Phimosis

An erect penis with a case of phimosis

Phimosis (fɪˈmoʊsɨs or faɪˈmoʊsɨs, from the Greek phimos (φῑμός "muzzle"), is a condition of the penis where the foreskin cannot be fully retracted over the glans penis. Phimosis is a condition, not a disease. Phimosis may or may not require treatment. Some men live their entire lives with a non-retractile foreskin. They are able to have sexual intercourse and father children.

Beaugé (1997) states that adult phimosis is caused by unusual methods of masturbation that fail to stretch the narrow foreskin of childhood. The condition may be treated by changing one's method of masturbation according to Beaugé.

There are three possible causes of non-retractile foreskin:

• The tip of the foreskin is too narrow to pass over the glans penis.
• The inner surface of the foreskin is fused or adherent by a synechia to the glans penis.
• The frenulum is too short to permit retraction. The medical name for this condition is frenulum breve.

All may be conservatively treated without circumcision.

Non-retractable foreskin of infancy and childhood

Percentage of boys with fused foreskin by age according to Øster

Boys are almost always born with non-retractable foreskin. The inner surface of the foreskin of a newborn baby is fused by a synechia to the surface of the glans penis so that is non-retractable. Moreover the tip of the foreskin at birth is usually too tight to permit any retraction. Thus normal, natural childhood non-retractable foreskin, which must be distinguished from pathological phimosis, has been given the name physiological phimosis to distinguish it from pathological phimosis in adults.

Physiological phimosis can be divided into three main categories - symptom-free, in need of therapy, and in need of surgery.

From a medical standpoint, an otherwise symptom-free phimosis, even after dissolution of preputial adhesions, does not require any treatment before the child enters puberty. The widespread notion that full retractability has to be achieved by a certain age, derives from obsolete assumptions and studies which only covered children's development until they entered school, but not beyond that point.

Even though the data from Jakob Øster's studies have been known for 54 years, some check lists for school doctors‘ examinations still erroneously refer to physiological phimosis as an abnormality.

In most cases, only watchful waiting is necessary, not surgery or other treatment. Parental reassurance is the only treatment required.

By age 10.4 years, about 50 percent of intact boys have a retractable foreskin. Most of the rest develop a retractable foreskin in their teenage years. About two percent of adult males live with a non-retractable foreskin.

If treatment is deemed necessary, the application of topical steroid ointment to assist manual stretching is the most cost-effective treatment.

Teen intact boys with a non-retractable foreskin may benefit by manual stretching.

Treatment options

No treatment

Non-retractile or tight foreskin is a condition, not a disease. It is not life threatening. One may elect to remain as one is, without treatment. Many men do not have an issue with non-retractile foreskin.

Many men can have sex, father children, and live happily with a non-retractile foreskin.

This option preserves the foreskin, its appearance, and most of the protective, immunological, sensory, and sexual [physiological functions], but does not make the foreskin retractable.

If desired, a non-retractile foreskin may be flushed out with warm water with the aid of a rubber-bulb ear syringe or a Water Pik.

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 masturbation aids in the process of stretching of the skin and detachment of any remaining childhood fusion. Manual stretching causes tissue expansion and a wider, retractable foreskin.

If, after that, the foreskin still remains too tight, resulting in pain during sexual activities, and making genital hygiene difficult, treatment is indicated. The individual should engage in stretching exercises, if needed with the aid of corticosteroid cream, which is available by prescription. Depending on the active substances, success rates of 80-90% have been documented.

Manual stretching preserves the foreskin and its many protective, immunological, sensory, and sexual physiological functions, and renders the foreskin retractable, but may take some months to achieve.

Carilli et al. (2021) tested the PhimoStop device which gradually dilates the foreskin over an extended period of time. Phimosed men were treated for sixty days. The treatment helped 52.1 percent of the men to resolve their phimosis.

Preputioplasty

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

There are several different methods:

• Dorsal slit with transverse suturing: this technique places a single lengthwise cut into the stenotic ring which is then closed transversely.

• Lateral preputioplasty: this is a refinement of the dorsal slit with transverse suturing. It consists of two lateral, longitudinal incisions sutured transversely.

• Triple incision: this is a method of foreskin widening. It typically consists of three incisions across the tight ring. They are closed from side to side, thereby increasing the circumference of the tight ring relative to the length of the cuts. From an aesthetic view, it has results far superior to those of a dorsal slit, and usually yields a good cosmetic result.

Preputioplasty also preserves the foreskin and its many protective, immunological, sensory, and sexual physiologial functions

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.

Frenuloplasty

Frenulum breve can prevent foreskin retraction. In many cases, foreskin retraction can be achieved, without treating the foreskin, by treating frenulum breve. One may stretch the frenulum to create tissue expansion or one may have a minor surgical procedure such as frenectomy or frenuloplasty. (See discussion below.)

