Phimosis (from

Greek Greek may refer to: Greece Anything of, from, or related to Greece, a country in Southern Europe: *Greeks, an ethnic group. *Greek language, a branch of the Indo-European language family. **Proto-Greek language, the assumed last common ancestor ...

φίμωσις ''phimōsis'' 'muzzling'.) is a condition in which the

foreskin In male human anatomy, the foreskin, also known as the prepuce, is the double-layered fold of skin, mucosal and muscular tissue at the distal end of the human penis that covers the glans and the urinary meatus. The foreskin is attached to the ...

of the

penis A penis (plural ''penises'' or ''penes'' () is the primary sexual organ that male animals use to inseminate females (or hermaphrodites) during copulation. Such organs occur in many animals, both vertebrate and invertebrate, but males d ...

cannot stretch to allow it to be pulled back past the glans. A balloon-like swelling under the foreskin may occur with urination. In teenagers and adults, it may result in pain during an

erection An erection (clinically: penile erection or penile tumescence) is a physiological phenomenon in which the penis becomes firm, engorged, and enlarged. Penile erection is the result of a complex interaction of psychological, neural, vascular, a ...

, but is otherwise not painful. Those affected are at greater risk of inflammation of the glans, known as balanitis, and other complications. In young children, it is normal not to be able to pull back the foreskin at all. Over 90% of cases resolve by the age of seven, although full retraction is still prevented by preputial adhesions in over half at this age. Occasionally, phimosis may be caused by an underlying condition such as scarring due to balanitis or balanitis xerotica obliterans. This can typically be diagnosed by seeing scarring of the opening of the foreskin. Typically, the condition resolves without treatment by the age of 18. Efforts to pull back the foreskin during the early years of a young male's life should not be attempted. For those in whom the condition does not improve further, time can be given or a steroid cream may be used to attempt to loosen the tight skin. If this method, combined with stretching exercises, is not effective, then other treatments such as

circumcision Circumcision is a procedure that removes the foreskin from the human penis. In the most common form of the operation, the foreskin is extended with forceps, then a circumcision device may be placed, after which the foreskin is excised. Top ...

may be recommended. A potential complication of phimosis is

paraphimosis Paraphimosis is an uncommon medical condition in which the foreskin of a penis becomes trapped behind the glans penis, and cannot be ''reduced'' (pulled back to its normal flaccid position covering the glans). If this condition persists for several ...

, where the tight foreskin becomes trapped behind the glans.

Signs and symptoms

At birth, the inner layer of the

is sealed to the

glans penis In male human anatomy, the glans penis, commonly referred to as the glans, is the bulbous structure at the distal end of the human penis that is the human male's most sensitive erogenous zone and their primary anatomical source of sexual pl ...

. The foreskin is usually non-retractable in early childhood, and some males may reach the age of 18 before their foreskin can be fully retracted. Medical associations advise not to retract the foreskin of an infant, in order to prevent scarring. Some argue that non-retractability may "be considered normal for males up to and including adolescence." Hill states that full retractability of the foreskin may not be achieved until late childhood or early adulthood. A Danish survey found that the mean age of first foreskin retraction is 10.4 years. 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.. Recent Australian statistics with good discussion of ascertainment problems arising from surgical statistics. 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. Some authors use the terms "physiologic" and "pathologic" to distinguish between these types of phimosis; others use the term "non-retractile foreskin" to distinguish this developmental condition from pathologic phimosis. In some cases a cause may not be clear, or it may be difficult to distinguish physiological phimosis from pathological phimosis if an infant appears to have discomfort while urinating or demonstrates obvious ballooning of the foreskin. However, ballooning does not indicate urinary obstruction. In women, a comparable condition is known as "clitoral phimosis", whereby the

clitoral hood In the female human body, the clitoral hood (also called preputium clitoridis and clitoral prepuce) is a fold of skin that surrounds and protects the glans of the clitoris; it also covers the external shaft of the clitoris, develops as part of th ...

cannot be retracted, limiting exposure of the

glans clitoridis The glans (, plural "glandes" ; from the Latin word for "acorn") is a vascular structure located at the tip of the penis in male mammals or a homologous genital structure of the clitoris in female mammals. Structure The exterior structure of ...

Severity

* Score 1: full retraction of foreskin, tight behind the glans. * Score 2: partial exposure of glans, prepuce (not congenital adhesions) limiting factor. * Score 3: partial retraction, meatus just visible. * Score 4: slight retraction, but some distance between tip and glans, i.e. neither meatus nor glans can be exposed. * Score 5: absolutely no retraction of the foreskin.

