Wednesday, June 10, 2009


Phimosis (fī-mō'sĭs, fĭ-), from the Greek phimos (φῑμός ("muzzle")), is a condition where, in men, the male foreskin cannot be fully retracted from the head of the penis. The term may also refer to clitoral phimosis in women, whereby the clitoral hood cannot be retracted, limiting exposure of the glans clitoris.[1]

In the neonatal period, it is rare for the foreskin to be retractable; Huntley et al. state that "non-retractability can be considered normal for males up to and including adolescence."[2] Rickwood, as well as other authors, has suggested that true phimosis is over-diagnosed due to failure to distinguish between normal developmental non-retractability and a pathological condition (a condition deemed a problem).[3] Some authors use the terms "physiologic" and "pathologic" to distinguish between these types of phimosis;[4] others use the term "non-retractile foreskin" to distinguish this developmental condition from (pathologic) phimosis.[3]

Pathological (acquired) phimosis has several causes. Lichen sclerosus et atrophicus (thought to be the same condition as balanitis xerotica obliterans), is regarded as a common (or even the main[5]) cause of pathological phimosis.[6] Other causes may include: scarring caused by forcible retraction of the foreskin,[4] and balanitis.[7] Beauge found that patients with phimosis had masturbation practices that differed from the usual pulling down of the foreskin that mimics sexual intercourse.[8] Some studies found phimosis to be a risk factor for urinary retention[9] and carcinoma of the penis.[10] Common treatments include steroid creams and circumcision.[11]

Contents [hide]
1 Natural development of the foreskin
2 Pathological/Acquired phimosis
3 Potential complications of acquired phimosis
4 Treatment of phimosis
5 Incidence
6 Phimosis in history
7 See also
8 References
9 External links
9.1 Pictures

[edit] Natural development of the foreskin
At birth, the inner layer of the foreskin is sealed to the glans of the penis. This attachment forms "early in fetal development and provide[s] a protective cocoon for the delicate developing glans."[12] The foreskin is usually non-retractable in infancy and early childhood, when the developing glans needs complete protection from the mechanical trauma of the nappy and clothing, and the chemical trauma of ammoniacal urine.[12]

Until recently, knowledge of the development of the foreskin has been a neglected subject. Physicians often saw the natural unretractability of the foreskin in infancy as pathological and recommended circumcision. Often it was used as justification for routine infant circumcision.[12] Patients with phimosis can develop into adulthood without any complications.

During the 20th century studies were released which furthered our understanding of the normal development of the foreskin.[13][14][15]

The American Academy of Pediatrics and the Canadian Pediatric Society state that no attempt should be made to retract the foreskin.[16][17] Age is reportedly a factor in non-retractability: according to Huntley et al. the foreskin is reportedly retractable in approximately 50% of cases at 1 year of age, 90% by 3 years of age, and 99% by age 17. These authors argue that, unless scarring or other abnormality is present, non-retractibility may "be considered normal for males up to and including adolescence."[2] Hill states that full retractability of the foreskin may not be achieved until late childhood or early adulthood.[18] Cantu states that acquired phimosis may be caused by forceful retraction, due to the formation of scar tissue.[19]

Although the rate of surgical treatment of phimosis (usually circumcision) is falling, some pediatric urologists have argued that many physicians continue to have trouble distinguishing developmental non-retractility from pathological phimosis, and that phimosis is overdiagnosed.[3][20][21]

Phimosis is sometimes used as a justification for circumcision,[21][22] so that it will be covered by a national health system or insurance plan. The definition may be stretched by a physician for an older child; particularly where (as in North America), post-neonatal circumcision is usually outpatient surgery by a pediatric urologist, more expensive than the neonatal procedure.[21] Most pediatricians[who?] do not consider it a compelling argument for routine neonatal circumcision.[23] While circumcision prevents phimosis, at least 10 to 20 healthy infants must be circumcised for each prevented case of potential phimosis according to some incidence statistics[citation needed].

