Changes

'''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]].<ref>{{URLwikipedia|Phimosis|Phimosis|2019-09-25}}</ref> Phimosis is a condition, not a disease, so it does not threaten health. Phimosis Men may or may not require treatmentelect to treat it. Some men live their entire lives with a non-retractile foreskin. [[Sex with phimosis| They are able to have sexual intercourse and father children]].==Pathologic phimosis==Pathologic phimosis is phimosis caused by lichen sclerosis et atrophicrus (LSA), formerly known as [[balanitis xerotica obliterans]] (BXO), on the [[foreskin]].<ref name="rickwood1980">{{REFjournal |last=Rickwood |first= |init=AMK |author-link= |last2=Hemalatha |first2= |init2=V |author2-link= |last3=Batcup |first3= |init3=G |author3-link= |last4=Spitz |first4= |init4=L |author4-link= |etal=no |title=Phimosis in boys. |trans-title= |language= |journal=Brit J Urol |location= |date=1980 |volume=52 |pages=147-50 |url=https://www.cirp.org/library/treatment/phimosis/rickwood/ |archived= |quote= |pubmedID=7191744 |pubmedCID= |DOI=10.1111/j.1464-410x.1980.tb02945.x |doi= |accessdate=2024-01-13}}</ref> Some success has been shown with treatment by topical steroid cream, but other cases may be an indication for [[circumcision]].<ref name="rickwood1980" /> See section on adult onset phimosis below. ==Physiologic phimosis==Beaugé (1997) states that adult phimosis is caused by unusual methods of [[masturbation]] that fail to stretch the narrow foreskin of [[Foreskin#Foreskin_in_infancy_and_childhood| childhood]].<ref name="beauge1997">{{REFjournal |last=Beaugé |first=Michel |init=M |author-link= |title=The causes of adolescent phimosis |journal=Brit J Sex Med |date=1997-9 |volume= |issue= |pages=26 |url=http://www.cirp.org/library/treatment/phimosis/beauge2/ |accessdate=2020-04-20}}</ref> The condition may be treated by changing one's method of [[masturbation]] according to Beaugé.

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" />=== Non-retractable foreskin of infancy and childhood ===[[File:Oester.jpg|frame|Percentage of boys with fused foreskin by age according to Øster]]Boys are almost always born with non-retractable [[foreskin]].<ref name="gairdner1949">{{GairdnerDM 1949}}</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 |init=GA |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> <ref name="shahid2012">{{REFjournal |last=Shahid |first=Sukhbir Kaur |init=SK |author-link= |etal=no |title=Phimosis in children |journal=ISRN Urology |location= |date=2012 |volume=707329 |issue= |pages= |url=https://www.hindawi.com/journals/isrn/2012/707329/ |quote= |pubmedID=23002427 |pubmedCID= |DOI=10.5402/2012/707329 |accessdate=2019-11-02}}</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= Medical indications "shahid2012" /> has been given the name ''physiological phimosis'' to distinguish it from ''pathological phimosis'' in adults.<ref name="shahid2012" /> 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 therapies 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,<ref name="Øster1968">{{OesterJ 1968}}</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. Parental reassurance is the only treatment required.<ref name="shahid2012" />  By age 10.4 years, about 50 percent of [[intact]] boys have a retractable foreskin.<ref name="Øster1968"/><ref name-"thorvaldsen2005">{{REFjournal |last=Thorvaldsen |init=MA |last2=Meyhoff |init2=HH |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"/> About two percent of adult males live with a non-retractable [[foreskin]].<ref name="shahid2012" /> If treatment is elected, the application of topical steroid ointment to assist manual [[stretching]] is the most cost-effective treatment.<ref name="vanhowe1998">{{REFjournal |last=Van Howe |first=Robert S. |init=RS |author-link=Robert Van Howe |etal=no |title=Cost-effective treatment of phimosis |journal=Pediatrics |location= |date=1998-04 |volume=102 |issue= |pages=e43 |url=https://pediatrics.aappublications.org/content/pediatrics/102/4/e43.full.pdf |quote= |pubmedID= |pubmedCID= |DOI=10.1542/peds.102.4.e43 |accessdate=2019-11-02}}</ref> Teen [[intact]] boys with a non-retractable [[foreskin]] may benefit by manual [[stretching]].<ref name="beauge1997" />

=== Physiological phimosis =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]].

