Difference between revisions of "Phimosis"
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* The [[frenulum]] is too short to permit retraction. The medical name for this condition is ''[[frenulum breve]]''. | * The [[frenulum]] is too short to permit retraction. The medical name for this condition is ''[[frenulum breve]]''. | ||
* The inner surface of the foreskin is fused or adherent by a [[synechia]] to the glans penis. | * The inner surface of the foreskin is fused or adherent by a [[synechia]] to the glans penis. | ||
| + | == Non-retractable foreskin of infancy and childhood== | ||
| − | + | Boys are almost always born with non-retractable foreskin.<ref name="gairdner1949">{{REFjournal | |
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | Boys are almost always born with non-retractable foreskin | ||
|last=Gairdner | |last=Gairdner | ||
|first=Douglas | |first=Douglas | ||
| Line 32: | Line 27: | ||
|DOI=10.1136/bmj.2.4642.1433 | |DOI=10.1136/bmj.2.4642.1433 | ||
|accessdate= | |accessdate= | ||
| − | }}</ref> | + | }}</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 |
| + | |last=Deibart | ||
| + | |first=G.A. | ||
| + | |title=The separation of the prepuce in the human penis | ||
| + | |journal=Anat Rec | ||
| + | |date=1933 | ||
| + | |volume=57 | ||
| + | |issue= | ||
| + | |pages=387-99 | ||
| + | |url=http://www.cirp.org/library/anatomy/deibert/ | ||
| + | |quote= | ||
| + | |pubmedID= | ||
| + | |pubmedCID= | ||
| + | |DOI=https://doi.org/10.1002/ar.1090570409 | ||
| + | |accessdate=2019-11-01 | ||
| + | }}</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 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. | Physiological phimosis can be divided into three main categories - symptom-free, in need of therapy, and in need of surgery. | ||
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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. | 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 | + | Even though the data from Jakob Øster's studies have been known for 51 years,<ref name="Øster1968">{{REFjournal |
| + | |last= | ||
| + | |first=Jakob | ||
| + | |title=Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys | ||
| + | |journal=Arch Dis Child | ||
| + | |date=1968-04-01 | ||
| + | |volume=43 | ||
| + | |issue= | ||
| + | |pages=200-3 | ||
| + | |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2019851/pdf/archdisch01557-0066.pdf | ||
| + | |quote= | ||
| + | |pubmedID=5689532 | ||
| + | |pubmedCID=2019851 | ||
| + | |DOI=10.1136/adc.43.228.200 | ||
| + | |accessdate=2019-11-01 | ||
| + | }}</ref> 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. | ||
| + | |||
| + | By age 10.4 years, about 50 percent of intact boys have a retractable foreskin.<ref name="Øster1968" /> <ref name-"thorvaldsen2005">{{REFjournal | ||
| + | |last=Thorvaldsen | ||
| + | |first=M.A. | ||
| + | |last2=Meyhoff | ||
| + | |first2=H.H. | ||
| + | |title=Phimosis: pathological or physiological? | ||
| + | |journal=Ugeskr Læge | ||
| + | |date=2005 | ||
| + | |volume=167 | ||
| + | |issue=17 | ||
| + | |pages=1858-62 | ||
| + | |url=http://www.cirp.org/library/normal/thorvaldsen1/ | ||
| + | |quote= | ||
| + | |pubmedID=15929334 | ||
| + | |pubmedCID= | ||
| + | |DOI= | ||
| + | |accessdate=2019-11-01 | ||
| + | }}</ref> Most of the rest develop a retractable foreskin in their teenage years.<ref name="Øster1968" /> | ||
| + | |||
| + | Teen boys with a non-retractable foreskin may benefit by manual stretching. | ||
| + | |||
| + | |||
| + | ==Medical indications and therapies== | ||
| + | |||
| + | There is a group of typical conditions of the foreskin, that can occur in more or less distinct ways. | ||
| + | |||
==Treatment options== | ==Treatment options== | ||
Revision as of 02:28, 2 November 2019
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.[1] 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.
