Changes

Beaugé (1997) states that adult phimosis is caused by unusual methods of [[masturbation ]] that fail to stretch the narrow foreskin of [[https://en.intactiwiki.org/wiki/Foreskin#Foreskin_in_infancy_and_childhood| childhood]].<ref name="beauge1997">{{REFjournal

There are three possible causes of non-retractile foreskin:<ref name='hill2012">{{REFweb |url=https://genitalwholeness.wordpress.com/article/phimosis-2y9nanfagw8nr-11/ |archived= |title=Phimosis: Non-retracticle foreskin |trans-title= |language=English |last=Hill |first=George |init=G |author-link=George Hill |publisher=genitalwholeness |website=wordpress |date=2012-05-28 |accessdate=2020-12-06 |format= |quote=Development of retractile foreskin in boys is very gradual and occurs over a period of years._The membrane that fuses the foreskin and the glans penis spontaneously disintegrates and the foreskin separates from the glans penis._Also, the opening at the tip becomes wider with increasing maturity.}}</ref>

All may be conservatively treated without [[Adolescent and adult circumcision| circumcision]].<ref name='hill2012" />

Boys are almost always born with non-retractable foreskin.<ref name="gairdner1949">{{REFjournal |last=Gairdner |first=Douglas |author-link=Douglas Gairdner |title=The fate of the foreskin: a study of circumcision |trans-title= |language= |journal=Brit Med J |date=GairdnerDM 1949-12-24 |volume=2 |issue= |pages=1433-7 |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2051968/pdf/brmedj03656-0009.pdf |quote= |pubmedID=15408299 |pubmedCID=2051968 |DOI=10.1136/bmj.2.4642.1433 |accessdate=2019-11-02}}</ref> 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.<ref>{{REFjournal

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}}</ref> Moreover the tip of the [[foreskin]] at birth is usually too tight to permit any retraction.<ref name="gairdner1949" /> Thus normal, natural childhood non-retractable foreskin, which must be distinguished from pathological phimosis,<ref name="shahid2012" /> has been given the name ''physiological phimosis'' to distinguish it from ''pathological phimosis'' in adults.<ref name="shahid2012" />

Even though the data from [[Jakob Øster]]'s studies have been known for 51 54 years,<ref name="Øster1968">{{Template:Jakob_Øster_1968OesterJ 1968}}</ref> some check lists for school doctors‘ examinations still erroneously refer to physiological phimosis as an abnormality.

By age 10.4 years, about 50 percent of [[intact ]] boys have a retractable foreskin.<ref name="Øster1968"/><ref name-"thorvaldsen2005">{{REFjournal

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|first2init2=H.H.HH |title=[Phimosis: pathological or physiological?]

}}</ref> Most of the rest develop a retractable foreskin in their teenage years.<ref name="Øster1968"/> About two percent of adult males live with a non-retractable [[foreskin]].<ref name="shahid2012" />

If treatment is deemed necessary, the application of topical steroid ointment to assist manual stretching is the most cost-effective treatment.<ref name="vanhowe1998">{{REFjournal

|first=Robert S. |init=RS

Teen [[intact ]] boys with a non-retractable [[foreskin ]] may benefit by manual [[stretching]].<ref name="beauge1997" />

|init=H |author-link=Hugh Young

This option preserves the [[foreskin]], it its appearance, and most of the protective, immunological, sensory, and sexual [[https://en.intactiwiki.org/wiki/Foreskin#Physiological_functions 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.

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.

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Manual [[stretching ]] preserves the [[foreskin]] and its many protective, immunological, sensory, and sexual [[Foreskin#Physiological_functions| 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.<ref>{{REFjournal |last=Carilli |first=Marco |init=M |author-link= |last2=Asimakopoulos |first2=Anastasios D. |init2=AD |author2-link= |last3=Pastore |first3=Serena |init3=S |author3-link= |last4=Germani |first4=Stephani |init4=S |author4-link= |etal=yes |title=Can circumcision be avoided in adult male with phimosis? Results of the PhimoStop^TM prospective trial |trans-title= |language= |journal=Transl Androl Urol. |location= |date=2021-11 |volume=10 |issue=11 |article= |page= |pages=4152-60 |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8661253/ |archived= |quote= |pubmedID=34984181 |pubmedCID=8661253 |DOI=10.21037/tau-21-673 |accessdate=2022-01-10}}</ref>

