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Transfer material on phimosis from foreskin article to phimosis article
* 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 to the glans penis.
=== Physiological phimosis ===
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 (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 ====
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 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.<ref>{{REFjournal
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| title=Conservative treatment of phimosis in children using a topical steroid
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| title=Treatment of [[phimosis]] with topical steroids in 194 children
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| last=Pileggi Fde O, Vicente YA
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| title=Phimotic ring topical corticoid cream (0.1% mometasone furoate) treatment in children
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| last=Ghysel C, Vander Eeckt K, Bogaert GA
| first=
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| 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
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| last=Reddy S, Jain V, Dubey M, Deshpande P, Singal AK
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| 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=
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| url=https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1651-2227.2011.02534.x
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| 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.
==== 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:
<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.
* 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.
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.
<ref>{{URLwikipedia|Lichen_sclerosus|Lichen sclerosus|2019-09-25}}</ref>
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:
<ref>{{URLwikipedia|Frenulum_breve|Frenulum breve|2019-09-25}}</ref>
* 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.
{{SEEALSO}}
* [[Foreskin#Physiological_Phimosis|Physiological Phimosis]], described in the [[Circumpendium]]
* [[Foreskin#Pathological_Phimosis|Pathological Phimosis]], described in the [[Circumpendium]]
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