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There is a group of typical conditions of the foreskin, that can occur in more or less distinct ways.
There is a group of typical conditions of the foreskin, that can occur in more or less distinct ways.


=== Short Frenulum (frenulum breve) ===
=== Short frenulum (frenulum breve) ===


If the frenulum is too short, it can hinder or even prohibit retraction of the foreskin. Since the underside of the glans is attached to the inner foreskin by the frenulum, it can be bent downwards due to the resulting tension when the foreskin is retracted. If the mechanical strain is too great, the frenulum can tear or rip apart. If the frenular artery, which runs within, is damaged in the process, it can lead to considerable and prolonged bleeding. When only small tears appear, it may heal spontaneously.
If the frenulum is too short, it can hinder or even prohibit retraction of the foreskin. Since the underside of the glans is attached to the inner foreskin by the frenulum, it can be bent downwards due to the resulting tension when the foreskin is retracted. If the mechanical strain is too great, the frenulum can tear or rip apart. If the frenular artery, which runs within, is damaged in the process, it can lead to considerable and prolonged bleeding. When only small tears appear, it may heal spontaneously.
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There are 3 surgical variants:
There are 3 surgical variants:
<ref>http://de.wikipedia.org/wiki/Frenulum_breve</ref>
<ref>{{URLwikipedia|Frenulum_breve|Frenulum breve|2019-09-25}}</ref>


* Frenectomy, the complete removal of the frenulum
* Frenectomy, the complete removal of the frenulum
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* Elongation of the frenulum with a skin graft.
* Elongation of the frenulum with a skin graft.


=== Physiological Phimosis ===
=== Physiological phimosis ===


Physiological phimosis can be divided into three main categories - symptom-free, in need of therapy, and in need of surgery.
Physiological phimosis can be divided into three main categories - symptom-free, in need of therapy, and in need of surgery.
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Even though the data from Jakob Øster's studies (see above) have been known for 45 years, some check lists for school doctors‘ examinations still erroneously refer to physiological phimosis as an abnormality.
Even though the data from Jakob Øster's studies (see above) have been known for 45 years, some check lists for school doctors‘ examinations still erroneously refer to physiological phimosis as an abnormality.


====Manual stretching====
==== Manual stretching ====


The growth and hormonal surge during puberty alter both the size and size ratio of the penis and penile skin significantly. Also, the first masturbations aid the process of stretching of the skin and detachment of any remaining chlidhood fusion.
The growth and hormonal surge during puberty alter both the size and size ratio of the penis and penile skin significantly. Also, the first masturbations aid the process of stretching of the skin and detachment of any remaining chlidhood fusion.


If, after that, the foreskin still remains too tight, resulting in pain during sexual activities, and
If, after that, the foreskin still remains too tight, resulting in pain during sexual activities, and making genital hygiene difficult, treatment is indicated. The boy himself should engage in stretching exercises, if needed with the aid of corticosteroid cream. Depending on the active substances, success rates of 80-90% have been documented.<ref>{{REFjournal
making genital hygiene difficult, treatment is indicated. The boy himself should engage in
| last=Orsola A, Caffaratti J, Garat JM
stretching exercises, if needed with the aid of corticosteroid cream. Depending on the active
| first=
substances, success rates of 80-90% have been documented.
| coauthors=
<ref>Orsola A, Caffaratti J, Garat JM. [http://www.cirp.org/library/treatment/phimosis/orsola1/| Conservative treatment of phimosis in children using a topical steroid]. ''Urology'' 2000;56(2):307-10.</ref>
| title=Conservative treatment of phimosis in children using a topical steroid
<ref>Ashfield JE, Nickel KR, Siemens DR, ''et al''. [http://www.cirp.org/library/treatment/phimosis/ashfield1/| Treatment of [[phimosis]] with topical steroids in 194 children]. ''J Urol.'' 2003;169(3):1106-8.</ref>
| journal=Urology
<ref>Pileggi Fde O, Vicente YA. [http://www.circinfo.org/pdf/Phim-Pileggi.pdf| Phimotic ring topical corticoid cream (0.1% mometasone furoate) treatment in children]. ''J Pediatr Surg''. 2007 Oct;42(10):1749-52.</ref>
| date=2000
<ref>Ghysel C, Vander Eeckt K, Bogaert GA. [https://reference.medscape.com/medline/abstract/19172103| Long-term efficiency of skin stretching and a topical corticoid cream application for unretractable foreskin and phimosis in prepubertal boys]. ''Urol Int''. 2009;82(1):81-8.</ref>
| volume=56
<ref>Reddy S, Jain V, Dubey M, Deshpande P, Singal AK. [https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1651-2227.2011.02534.x| Local steroid therapy as the first line treatment for boys with symptomatic phimosis - A long term prospective study]. ''Acta Paediatr''. 2011 Nov 21. [Epub ahead of print]</ref>
| issue=2
| pages=307-310
| url=http://www.cirp.org/library/treatment/phimosis/orsola1/
| quote=
| pubmedID=
| pubmedCID=
| DOI=
| accessdate=
}}</ref><ref>{{REFjournal
| last=Ashfield JE, Nickel KR, Siemens DR
| first=
| coauthors=et al.
| title=Treatment of [[phimosis]] with topical steroids in 194 children
| journal=J Urol
| date=2003
| volume=169
| issue=3
| pages=1106-1108
| url=http://www.cirp.org/library/treatment/phimosis/ashfield1/
| quote=
| pubmedID=
| pubmedCID=
| DOI=
| accessdate=2019-09-25
}}</ref><ref>{{REFjournal
| last=Pileggi Fde O, Vicente YA
| first=
| coauthors=
| title=Phimotic ring topical corticoid cream (0.1% mometasone furoate) treatment in children
| journal=J Pediatr Surg
| date=2007 Oct
| volume=42
| issue=10
| pages=1749-1752
| url=http://www.circinfo.org/pdf/Phim-Pileggi.pdf
| quote=
| pubmedID=
| pubmedCID=
| DOI=
| accessdate=2019-09-25
}}</ref><ref>{{REFjournal
| last=Ghysel C, Vander Eeckt K, Bogaert GA
| first=
| coauthors=
| title=Long-term efficiency of skin stretching and a topical corticoid cream application for unretractable foreskin and phimosis in prepubertal boys
| journal=Urol Int
| date=2009
| volume=82
| issue=1
| pages=81-88
| url=https://reference.medscape.com/medline/abstract/19172103
| quote=
| pubmedID=
| pubmedCID=
| DOI=
| accessdate=2019-09-25
}}</ref><ref>{{REFjournal
| last=Reddy S, Jain V, Dubey M, Deshpande P, Singal AK
| first=
| coauthors=
| title=Local steroid therapy as the first line treatment for boys with symptomatic phimosis - A long term prospective study
| journal=Acta Paediatr
| date=2011-11-21 [Epub ahead of print]
| volume=
| issue=
| pages=
| url=https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1651-2227.2011.02534.x
| quote=
| pubmedID=
| pubmedCID=
| DOI=10.1111/j.1651-2227.2011.02534.x
| accessdate=2019-09-25
}}</ref>