[edit] Pathological/Acquired phimosis
Pathological phimosis (as opposed to the natural non-retractability of the foreskin) in childhood is rare and the causes are varied. Some cases may arise from balanitis (inflammation of the glans penis), perhaps due in turn to inappropriate efforts to separate and retract an infant foreskin. Other cases of non-retractile foreskin may be caused by preputial stenosis or narrowness that prevents retraction, by fusion of the foreskin with the glans penis in children, or by frenulum breve, which prevents retraction. In some cases a cause may not be clear, or it may be difficult to distinguish physiological phimosis from pathological if an infant appears to be in pain with urination or has obvious ballooning of the foreskin with urination or apparent discomfort. However, even ballooning does not always indicate urinary obstruction.[24]

Phimosis in older children and adults can vary in severity, with some men able to retract their foreskin partially ("relative phimosis"), and some completely unable to retract their foreskin even in the flaccid state ("full phimosis").

When phimosis develops in an uncircumcised adult who was previously able to retract his foreskin, it is nearly always due to a pathological cause, and is far more likely to cause problems for the man.

Beaugé noted that unusual masturbation practices, such as lying face down on a bed and rubbing the penis against the mattress, may cause phimosis. Patients are advised to stop the exacerbating masturbation techniques and are encouraged to masturbate by moving the foreskin up and down so as to mimic more closely the action of sexual intercourse. After giving this advice Beaugé noted not once did he have to recommend circumcision.[8][25]

One cause of acquired, pathological phimosis is chronic balanitis xerotica obliterans (BXO), a skin condition of unknown origin that causes a whitish ring of indurated tissue (a cicatrix) to form near the tip of the prepuce. This inelastic tissue prevents retraction. Some evidence suggests that BXO may be the same disease as lichen sclerosus et atrophicus of the vulva in females.[26] Infectious, inflammatory, and hormonal factors have all been implicated or proposed as contributing factors.

Phimosis may occur after other types of chronic inflammation (e.g., balanoposthitis), repeated catheterization, or forceful foreskin retraction.[19]

Phimosis may also arise in diabetics due to the presence of glucose in their urine giving rise to infection in the foreskin.[27]

[edit] Potential complications of acquired phimosis
Chronic complications of acquired (pathological) phimosis can include discomfort or pain during urination or sexual intercourse. The urinary stream can be impeded, resulting in dribbling and wetness after urination. Harmful urinary obstruction is possible but uncommon. Pain may occur when a partially retractable foreskin retracts during intercourse and chokes the glans penis. A totally non-retractable foreskin is rarely painful. There is some evidence that phimosis may be a risk factor for penile cancer.[28]

The most acute complication is paraphimosis (Paraphimosis image). In this acute condition, the glans is swollen and painful, and the foreskin is immobilized by the swelling in a partially retracted position. The proximal penis is flaccid.

[edit] Treatment of phimosis
Phimosis in infancy is nearly always physiological, and needs to be treated only if it is causing obvious problems such as urinary discomfort or obstruction. In older children and men, phimosis should be distinguished from frenulum breve, which more often requires surgery, though the two conditions can occur together.

If phimosis in older children or adults is not causing acute and severe problems, nonsurgical measures may be effective. Choice of treatment is often determined by whether the patient (or doctor) views circumcision as an option of last resort to be avoided or as the preferred course. Some men with nonretractile foreskins have no difficulties and see no need for correction.

Non surgical methods include:

Beaugé treated several hundred adolescents by advising them to change their masturbation habits to closing their hand over their penis and moving it back and forth. Retraction of the foreskin was generally achieved after four weeks and he stated that he never had to refer one for surgery.[8][25]
Application of topical steroid cream for 4-6 weeks to the narrow part of the foreskin is relatively simple and less expensive than surgical treatments.[21] It has replaced circumcision as the preferred treatment method for some physicians in the U.K. National Health Service.[29][30]
Stretching of the foreskin can be accomplished manually. Skin that is under tension expands by growing additional cells. A permanent increase in size occurs by gentle stretching over a period of time. The treatment is non-traumatic and non-destructive. Manual stretching may be carried out without the aid of a medical doctor. The stretching can also be accomplished with balloons placed under the foreskin skin under anaesthesia,[31] or with a tool.[32] The tissue expansion promotes the growth of new skin cells to permanently expand the narrow preputial ring that prevents retraction.
Some may opt for surgery treatment straight away. This consists of the removal of the foreskin or cutting a slit in the foreskin:

Circumcision is the traditional surgical solution for pathological phimosis, and is effective. Serious complications from circumcision are very rare, but minor complication rates (e.g., having to perform a second procedure or meatotomy to revise the first or to re-open the urethra) have been reported in about 0.2-0.6% in most reported series,[23] though others quote higher rates.[21]
Preputioplasty, in which a limited dorsal slit with transverse closure is made along the constricting band of skin[33][34] can be an effective alternative to full circumcision.[21] It has the advantage of only limited pain and a short time of healing relative to circumcision, and avoids cosmetic effects.

