Phimosis


Article Author:
Arthur McPhee


Article Editor:
Alastair McKay


Editors In Chief:
Laurie Graham
Andrew Wilt
Mary Cataletto


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
1/30/2019 10:24:39 AM

Introduction

Phimosis is a term used to describe the difficulty in retracting the prepuce. The term is Greek in origin, with the literal translation of “muzzling.” However, its use interchangeably in several conditions can often lead to the notion of a pathological process where none exists. Often non-retractile foreskin is the presenting complaint of a patient, or their parent/guardian, as such it is best to establish whether the process is physiological or pathological.

Etiology

Physiological Phimosis

At birth, the prepuce is non-retractile and remains so for a variable length of time. First appearing in the eighth week of gestation as an epithelial ridge, by 16 weeks of gestation the prepuce is complete and encases the glans. At this stage, the epithelial lining of the glans and prepuce are contiguous, and these preputial adhesions are essentially a normal developmental process. Separation begins proximally by the process of desquamation with small spaces forming, which eventually coalesce to form the preputial sac.

Pathological Phimosis 

The pathological process gives characteristic stenosis scarring and pallor of the preputial opening. It is typically caused by balanitis xerotica obliterans (BXO). BXO is a cicatrizing skin condition histologically identical to lichen sclerosis. It is a chronic skin condition with some evidence suggesting an autoimmune etiology. There has been controversy regarding BXO as a precipitant for penile cancer later in life.

Epidemiology

The natural history of non-retractile foreskin and preputial adhesions was extensively documented in the mid-twentieth century, firstly by Gairdner in 1949 and then Oster in 1968. Their combined studies show that in all but a small proportion of boys the foreskin will be retractile once the boys mature into their teenage years. These studies demonstrated that phimosis is present in 8% of 6- to 7-year-olds, 6% of 10- to 11-year-olds and 1% of 16- to 17-year-old boys. By contrast, preputial adhesions remain much more common throughout childhood and adolescence, but by 17-years of age, only 3% will have persisting adhesions. [1],[2]

VTrue pathological phimosis caused by BXO has a relatively stable incidence across all decades of life, with a spike in the third decade of life. Relatively rare in children under the age of 5, there is a peak childhood incidence between 9 and 11 years of age, with 0.6% of boys affected by years of age. Modern studies are questioning this doctrine, reporting varied incidence from 5% to 52% and children younger than 5 years as having BXO. [3]

Pathophysiology

In physiological phimosis, attempted retraction of the foreskin results in an apparent constriction ring a few millimeters proximal to the preputial orifice. The orifice on retraction has been described as akin to a flower, with a moist supple and unscarred appearance with pouting of the inner mucosa. 

In contrast, BXO has a sclerotic constricting band 1 to 2 cm proximal to the distal end, and there may be glans involvement in a diffuse pattern with whitish discoloration of the peri-meatal area and an erythematous area being pathognomonic. [4]

Histopathology

BXO has the following characteristic histological features: hyperkeratosis with follicular plugging, atrophy of the stratum spongiosum with hydropic degermation of basal cells, hyalinosis, and a band-like chronic inflammatory cell infiltrate with the homogenization of collagen. [4]

History and Physical

In physiological phimosis, ballooning of the foreskin is a common presentation in childhood when the foreskin is still non-retractile. Typically occurring between 2 to 4 years of age, it is a self-limiting phenomenon that resolves once the foreskin becomes more retractile. Parents can be reassured that this does not have any effect on the child’s bladder or ability to void. [5]

BXO has an insidious onset; there may be associated irritation, local infection, dysuria, bleeding before atrophy phimosis, and meatal stenosis. The disease can also have a cyclical course with periods of remission. On rare occasions, patients can present with acute urinary retention or nocturnal enuresis from chronic outflow obstruction.

Evaluation

Laboratory tests and radiography are not typically required in the assessment of phimosis, and studies have demonstrated no evidence of obstruction from physiological phimosis. [5]

Pathological phimosis treated with surgery should have any surgically excised skin sent for histology to confirm the diagnosis and exclude any evidence of malignancy.

Treatment / Management

Treatment of physiological phimosis is not indicated, and reassurance and an explanation of the natural history of the healthy non-retractile foreskin should be given to concerned parents. Circumcision is the preferred treatment for pathological phimosis and represents the only absolute indication for this procedure in children.

Alternatives to circumcision are not suitable to treat phimosis due to BXO but are designed to achieve a fully retractile foreskin. These treatments can be particularly useful with patients experiencing balanoposthitis. Topical steroids have been extensively studied, and topical application to the foreskin can render it retractable at an earlier stage. A typical treatment course is 4 to 8 weeks, with regular attempts at retraction during this time. Given the low risk associated with short duration topical steroid use, this can be repeated if necessary. [6],[7]

An alternative surgical approach to circumcision is the preputioplasty; this approach allows preservation of the foreskin. Initially, postoperative appearances are similar to a dorsal slit procedure, but with regular retraction of the foreskin following the procedure, this resolves into a normal retractile prepuce. [8],[9]

Differential Diagnosis

Acute balanoposthitis is a purulent, pyogenic infection of the prepuce and represents the most severe form of posthitis. These conditions lead to erythema and edema of the prepuce. Dysuria is common, and minor bleeding may occur. These episodes typically resolve with antibiotic treatment and require no further intervention unless recurrent episodes occur.

