Phimosis

The term phimosis loosely describes the condition in which the foreskin cannot be drawn back (retracted) to uncover the glans (head) of the penis. Unfortunately, the term has been misused for over 100 years, and inappropriately used as an excuse for circumcision. It has been used to refer to both a normal, physiological, developmental stage in children, and as well as to a pathological condition, usually of adults, but rarely found in children. The former requires no treatment whatsoever, and the latter can be typically be prevented by proper care and/or treated conservatively. It is important to distinguish between these two meanings.

Foreskin retractability by age, per Øster 1968.

Normal physiological non-retractability – At birth, the foreskin is usually fused to the glans (head) of the penis, and so cannot be retracted. A non-retractable foreskin in itself is not a disease but a physiologically normal developmental stage in boys. There is no set age by which a boy “must” be retractable. The foreskin gradually becomes retractable, all by itself, between infancy and early adulthood.[7] About 50% of boys are able to fully retract their foreskin by 10 years of age, and only about 1 percent of males aged 18-plus have a non-retractile foreskin.[8,9] In the absence of tissue changes indicating a disease process, a diagnosis of “phimosis” in a pathological sense is inappropriate for most children and adolescents.

Physiological non-retractability requires no treatment. The fusion of the foreskin with the glans penis naturally dissolves gradually over time (along with accompanying loosening of the foreskin outlet) without any need for intervention. Occasional spraying of urine, or the presence of ballooning upon urination, are typically harmless, transitory phenomena sometimes seen during the developmental process.[10] Even those few men who retain a non-retractable foreskin into adulthood may never have any problems with hygiene, comfort, or sexual performance.

Pathological and problem phimosis. Pathological phimosis is rare; one large study found the cumulative risk to be 0.6% by age 15 years.[11] Most cases are likely caused by forced retraction of the foreskin in childhood (often by health professionals, or by parents following improper medical advice) that causes tears, resulting in scarring and adhesion of the foreskin to the glans as the tissue heals.

Phimosis can also be the result of a rare condition called balanitis xerotica obliterans (BXO), in which disease processes harden the tissue of the foreskin outlet. Since BXO may be a precursor to squamous cell carcinoma (a cancer of the skin and internal linings),[12] this may in part explain the observed association of penile cancer with a history of phimosis.[13]

When treatment is deemed necessary, for example, if the foreskin is too tight to allow for urination, 80% to 95% of cases can be successfully treated by application of topical steroid ointment which avoids surgical risk.[14,15] Older boys and men may treat a non-retractable foreskin with gentle manual stretching to accomplish permanent tissue expansion.[16,17] With the development of conservative treatments, including topical therapies and foreskin-sparing surgical techniques,[18,19] the use of circumcision as a treatment of choice to prevent or relieve phimosis is obsolete.

Phimosis can occasionally be caused by a condition called frenulum breve in which the frenulum (the web of tissue connecting the foreskin to the underside of the glans) is too short to allow retraction. Frenulum breve may be relieved by a minor incision in the frenulum (frenuloplasty).[20]

Infant circumcision itself can actually cause a phimotic condition, as the circular scar may contract over the top of the glans following surgery, trapping it behind a ring of scar tissue. One study found that phimosis occurs in 2.9% of circumcision patients[21] – a figure that easily exceeds the incidence of pathological phimosis in intact males.[11] Since circumcision may cause more cases of phimosis than it prevents, it cannot be recommended to prevent phimosis.

Balanitis

Intact males may sometimes present with balanitis − a catch-all term covering various minor inflammatory problems affecting the foreskin and/or glans. Balanitis can be caused by mechanical or chemical irritation (e.g. from soiled diapers, soap, or harsh pool chemicals), or by infection with bacteria or fungi. It is rarely an indication for therapeutic circumcision, and never for prophylactic circumcision. Effective conservative treatment measures exist for all types of balanitis, including BXO, and are considered the first line of treatment.[12]

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