[edit] Incidence
A number of medical reports of phimosis incidence have been published over the years. They vary widely because of the difficulties of distinguishing physiological phimosis (developmental nonretractility) from pathological phimosis, definitional differences, ascertainment problems, and the multiple additional influences on post-neonatal circumcision rates in cultures where most newborn males are circumcised. A commonly cited incidence statistic for pathological phimosis is 1% of uncircumcised males.[19][35],[20] When phimosis is simply equated with nonretractility of the foreskin after age 3 years, considerably higher incidence rates have been reported.[14][36] Others have described incidences in adolescents and adults as high as 50%, though it is likely that many cases of physiological phimosis or partial nonretractility were included.[37]

[edit] Phimosis in history
According to some accounts, phimosis prevented Louis XVI of France from impregnating his wife, Marie Antoinette, for the first seven years of their marriage. She was 14 and he was 15 when they married in 1770. However, the presence and nature of his genital anomaly is not considered certain, and some scholars (Vincent Cronin and Simone Bertiere) assert that surgical repair would have been mentioned in the records of his medical treatments if it had occurred.[citation needed]
US President James Garfield was assassinated by Charles Guiteau in 1881. The autopsy report for Guiteau indicated that he had phimosis. At the time, this led to the simplistic speculation that Guiteau's murderous behavior was due to phimosis-induced insanity.[38]
Josef Fritzl had this condition when he was a child, according to a court psychologist. [39]