Circumcision

Circumcision was the classic treatment for phimosis, but has many disadvantages and drawbacks. Circumcision is less performed today, because it is becoming outmoded by newer and better treatments.

• Circumcision is the most expensive treatment.

• Circumcision exposes the patient to the surgical risks of bleeding, infection, and surgical misadventure, which rarely can include loss of the glans penis, loss of the penis or death.

• Circumcision has a long, painful, and difficult recovery. Erections are painful. Post-circumcision lymphoedema caused swelling can last for many months. Recovery time is placed at six weeks. Erections may cause sutures to pull out, thus opening the surgical wound, causing wound dehiscence. Sexual and psychological issues abound. As with other surgery, complications are surgical misadventure, hemorrhage, and infection. Loss of the penis and death are known.

• Circumcision permanently and irreversibly amputates the highly innervated, erogenous foreskin, so its multiple protective, immunological, sensory, and sexual physiological functions are destroyed and has many risks and complications. The sensitive head of the penis will be permanently exposed so the head will rub against clothing. Many men find this to be very painful.
• Most men report a permanent loss of sexual sensation.
• Circumcision results in a permanent circumcision scar.

Circumcision should be the treatment of last resort, to be used only after conservative methods of treatment fail.

Kumar et al. (2017) graded phimosis from 0 to 5. They argue that circumcision is necessary to treat grades 4 and 5.

Adult onset phimosis

Phimosis or tight foreskin may be caused by a yeast infection. The proper treatment is to use an anti-fungal drug such as, for example, a cream that contains Clotrimazole.

Lichen Scleroses, formerly called balanitis xerotica obliterans when it occurs in males, hardens the foreskin and makes it non-retractable.

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.

Pathological phimosis usually requires treatment.

A circumcision may be indicated in severe cases of pathological phimosis, where neither non-surgical methods with corticosteroid cream nor foreskin-preserving preputioplasty are promising (for example with chronic balanitis xerotica obliterans) or have failed in previous attempts.

Short frenulum (frenulum breve)

If the frenulum is too short, it can hinder or even prohibit retraction of the foreskin. 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.

Frenulum breve is frequently confused with phimosis. To make a differential diagnosis, one may attempt to retract the foreskin when the penis is erect. Since the underside of the glans is attached to the inner foreskin by the frenulum, if frenulum breve is present, the head of the penis will bend downwards due to the resulting tension when the foreskin is retracted.

To help the healing, lukewarm camomile baths or cremes containing panthenol can be applied. With a very short frenulum and previous large tears, surgical treatment is advised.

There are 3 surgical variants:

• Frenectomy, the complete removal of the frenulum
• Frenuloplasty, where the frenulum is cut horizontally, and sewed together vertically
• Elongation of the frenulum with a skin graft.

Circumcision is not appropriate or necessary to treat frenulum breve. Patients must be careful when consulting a urologist, because urologists earn an attractive fee from performing a circumcision, so may be quick to recommend inappropriate and unnecessary injurious circumcision to an unwary patient.

See also

• Adolescent and adult circumcision
• Foreskin
• Frenulum breve
• Issues with American urologists and the practice of male circumcision
• Mitosis
• Paraphimosis
• Regret men
• Sexual effects of circumcision
• Stretching
• Tissue expansion
• Retraction of the foreskin
• Physiological Phimosis, described in the Circumpendium
• Pathological Phimosis, described in the Circumpendium

External links

• Rickwood AMK, Hemalatha V, Batcup G, Spitz L. Phimosis in boys. Brit J Urol. April 1980; 52: 147-50. PMID. DOI. Retrieved 9 November 2021.
• Hodges FM. Phimosis in antiquity. World J Urol. June 1999; 17(3): 133-6. PMID. DOI. Retrieved 16 June 2022.
  Quote: As demonstrated by their visual art, the Greeks highly esteemed the foreskin as a defining feature of the male body.

• A Phimosis Journey - Guide to Treating Phimosis. Retrieved 4 November 2019.

• Willy Well-being. Retrieved 17 June 2020.

• Anonymous (12 July 2006). Conservative Treatment of Phimosis: Alternatives to Radical Circumcision, Circumcision Reference Library. Retrieved 1 November 2019.

• Everything about phimosis.. Retrieved 23 November 2019.

• Phimosis stretching guide, Phimostretch. Retrieved 19 November 2019.
  Quote: The goal of phimosis stretching is to get to a stage where you can move your foreskin, back and forth, freely over the glans while the penis is erect.

• How to Do Phimosis Stretching

• Blacker, Anthony (22 May 2018). Phimosis and Circumcision (Adult), National Health Service - Coventry and Warwickshire. Retrieved 24 June 2022.
  Quote: Phimosis is a condition in where the foreskin of the penis is too tight to be pulled back to reveal the glans.