Paraphimosis is related to manipulation of the foreskin with failure to reduce the foreskin to its natural position. Presentation with pain and edema of both the prepuce and the glans is typical. Paraphimosis does not represent a disease process, and single episodes, once resolved, warrant no surgical intervention. Recurrent episodes are unusual and are an indication for circumcision.

Congenital megaprepuce is a rare condition. On examination, the outer preputial skin directly meets the abdominal wall dorsally, the scrotum ventrally with an absence of penile shaft skin. Micturition is always abnormal with the entire preputial sac filling with urine. This can be expressed to leave a more normal appearance. This condition must be treated with a modified circumcision; any attempt to treat this condition with a standard circumcision will result in the requirement for revision surgery complicated by the loss of outer preputial skin.

Preputial adhesions are a normal physiological feature and resolve spontaneously over time [1]. Surgical intervention plays a very minor role except in severe cases.

Pearls and Other Issues

  • Although the prepuce is typically non-retractile at birth, physiological phimosis will resolve, resulting in a fully and easily retractable prepuce in approximately 99% of boys by the age of 16.
  • Conservative treatment of physiological phimosis involves educating parents and children about the natural history of physiological phimosis.
  • Alternatives to circumcision exist for physiological phimosis including topical steroid therapy and preputioplasty.
  • Balanitis xerotica obliterans (BXO) remains an absolute indication for circumcision at all ages.

Enhancing Healthcare Team Outcomes

The management of phimosis is multidisciplinary. Although the condition is often first seen by the primary caregiver or nurse practitioner, in many cases a referral to a urologist is recommended.  Treatment of physiological phimosis is not indicated, and reassurance and an explanation of the natural history of the healthy non-retractile foreskin should be given to concerned parents. Circumcision is the preferred treatment for pathological phimosis and represents the only absolute indication for this procedure in children.

Alternatives to circumcision are not suitable to treat phimosis due to BXO but are designed to achieve a fully retractile foreskin. These treatments can be particularly useful with patients experiencing balanoposthitis. Topical steroids have been extensively studied, and topical application to the foreskin can render it retractable at an earlier stage. An alternative surgical approach to circumcision is the preputioplasty; this approach allows preservation of the foreskin. In most infants and children, the outcomes of phimosis treatment are good.[10] (Level 11)


  • Image 6769 Not availableImage 6769 Not available
    Contributed by A.McPhee
Attributed To: Contributed by A.McPhee

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Phimosis - Questions

Take a quiz of the questions on this article.

Take Quiz
What is the treatment of choice for an individual with phimosis but without urinary obstruction or hematuria?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the most common indication for circumcision in adults?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Phimosis is most likely to occur in a child with which of the following conditions?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 3-year-old child was seen in the clinic because the mother was unable to retract the penile foreskin. What is the most appropriate management of this case?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 2-year-old child was brought by his mother because she had difficulty retracting the foreskin of his penis. What is the best management?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the inability to retract the distal foreskin over the glans penis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which is true regarding phimosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Phimosis - References

References

Celis S,Reed F,Murphy F,Adams S,Gillick J,Abdelhafeez AH,Lopez PJ, Balanitis xerotica obliterans in children and adolescents: a literature review and clinical series. Journal of pediatric urology. 2014 Feb     [PubMed]
Das S,Tunuguntla HS, Balanitis xerotica obliterans--a review. World journal of urology. 2000 Dec     [PubMed]
Babu R,Harrison SK,Hutton KA, Ballooning of the foreskin and physiological phimosis: is there any objective evidence of obstructed voiding? BJU international. 2004 Aug     [PubMed]
Yang SS,Tsai YC,Wu CC,Liu SP,Wang CC, Highly potent and moderately potent topical steroids are effective in treating phimosis: a prospective randomized study. The Journal of urology. 2005 Apr     [PubMed]
Makhija D,Shah H,Tiwari C,Dwiwedi P,Gandhi S, Outcome of topical steroid application in children with non-retractile prepuce. Developmental period medicine. 2018     [PubMed]
Benson M,Hanna MK, Prepuce sparing: Use of Z-plasty for treatment of phimosis and scarred foreskin. Journal of pediatric urology. 2018 Jun 8     [PubMed]
Cuckow PM,Rix G,Mouriquand PD, Preputial plasty: a good alternative to circumcision. Journal of pediatric surgery. 1994 Apr     [PubMed]
GAIRDNER D, The fate of the foreskin, a study of circumcision. British medical journal. 1949 Dec 24     [PubMed]
Oster J, Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Archives of disease in childhood. 1968 Apr     [PubMed]
Huang C,Song P,Xu C,Wang R,Wei L,Zhao X, Comparative efficacy and safety of different circumcisions for patients with redundant prepuce or phimosis: A network meta-analysis. International journal of surgery (London, England). 2017 Jul;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of NP-Pediatric Primary Care. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for NP-Pediatric Primary Care, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in NP-Pediatric Primary Care, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of NP-Pediatric Primary Care. When it is time for the NP-Pediatric Primary Care board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study NP-Pediatric Primary Care.