[edit] See also
Medical analysis of circumcision
frenulum breve
David Reimer

[edit] References
^ The prevalence of phimosis of the clitoris in women presenting to the sexual dysfunction clinic: Lack of correlation to disorders of desire, arousal and orgasm
^ a b Huntley JS, Bourne MC, Munro FD, Wilson-Storey D (September 2003). "Troubles with the foreskin: one hundred consecutive referrals to paediatric surgeons". J R Soc Med 96 (9): 449–51. doi:10.1258/jrsm.96.9.449. PMID 12949201. PMC: 539600.
^ a b c Rickwood AM, Walker J (1989). "Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence?". Ann R Coll Surg Engl 71 (5): 275–7. PMID 2802472. "Authors review English referral statistics and suggest phimosis is overdiagnosed, especially in boys under 5 years, because of confusion with developmentally nonretractile foreskin.".
^ a b McGregor TB, Pike JG, Leonard MP (March 2007). "Pathologic and physiologic phimosis: approach to the phimotic foreskin". Can Fam Physician 53 (3): 445–8. PMID 17872680. PMC: 1949079.
^ Bolla G, Sartore G, Longo L, Rossi C (2005). "[The sclero-atrophic lichen as principal cause of acquired phimosis in pediatric age]" (in Italian). Pediatr Med Chir 27 (3-4): 91–3. PMID 16910457.
^ Buechner SA (September 2002). "Common skin disorders of the penis". BJU Int. 90 (5): 498–506. doi:10.1046/j.1464-410X.2002.02962.x. PMID 12175386.
^ Edwards S (June 1996). "Balanitis and balanoposthitis: a review". Genitourin Med 72 (3): 155–9. PMID 8707315.
^ a b c Beaugé M (1997). "The causes of adolescent phimosis". Br J Sex Med 26 (Sept/Oct).
^ Minagawa T, Murata Y (June 2008). "[A case of urinary retention caused by true phimosis]" (in Japanese). Hinyokika Kiyo 54 (6): 427–9. PMID 18634440.
^ Daling JR, Madeleine MM, Johnson LG, et al. (September 2005). "Penile cancer: importance of circumcision, human papillomavirus and smoking in in situ and invasive disease". Int. J. Cancer 116 (4): 606–16. doi:10.1002/ijc.21009. PMID 15825185.
^ Steadman B, Ellsworth P (June 2006). "To circ or not to circ: indications, risks, and alternatives to circumcision in the pediatric population with phimosis". Urol Nurs 26 (3): 181–94. PMID 16800325.
^ a b c J.E. Wright (february 1994). "Further to 'the further fate of the foreskin'". The Medical Journal of Australia 160. PMID 8295581.
^ Gairdner D (1949). "The fate of the foreskin, a study of circumcision". Br Med J 2 (4642): 1433–7, illust. doi:10.1136/bmj.2.4642.1433. PMID 15408299.
^ a b Oster J (1968). "Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys". Arch. Dis. Child. 43 (228): 200–3. doi:10.1136/adc.43.228.200. PMID 5689532.
^ Kabaya, Hiroyuki; Hiromi Tamura,Seiichi Kitajima, Yoshiyuki Fujiwara, Tetsuo Kato, Tetsuro Kato (November 1996). "Analysis of shape and retractability of the prepuce in 603 Japanese boys". Journal of urology 156 (5): 1813–1815. doi:10.1016/S0022-5347(01)65544-7. PMID 8863623.
^ "Care of the Uncircumcised Penis". Guide for parents. American Academy of Pediatrics. September 2007.
^ "Caring for an uncircumcised penis". Information for parents. Canadian Paediatric Society. November 2004.
^ George Hill (2003). "Circumcision for phimosis and other medical indications in Western Australian boys". The Medical Journal of Australia 178 (11): 587. PMID 12765511.
^ a b c Cantu Jr. S. Phimosis and paraphimosis at eMedicine
^ a b Spilsbury K, Semmens JB, Wisniewski ZS, Holman CD (2003). "Circumcision for phimosis and other medical indications in Western Australian boys". Med. J. Aust. 178 (4): 155–8. PMID 12580740. . Recent Australian statistics with good discussion of ascertainment problems arising from surgical statistics.
^ a b c d e f Van Howe RS (1998). "Cost-effective treatment of phimosis". Pediatrics 102 (4): E43. doi:10.1542/peds.102.4.e43. PMID 9755280. A review of estimated costs and complications of 3 phimosis treatments (topical steroids, praeputioplasty, and surgical circumcision). The review concludes that topical steroids should be tried first, and praeputioplasty has advantages over surgical circumcision. This article also provides a good discussion of the difficulty distinguishing pathological from physiological phimosis in young children and alleges inflation of phimosis statistics for purposes of securing insurance coverage for post-neonatal circumcision in the United States.
^ Dewan PA (2003). "Treating phimosis". Med. J. Aust. 178 (4): 148–50. PMID 12580737.
^ a b "Circumcision policy statement. American Academy of Pediatrics. Task Force on Circumcision". Pediatrics 103 (3): 686–93. 1999. PMID 10049981. Although not directly focusing on phimosis, this American Academy of Pediatrics report provides a synopsis of circumcision statistics and benefits, with noncommittal final recommendation. "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision, in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child."
^ Babu R, Harrison SK, Hutton KA (2004). "Ballooning of the foreskin and physiological phimosis: is there any objective evidence of obstructed voiding?". BJU Int. 94 (3): 384–7. doi:10.1111/j.1464-410X.2004.04935.x. PMID 15291873.
^ a b Beaugé, Michel (1991). "Conservative Treatment of Primary Phimosis in Adolescents". Faculty of Medicine, Saint-Antoine University.
^ Laymon CW, Freeman C (1944). "Relationship of Balanitis Xerotica Obliterans to Lichen Sclerosus et Atrophicus". Arch Dermat Syph 49: 57–9.
^ Bromage, Stephen J.; Anne Crump and Ian Pearce (2008). "Phimosis as a presenting feature of diabetes". BJU International 101 (3): 338–340. doi:10.1111/j.1464-410X.2007.07274.x.
^ Willcourt RJ. Discussion of Rickwood et al. (2000) e-letters, 30 June 2005.
^ Berdeu D, Sauze L, Ha-Vinh P, Blum-Boisgard C (2001). "Cost-effectiveness analysis of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect". BJU Int. 87 (3): 239–44. doi:10.1046/j.1464-410x.2001.02033.x. PMID 11167650.
^ Chu CC, Chen KC, Diau GY (1999). "Topical steroid treatment of phimosis in boys". J. Urol. 162 (3 Pt 1): 861–3. doi:10.1097/00005392-199909010-00078. PMID 10458396.
^ He Y, Zhou XH (1991). "Balloon dilation treatment of phimosis in boys. Report of 512 cases". Chin. Med. J. 104 (6): 491–3. PMID 1874025.
^ The Glansie
^ Cuckow PM, Rix G, Mouriquand PD (1994). "Preputial plasty: a good alternative to circumcision". J. Pediatr. Surg. 29 (4): 561–3. doi:10.1016/0022-3468(94)90092-2. PMID 8014816.
^ Saxena AK, Schaarschmidt K, Reich A, Willital GH (2000). "Non-retractile foreskin: a single center 13-year experience". Int Surg 85 (2): 180–3. PMID 11071339.
^ Shankar KR, Rickwood AM (1999). "The incidence of phimosis in boys". BJU Int. 84 (1): 101–2. doi:10.1046/j.1464-410x.1999.00147.x. PMID 10444134. This study gives a low incidence of pathological phimosis (0.6% of uncircumcised boys by age 15 years) by asserting that balanitis xerotica obliterans is the only indisputable type of pathological phimosis and anything else should be assumed "physiological". Restrictiveness of definition and circularity of reasoning have been criticized.
^ Imamura E (1997). "Phimosis of infants and young children in Japan". Acta Paediatr Jpn 39 (4): 403–5. PMID 9316279. A study of phimosis prevalence in over 4,500 Japanese children reporting that over a third of uncircumcised had a nonretractile foreskin by age 3 years.
^ Ohjimi T, Ohjimi H (1981). "Special surgical techniques for relief of phimosis". J Dermatol Surg Oncol 7 (4): 326–30. PMID 7240535.
^ Hodges FM (1999). "The history of phimosis from antiquity to the present". in Milos, Marilyn Fayre; Denniston, George C.; Hodges, Frederick Mansfield. Male and female circumcision: medical, legal, and ethical considerations in pediatric practice. New York: Kluwer Academic/Plenum Publishers. pp. 37–62. ISBN 0-306-46131-5.