There are three causes of phimosis:
- The tip of the foreskin is too narrow to pass over the glans penis.
- The frenulum is too short to permit retraction. The medical name for this condition is frenulum breve.
- The inner surface of the foreskin is fused or adherent by a synechia to the glans penis.
Contents
Non-retractable foreskin of infancy and childhood
Boys are almost always born with non-retractable foreskin.[2] 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.[3] Moreover the tip of the foreskin at birth is usually too tight to permit any retraction.[2] Thus normal, natural childhood non-retractable foreskin 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 51 years,[4] 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.
By age 10.4 years, about 50 percent of intact boys have a retractable foreskin.[4] [5] Most of the rest develop a retractable foreskin in their teenage years.[4]
Teen boys with a non-retractable foreskin may benefit by manual stretching.
Medical indications and therapies
There is a group of typical conditions of the foreskin, that can occur in more or less distinct ways.
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 can have sex, father children, and live happily with a non-retractile foreskin.[6]
This option preserves the foreskin, it appearance, and most of the protective, immunological, sensory, and sexual functions, but does not make the foreskin retractable.
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 in the process of stretching of the skin and detachment of any remaining childhood fusion.
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.[7][8][9][10][11]
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.
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.
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.
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. [12]
Pathological phimosis usually requires treatment.
A circumcision is 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. 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.
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: [13]
- 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.
See also
- Retraction of the foreskin
- Physiological Phimosis, described in the Circumpendium
- Pathological Phimosis, described in the Circumpendium
External links
Conservative Treatment of Phimosis: Alternatives to Radical Circumcision
. Retrieved 1 November 2019.
References
- ↑ Wikipedia article: Phimosis. Retrieved 25 September 2019.
- ↑ a b
Gairdner, Douglas. The fate of the foreskin: a study of circumcision. Brit Med J. 24 December 1949; 2: 1433-7. PMID. PMC. DOI.
- ↑ Deibart, G.A.. The separation of the prepuce in the human penis. Anat Rec. 1933; 57: 387-99. DOI. Retrieved 1 November 2019.
- ↑ a b c Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child. 1 April 1968; 43: 200-3. PMID. PMC. DOI. Retrieved 1 November 2019.
- ↑ Thorvaldsen, M.A., Meyhoff, H.H.. Phimosis: pathological or physiological?. Ugeskr Læge. 2005; 167(17): 1858-62. PMID. Retrieved 1 November 2019.
- ↑ Young, Hugh.
Adult non-retracting foreskin ("Phimosis")
, Circumstitions. Retrieved 1 November 2019.
Quote:The foreskin never retracts, and nor does it cause any kind of problem while having intercourse or masturbating. I have been enjoing a very healthy sex life with my girlfriend since the last two years.
- ↑ Orsola, A., Caffaratti, J., Garat, J.M.. Conservative treatment of phimosis in children using a topical steroid. Urology. 2000; 56(2): 307-310.
- ↑ Ashfield, J.E., Nickel, K.R., Siemens, D.R., et al. Treatment of phimosis with topical steroids in 194 children. J Urol. 2003; 169(3): 1106-1108. Retrieved 25 September 2019.
- ↑ Pileggi Fde, O., Vicente, Y.A.. Phimotic ring topical corticoid cream (0.1% mometasone furoate) treatment in children. J Pediatr Surg. October 2007; 42(10): 1749-1752. Retrieved 25 September 2019.
- ↑ Ghysel, C., Vander Eeckt, K., Bogaert, G.A.. 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): 81-88. PMID. Retrieved 16 October 2019.
- ↑ Reddy, S., Jain, V., Dubey, M., Deshpande, P., Singal, A.K.. Local steroid therapy as the first line treatment for boys with symptomatic phimosis - A long term prospective study. Acta Paediatr. error; DOI. Retrieved 25 September 2019.
- ↑ Wikipedia article: Lichen sclerosus. Retrieved 25 September 2019.
- ↑ Wikipedia article: Frenulum breve. Retrieved 25 September 2019.