Boys are almost always born Many men can have sex, father children, and live happily with a non-retractable retractile foreskin..<refname="young">{{REFjournalREFweb |lasturl=Gairdner |first=Douglas |authorhttp://www.circumstitions.com/Restric/adult-non-link= |coauthors=retr.html#adult |title=The fate of the Adult non-retracting foreskin: a study of circumcision("Phimosis")

|journallast=Brit Med JYoung |datefirst=1949-12-24Hugh |volumeinit=2H |issueauthor-link=Hugh Young |pagespublisher=1433-7Circumstitions |urlwebsite=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2051968/pdf/brmedj03656-0009.pdf |quotedate= |pubmedIDaccessdate=154082992019-11-01 |pubmedCIDformat=2051968 |DOIquote=10.1136/bmj.2The foreskin never retracts, and nor does it cause any kind of problem while having intercourse or masturbating.4642I have been enjoying a very healthy sex life with my girlfriend since the last two years.1433 |accessdate=

Physiological phimosis can be divided into three main categories Adequate lubrication has been recommended when penetrating the [[vagina]] with a non- symptom-free, in need of therapy, and in need of surgeryretractile foreskin covered [[penis]].

From a medical standpoint, an otherwise symptom-free This option preserves the [[phimosisforeskin]], even after dissolution its appearance, and most of preputial adhesionsthe protective, does not require any treatment before the child enters puberty. The widespread notion that full retractability has to be achieved by a certain ageimmunological, sensory, derives from obsolete assumptions and studies which only covered children's development until they entered schoolsexual [[https://en.intactiwiki.org/wiki/Foreskin#Physiological_functions physiological functions]], but does not beyond that pointmake the foreskin retractable.

Even though If desired, a non-retractile foreskin may be flushed out with warm water with the data from Jakob Øster's studies (see above) have been known for 51 years, some check lists for school doctors‘ examinations still erroneously refer to physiological phimosis as an abnormalityaid 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 masturbations aid [[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 boy himself 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.<ref>{{REFjournal | last=Orsola |init=A, |last2=Caffaratti |init2=J, Garat JM | firstlast3=Garat | coauthorsinit3=JM | title=Conservative treatment of phimosis in children using a topical steroid | journal=Urology | date=2000 | volume=56 | issue=2 | pages=307-310 | url=http://www.cirp.org/library/treatment/phimosis/orsola1/ | quote= | pubmedID= | pubmedCID= | DOI= | accessdate=

| last=Ashfield |init=JE, |last2=Nickel |init2=KR, |last3=Siemens DR | firstinit3=DR | coauthorsetal=et al.yes | 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

| last=Pileggi Fde |init=O, Vicente YA | firstlast2=Vicente | coauthorsinit2=YA | title=Phimotic ring topical corticoid cream (0.1% mometasone furoate) treatment in children | journal=J Pediatr Surg | date=2007 Oct-10 | volume=42 | issue=10 | pages=1749-1752 | url=http://www.circinfo.org/pdf/Phim-Pileggi.pdf | quote= | pubmedID= | pubmedCID= | DOI= | accessdate=2019-09-25

| last=Ghysel |init=C, |last2=Vander Eeckt |init2=K, Bogaert GA | firstlast3=Bogaert | coauthorsinit3=GA | 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://referencewww.ncbi.nlm.medscapenih.com/medlinegov/abstractpubmed/19172103 | quote= | pubmedID=19172103 | pubmedCID= | DOI= | accessdate=2019-0910-2516}}</ref><ref>{{REFjournal | last=Reddy |init=S, |last2=Jain |init2=V, |last3=Dubey |init3=M, |last4=Deshpande |init4=P, Singal AK | firstlast5=Singal | coauthorsinit5=AK | 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=Epub ahead of print | 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

Should those therapies not yield Manual [[stretching]] preserves the desired outcomes[[foreskin]] and its many protective, there is a surgical optionimmunological, namely a preputioplastysensory, 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>

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.

