammation may actually contribute to pathological phimosis at an older age. Although the rate of surgical treatment of phimosis (usually circumcision) is falling, some pediatric urologists have argued that many physicians continue to have trouble distinguishing developmental non-retractility from pathological phimosis, and that phimosis is overdiagnosed.
Phimosis is sometimes used as a justification for circumcision, so that it will be covered by a national health system or insurance plan. The definition may be stretched by a physician for an older child; particularly where (as in North America), post-neonatal circumcision is usually outpatient surgery by a pediatric urologist, more expensive than the neonatal procedure.
Most infantile phimosis is simply physiological. Though uncommon, phimosis can occasionally lead to urinary obstruction or pain. Causes of pathological phimosis in infancy are varied. Some cases may arise from balanitis (inflammation of the glans penis), perhaps due in turn to inappropriate efforts to separate and retract an infant 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, even ballooning does not always indicate urinary obstruction.
There are several management approaches to infant phimosis. Most cases of simple physiological phimosis need no "management" but will disappear with time or simple stretching of the foreskin. Various topical steroid ointments have been effective at hastening separation without surgery. Several surgical techniques have been devised, which range from simple slitting of a segment of the foreskin to removal of it (circumcision).
Phimosis in older children and adults can vary in severity, with some men able to retract their foreskin partially ("relative phimosis"), and some completely unable to retract their foreskin even in the flaccid state ("full phimosis").
Because of the "elasticity" of the diagnostic criteria, there has been considerable variation in the reported prevalence of pathological phimosis. An incidence rate of 1% to 2% of the uncircumcised adult male population is often cited, though some studies of older children or adolescents have reported higher rates. Relative phimosis is more common, with estimates of its frequency at approximately 8% of uncircumcised men.
When phimosis develops in an uncircumcised 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.
An important 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. Some evidence suggests that BXO may be the same disease as lichen sclerosus et atrophicus of the vulva in females. Infectious, inflammatory, and hormonal factors have all been implicated or proposed as contributing factors. Circumcision is usually recommended though alternatives have been advocated.
Phimosis may occur after other types of chronic inflammation (e.g., balanoposthitis), repeated catheterization, or forceful foreskin retraction.
Phimosis may also sometimes be brought on by diabetes, due to high levels of sugar being present in the urine of some diabetics, which creates the right conditions for bacteria to breed, under the foreskin.
Potential complications of acquired phimosis
Chronic complications of acquired (pathological) phimosis can include discomfort or pain during urination or sexual intercourse. The urinary stream can be impeded, resulting in dribbling and wetness after urination. Harmful urinary obstruction is possible but uncommon. Pain may occur when a partially retractable foreskin retracts during intercourse and chokes the glans penis. A totally non-retractable foreskin is rarely painful. There is some evidence that phimosis may be a risk factor for penile cancer.
The most acute complication is paraphimosis (Image. ). In this acute 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. Paraphimosis is considered an emergency.
Treatment of phimosis
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. Some adults with nonretractile foreskins have no difficulties and see no need for correction.
Circumcision is the traditional surgical solution for pathological phimosis, and is effective. Serious complications from circumcision are very rare, but minor complication rates (e.g., having to perform a second procedure or meatotomy to revise the first or to re-open the urethra) have been reported in about 0.2-0.6% in most reported series, though others quote higher rates.
Preputioplasty, in which a limited dorsal slit with transverse closure is made along the constricting band of skin can be an effective alternative to full circumcision. It has the advantage of only extremely limited pain and a very short time of healing relative to the rather more traumatic circumcision, together with no cosmetic effects.
High rates of success have been reported with several nonsurgical measures:
Application of topical steroid cream for 4-6 weeks to the narrow part of the foreskin is relatively simple and less expensive than surgical treatments. It has replaced circumcision as the preferred treatment method for some physicians in the U.K. National Health Service.
There is a school of opinion among the medical profession that advocates and promotes a number of alternative methods where surgery, with all the attendant risks, can be avoided. Stretching of the foreskin can be accomplished manually, sometimes with masturbation, also known as the Beaugé method. The stretching can also be accomplished with balloons placed under the foreskin skin under anaesthesia,or with a tool. The tissue expansion promotes the growth of new skin cells to permanently expand the narrow preputial ring that prevents retraction.
Dilation and Stretching
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 treatment is inexpensive. Relief of phimosis by a stretching technique has the advantage of preserving all foreskin tissue and the sexual pleasure nerves. The Beaugé Method has proved successful for many.
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 post-neonatal circumcision rates in cultures where most newborn males are circumcised. A commonly cited incidence statistic for pathological phimosis is 1% of uncircumcised males., When phimosis is simply equated with nonretractility of the foreskin after age 3 years, considerably higher incidence rates have been reported.
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. Almost half of Japanese adolescent and adult men suffer from some degree of phimosis.
Phimosis in history
According to some accounts, phimosis prevented Louis XVI of France from impregnating his wife, Marie Antoinette, 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 (Vincent Cronin and Simone Bertiere) assert that surgical repair would have been mentioned in the records of his medical treatments if it had occurred.
US President James Garfield was assassinated by Charles Guiteau in 1881. The autopsy report for Guiteau 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.