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

This surgical method preserves the [[foreskin]]. <ref>{{REFjournal |last=Hotonu |first=Sesi |init=S |author-link= |last2=Mohamed |first2=Ahmed |init2=A |author2-link= |last3=Rajimwale |first3=Ashok |init3=A |author3-link= |last4=Gopal |first4=Milan |init4=M |author4-link= |etal=no |title=Save the foreskin: Outcomes of preputioplasty in the treatment of childhood phimosis |trans-title= |language= |journal=The Surgeon |location= |date=2020-06 |volume=`8 |issue=3 |article= |page= |pages=150-3 |url=https://www.sciencedirect.com/science/article/abs/pii/S1479666X19301106 |archived= |quote= |pubmedID=31548120 |pubmedCID= |DOI=10.1016/j.surge.2019.08.004 |accessdate=2021-06-26}}</ref> 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.

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[[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 is was the classic treatment for phimosis, but has many disadvantages and drawbacks. [[Adolescent and adult circumcision| Circumcision]] is less performed today, because it is becoming outmoded by newer and better treatments.<ref name="shahid2012" />

|url=Complications of circumcisionhttp://www.cirp.org/library/complications/williams-kapila/

|accessdate=20192021-1106-0210

* Circumcision permanently and irreversibly amputates the [[Foreskin sensitivity| 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. 

[[Adolescent and adult circumcision| 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.<ref name="kumar2017">{{REFjournal |last=Kumar |first= |init=JN |author-link= |last2=Neeraj |first2=G |init2=G |author2-link= |last3=Rajesh |first3=L |init3=L |author3-link= |last4=Kumar |first4= |init4=MS |author4-link= |etal=yes |title=Phimosis: Nonsurgical Versus Surgical Management |trans-title= |language=English |journal=Journal of Medical Science and Clinical Research |location= |date=2017-02 |volume=5 |issue=2 |article= |page= |pages=17556-60 |url=http://jmscr.igmpublication.org/v5-i2/57%20jmscr.pdf |archived= |quote= |pubmedID= |pubmedCID= |DOI= |accessdate=2021-01-14}}</ref>

Phimosis or tight foreskin may be caused by a yeast infection. The proper treatment is to use an anti-fungal drug such as, for examleexample, a cream that contains [https://www.webmd.com/drugs/2/drug-4316/clotrimazole-topical/details Clotrimazole].

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

Repeated infections of the tight foreskin cause this scarring. Also, forceful attempts to retract the foreskin cause tearing with subsequential scarred [[phimosis]]. [[Balanitis xerotica obliterans| 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>{{URLwikipedia|Lichen_sclerosus|Lichen sclerosus|2019-09-25}}</ref>

A [[Adolescent and adult circumcision is | 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.

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.

[[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.

* 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 a nice an attractive fee from performing a circumcision, so may be quick to recommend inappropriate and unnecesary unnecessary injurious [[circumcision ]] to an unwary patient.

* {{REFwebREFjournal |last=Rickwood |init=AMK |author-link= |last2=Hemalatha |init2=V |author2-link=|last3=Batcup |first3= |init3=G |author3-link= |last4=Spitz |first4= |init4=L |author4-link= |url=httpshttp://genitalwholenesswww.wordpresscirp.comorg/articlelibrary/treatment/phimosis/rickwood/ |title=Phimosis in boys |journal=Brit J Urol |date=1980-04 |volume=52 |issue= |pages=147-2y9nanfagw8nr50 |accessdate=2021-11-09 |pubmedID=7191744 |pubmedCID= |DOI=10.1111/j.1464-410x.1980.tb02945.x}}* {{REFjournal |last=Hodges |first=Frederick M. |init=FM |author-link=Frederick M. Hodges |etal=no |title=Phimosis in antiquity |trans-title= |language= |journal=World J Urol |location= |date=1999-06 |season= |volume=17 |issue=3 |article= |page= |pages=133-6 |url=http://www.cirp.org/library/history/hodges1/

|titlequote=Phimosis: Non-retracticle As demonstrated by their visual art, the Greeks highly esteemed the foreskinas a defining feature of the male body. |trans-titlepubmedID=10418085 |languagepubmedCID=English |lastDOI=Hill |first=George |author-link=George Hill |publisher=genitalwholeness |website=wordpress |date=2012-05-2810.1007/s003450050120 |accessdate=20202022-1206-06 |format= |quote=Development of retractile foreskin in boys is very gradual and occurs over a period of years._The membrane that fuses the foreskin and the glans penis spontaneously disintegrates and the foreskin separates from the glans penis._Also, the opening at the tip becomes wider with increasing maturity.16