[edit] External links
Wikimedia Commons has media related to: Phimosis
Our son is not circumcised. When will his foreskin retract? by American Academy of Pediatrics
Normal development of the foreskin: Birth through age 18 by CIRP
Conservative Treatment of Phimosis: Alternatives to Radical Circumcision by CIRP
Male Initiation and the Phimosis Taboos
Encyclopedia of Phimosis Statistics
NORM-UK: Information about conservative treatment of phimosis
The Manitoban article on phimosis and frenulum breve

[edit] Pictures
Picture of a penis with phimosis
Pictures of a penis with fully retracted foreskin after successful treatment of phimosis
[hide]v • d • eDiseases of the pelvis and genitals (N40-N99, 600-629)

Female Adnexa Ovary Oophoritis · Ovarian cyst (Follicular cyst of ovary, Corpus luteum cyst, Chocolate cyst of ovary) · Ovarian hyperstimulation syndrome · Anovulation · Mittelschmerz

Fallopian tube Salpingitis · Hydrosalpinx · Hematosalpinx

Parametrium Parametritis

Uterus Endometrium: Endometriosis (Adenomyosis) · Endometrial polyp
menstruation (Amenorrhoea, Anovulation, Hypomenorrhea, Oligomenorrhea, Menorrhagia, Menometrorrhagia, Metrorrhagia, Dysmenorrhea)

Hematometra · Retroverted uterus · Asherman's syndrome

Cervix Cervicitis - Cervical polyp - Nabothian cyst

Vagina Vaginitis (Bacterial vaginosis, Atrophic vaginitis) · Leukorrhea · Hematocolpos/Hydrocolpos
intercourse (Dyspareunia, Vaginismus)

Prolapse (Cystocele, Rectocele, Urethrocele) · Fistulae (Vesicovaginal, Rectovaginal)

Vulva Vulvitis · Bartholin's cyst

Other/general Pelvic inflammatory disease · Female infertility (Habitual abortion)

Male Testicular Orchitis · Hydrocele testis · Testicular torsion · Male infertility (Azoospermia, Oligospermia)

Epididymis Epididymitis · Spermatocele · Hematocele

Prostate Prostatitis (Acute prostatitis, Chronic bacterial prostatitis, Chronic prostatitis/chronic pelvic pain syndrome) · Benign prostatic hyperplasia

Penis Balanoposthitis/Balanitis · Phimosis · Priapism · Sexual dysfunction (Erectile dysfunction) · Peyronie's disease · Penile fracture

Other Hematospermia · Retrograde ejaculation

See also congenital, neoplasia

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