^ abcdef Cantu Jr. S. Phimosis and paraphimosis emedicine.com. Excellent Emedicine overview.
^ abc Dewan PA. Treating phimosis Med J Austral 178:148-150, 2003. Discussion of physiological and pathological phimosis in childhood and use of diagnosis to justify surgery for parents' sake. Pictures of infant penises with and without phimosis.
^ ab Multiple authors. "Matters arising" Med J Austral 178:587-90, 2003. Letters to the Med J Austral debating the phimosis statistics of Spilsbury and the treatment recommendations of Dewan from both proponents and opponents of circumcision.
^ ab Shankar KR, Rickwood AM. The incidence of phimosis in boys Brit J Urol Internat 84:101-102, 1999. This study gives a low incidence of pathological phimosis (0.6% of uncircumcised boys by age 15 years) by asserting that balanitis xerotica obliterans is the only indisputable type of pathological phimosis and anything else should be assumed "physiological". Restrictiveness of definition and circularity of reasoning have been criticized.
^ Ezell C. Anatomy and Sexual Dysfunction Scientific American.com news item, October 31, 2000
^ abc Lannon CM, Bailey AGD, Fleischman AR, Kaplan GW, Shoemaker CT, Swanson JT, Coustan D. Circumcision Policy Statement Pediatrics 103:686-693, 1999. Although not directly focusing on phimosis, this American Academy of Pediatrics report provides a synopsis of circumcision statistics and benefits, with noncommittal final recommendation. "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision, in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child."
^ Rickwood AM, Walker J. Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence? Ann R Coll Surg Engl 71:275-7, 1989. Authors review English referral statistics and suggest phimosis is overdiagnosed, especially in boys under 5 years, because of confusion with developmentally nonretractile foreskin.
^ ab Spilsbury K, Semmens JB, Wisniewski ZS, Holman CDJ. Circumcision for phimosis and other medical indications in Western Australian boys Med J Austral 178:155-158, 2003. Recent Australian statistics with good discussion of ascertainment problems arising from surgical statistics. PMID 10444134
^ abcdefg Van Howe RS. Cost-effective treatment of phimosis Pediatrics 102: 4 October 1998, p. e43. A pediatrician and anti-circumcision activist reviews estimated costs and complications of 3 phimosis treatments (topical steroids, praeputioplasty, and surgical circumcision) and 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.
^ Babu R, Harrison SK, Hutton KAR. Ballooning of the foreskin and physiological phimosis: is there any objective evidence of obstructed voiding? BJU Internat 2004; 94:384-7
^ Monsour MA, Rabinovitch HH, Dean GE. Medical management of phimosis in children: our experience with topical steroids J Urol 162:1162-4, 1999. Good description of topical steroid use as alternative to surgery.
^ Stuart R. Encyclopedia of Phimosis Statistics male-initiation.net
^ Laymon, CW, Freeman, C. Relationship of Balanitis Xerotica Obliterans to Lichen Sclerosus et Atrophicus Arch Dermat Syph 49:57-9, 1944
^ Willcourt RJ. Discussion of Rickwood et al (2000) BMJ.com e-letters, 30 June 2005.
^ Cuckow, PR, Rix, G, Mouriquand, PDE. Preputial Plasty: A Good Alternative to Circumcision J Pediatr Surg 29(4):561-3, 1994
^ Saxena AK, Schaarschmidt K, Reich A, Willital GH. Non-retractile foreskin: a single center 13-year experience Int Surg 85(2):180-3, 2000
^ Berdeu D, Sauze L, Ha-Vinh P. Blum-Boisgard C. Cost-effectiveness analysis of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect BJU Int 87(3):239-244, 2001.
^ Imamura E. Phimosis of infants and young children in Japan Acta Paediatr Jpn 39:403-5, 1997. A study of phimosis prevalence in over 4,500 Japanese children reporting that over a third of uncircumcised had a nonretractile foreskin by age 3 years.
^ Øster J. Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys Arch Dis Child 43(228):200-3,1968
^ Ohjimi T, Ohjimi H. surgical techniques for relief of phimosis J Dermatol Surg Oncol 7:326-30, 1981.
^ Hodges FM.  The history of phimosis from antiquity to the present. in: Denniston GC, Hodges MF, Milos MF (eds.), Male and Female Circumcision: Medical, Legal, and Ethical Considerations in Pediatric Practice (New York/London: Kluwer Academic/Plenum Publishing, 1999), pp. 37-62.
Gairdner D. The fate of the foreskin, a study of circumcision Brit Med J 2:1433-7, 1949. This study was one of the first attempts to determine incidence and is still cited by both advocates and opponents of circumcision. He reported both a high rate (92%) of retractability by age 5 years (though the report is criticised because he "ran a probe around to loosen the adherence of foreskin to glans") and a high rate (20%) of boys older than 5 without full retractability.
Holman JR, Stuessi KA. Adult circumcision American Family Physician 1999;59(6): 1514. Technique for circumcision with some discussion of phimosis as most common indication for adult circumcision.
Diseases of the pelvis, genitals and breasts (N40-N99, 600-629)