Should those therapies not yield the desired outcomes, there is a surgical option, namely a preputioplasty.
Should those therapies not yield the desired outcomes, there is a surgical option, namely a preputioplasty.


====Preputioplasty====
==== Preputioplasty ====


This surgical method preserves the foreskin. A good cosmetic result and total preservation of the foreskin are achieved. The basic principle of most of those methods consists of making one or more small longitudinal incisions, and then suturing the wound or wounds transversely.
This surgical method preserves the foreskin. A good cosmetic result and total preservation of the foreskin are achieved. The basic principle of most of those methods consists of making one or more small longitudinal incisions, and then suturing the wound or wounds transversely.


There are several different methods:
There are several different methods:
<ref>[http://de.wikipedia.org/wiki/Phimose#Pr.C3.A4putiumsplastik| Phimose]</ref>
<ref>{{URLwikipedia|Phimosis: Surgical|Phimosis: Surgical|2019-09-25}}</ref>


* Dorsal slit with transverse suturing: this technique places a single lengthwise cut into the stenotic ring which is then closed transversely.
* Dorsal slit with transverse suturing: this technique places a single lengthwise cut into the stenotic ring which is then closed transversely.
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If after a failed attempt to stretch the foreskin with corticosteroid cream a surgical intervention is necessary, a preputioplasty is always to be preferred over classic circumcision, due to its lower morbidity, lower rate of complications and lower costs.
If after a failed attempt to stretch the foreskin with corticosteroid cream a surgical intervention is necessary, a preputioplasty is always to be preferred over classic circumcision, due to its lower morbidity, lower rate of complications and lower costs.


=== Pathological Phimosis ===
=== Pathological phimosis ===


In pathological phimosis, the foreskin cannot be retracted over the glans without injury, due to a lack of elasticity caused by scarring or hardening.
In pathological phimosis, the foreskin cannot be retracted over the glans without injury, due to a lack of elasticity caused by scarring or hardening.


Repeated infections of the tight foreskin cause this scarring. Also, forceful attempts to retract the foreskin cause tearing with subsequential scarred [[phimosis]]. [[Lichen sclerosus]], that first leads to adhesion and then to shrinking, can also be the cause of [[phimosis]]. This rare, non-contagious chronic skin disease is partly genetically caused and considered incurable.
Repeated infections of the tight foreskin cause this scarring. Also, forceful attempts to retract the foreskin cause tearing with subsequential scarred [[phimosis]]. [[Lichen sclerosus]], that first leads to adhesion and then to shrinking, can also be the cause of [[phimosis]]. This rare, non-contagious chronic skin disease is partly genetically caused and considered incurable.
<ref>http://de.wikipedia.org/wiki/Lichen_sclerosus_et_atrophicus</ref>
<ref>{{URLwikipedia|Lichen_sclerosus|Lichen sclerosus|2019-09-25}}</ref>


Pathological phimosis usually requires treatment.
Pathological phimosis usually requires treatment.
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