* 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.<ref>{{REFjournal |last=Wahlin |init=N |author-link= |etal=yes |title="Triple incision plasty". A convenient procedure for preputial relief |journal=Scand J Urol Nephrol |location= |date=1992 |volume=26 |issue=2 |pages= |url=107-10 |quote= |pubmedID=1626197 |pubmedCID= |DOI=10.1080/00365599.1992.11690439 |accessdate=2019-11-02}}</ref> Preputioplasty also preserves the foreskin and its many protective, immunological, sensory, and sexual [[Foreskin#Physiological_functions| physiologial functions]]

=== Pathological =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. [[Adolescent and adult circumcision| Circumcision]] is less performed today, because it is becoming outmoded by newer and better treatments.<ref name="shahid2012" /> * Circumcision is the most expensive treatment.<ref name="vanhowe1998" /> * 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 of male circumcision| psychological]] issues abound. As with other surgery, complications are surgical misadventure, hemorrhage, and infection. Loss of the penis and [[death]] are known.<ref name="shahid2012" /> <ref name="williams-kapila1993">{{REFjournal |last=Williams |first=Neville |init=N |author-link= |last2=Kapila |first2=Leela |init2=L |author2-link= |etal=no |title=Complications of circumcision |journal=Brit J Surg |location= |date=1993 |volume=80 |issue= |pages=1231-6 |url=http://www.cirp.org/library/complications/williams-kapila/ |quote= |pubmedID=8242285 |pubmedCID= |DOI=10.1002/bjs.1800801005 |accessdate=2021-06-10}}</ref> * 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.* Most men report a permanent loss of sexual sensation.* Circumcision results in a permanent [[circumcision scar]]. <u>[[Adolescent and adult circumcision| Circumcision]] should be the treatment of last resort, to be used only after conservative methods of treatment fail.</u> 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> Many men would prefer to live with phimosis in preference to losing one's [[foreskin]] to an [[adult circumcision]]. == 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 [https://www.webmd.com/drugs/2/drug-4316/clotrimazole-topical/details Clotrimazole]. Lichen Scleroses, 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. == Short frenulum (frenulum breve) ==

=== Short 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 breve) ===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 [[Frenulum breve]] is too shortfrequently confused with phimosis. To make a differential diagnosis, it can hinder or even prohibit retraction of one may attempt to retract the foreskinwhen the penis is erect. Since the underside of the glans is attached to the inner foreskin by the [[frenulum]], if frenulumbreve is present, it can be bent the head of the penis will bend 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.

* 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.==Video==<br><youtube>v=NPwFMSZjiII</youtube>

<!{{LINKS}} * {{REFjournal |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=http://www.cirp.org/library/treatment/phimosis/rickwood/ |title=Phimosis in boys |journal=Brit J Urol |date=1980-04 |volume=52 |issue= |pages=147-50 |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/ |archived= |quote=As demonstrated by their visual art, the Greeks highly esteemed the foreskin as a defining feature of the male body. |pubmedID=10418085 |pubmedCID= |DOI=10.1007/s003450050120 |accessdate=2022-06-16}} * {{REFweb |url=http://phimosisjourney.com/ |title=A Phimosis Journey - Guide to Treating Phimosis |accessdate=2019-11-04}} * {{REFweb |url=http://willywellbeing.com/ |title=Willy Well-being |last= |first= |accessdate=2020- 06-17}} * {{LINKSREFweb |url=http://www.cirp.org/library/treatment/phimosis/ |title=Conservative Treatment of Phimosis: Alternatives to Radical Circumcision |last=Anonymous |first= |publisher=Circumcision Reference Library |date=2006-07-12 |accessdate=2019-11-01}} * {{REFweb |url=https://www.tightforeskin.org/ |title=Everything about phimosis. |accessdate=2019-11-23}} * {{REFweb |url=https://www.phimostretch.com/blogs/news/phimosis-stretching-guide |title=Phimosis stretching guide |trans-title= |language= |last= |first= |author-link= |publisher=Phimostretch |website= |date= |accessdate=2019-11-19 |format= |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.}} * [https://www.wikihow.fitness/Do-Phimosis-Stretching How to Do Phimosis Stretching] * {{REFweb |title=Phimosis and Circumcision (Adult) |url=https://www.coventryrugbygpgateway.nhs.uk/pages/phimosis-2/ |archived= |trans-title= |language= |last=Blacker |first=Anthony |author-link= |publisher=National Health Service - Coventry and Warwickshire |website= |date=2018-05-22 |accessdate=2022-06-24 |format= |quote=Phimosis is a condition in where the foreskin of the penis is too tight to be pulled back to reveal the glans.}} * {{REFweb |url=https://treatphimosis.com/ |title=treat phimosis |last= |first= |init= |publisher= |date= |accessdate=2023-11->01}}