Cause

There are three mechanical conditions that prevent foreskin retraction: :* The tip of the foreskin is too narrow to pass over the

. This is normal in children and adolescents. : :* The inner surface of the foreskin is fused with the glans penis. This is normal in children and adolescents but abnormal in adults. : :* The

frenulum A frenulum (or frenum, plural: frenula or frena, from the Latin ''frēnulum'', "little bridle", the diminutive of ''frēnum'') is a small fold of tissue that secures the motion of a mobile organ in the body. In human anatomy Frenula on the h ...

is too short to allow complete retraction of the foreskin (a condition called

frenulum breve A frenulum (or frenum, plural: frenula or frena, from the Latin ''frēnulum'', "little bridle", the diminutive of ''frēnum'') is a small fold of tissue that secures the motion of a mobile organ in the body. In human anatomy Frenula on the ...

). 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).

Lichen sclerosus et atrophicus A lichen ( , ) is a composite organism that arises from algae or cyanobacteria living among filaments of multiple fungi species in a mutualistic relationship.balanitis xerotica obliterans) is regarded as a common (or even the main) cause of pathological phimosis. This is a skin condition of unknown origin that causes a whitish ring of indurated tissue (a

cicatrix ''Cicatrix'' is a genus of wasp A wasp is any insect of the narrow-waisted suborder Apocrita of the order Hymenoptera which is neither a bee nor an ant; this excludes the broad-waisted sawflies (Symphyta), which look somewhat like ...

) to form near the tip of the prepuce. This inelastic tissue prevents retraction. Phimosis may occur after other types of chronic inflammation (such as balanoposthitis), repeated

catheterization In medicine, a catheter (/ˈkæθətər/) is a thin tube made from medical grade materials serving a broad range of functions. Catheters are medical devices that can be inserted in the body to treat diseases or perform a surgical procedure. Cat ...

, or forcible foreskin retraction.Cantu Jr. S. Phimosis may also arise in untreated diabetics due to the presence of glucose in their urine giving rise to infection in the foreskin. Beaugé noted that unusual

masturbation Masturbation is the sexual stimulation of one's own genitals for sexual arousal or other sexual pleasure, usually to the point of orgasm. The stimulation may involve hands, fingers, everyday objects, sex toys such as vibrators, or combinat ...

practices, such as thrusting against the bed or rubbing the foreskin forward may cause phimosis. Patients are advised to stop 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 Sexual intercourse (or coitus or copulation) is a sexual activity typically involving the insertion and thrusting of the penis into the vagina for sexual pleasure or reproduction.Sexual intercourse most commonly means penile–vaginal pene ...

. After giving this advice Beaugé noted not once did he have to recommend circumcision. Phimosis in older children and adults can vary in severity, with some able to retract their foreskin partially (relative phimosis), while others are completely unable to retract their foreskin, even when the penis is in a flaccid state (full phimosis).

Treatment

Physiologic phimosis, common in males 10 years of age and younger, is normal, and does not require intervention. Non-retractile foreskin usually becomes retractable during the course of

puberty Puberty is the process of physical changes through which a child's body matures into an adult body capable of sexual reproduction. It is initiated by hormonal signals from the brain to the gonads: the ovaries in a girl, the testes in a ...

. 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 circumcision is viewed as an option of last resort or as the preferred course.

Nonsurgical

* Patients are advised to stop exacerbating masturbation techniques and are encouraged to masturbate by moving the foreskin up and down so as to mimic more closely the action of

. After giving this advice Beaugé noted not once did he have to recommend circumcision. * Topical

steroid A steroid is a biologically active organic compound with four rings arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes that alter membrane fluidity; and ...

creams such as

betamethasone Betamethasone is a steroid medication. It is used for a number of diseases including rheumatic disorders such as rheumatoid arthritis and systemic lupus erythematosus, skin diseases such as dermatitis and psoriasis, allergic conditions such ...

, mometasone furoate and

cortisone Cortisone is a pregnene (21-carbon) steroid hormone. It is a naturally-occurring corticosteroid metabolite that is also used as a pharmaceutical prodrug; it is not synthesized in the adrenal glands. Cortisol is converted by the action of the enz ...

are effective in treating phimosis and should be considered before circumcision. It is theorized that the steroids work by reducing the body's inflammatory and immune responses, and also by thinning the skin. * Gently stretching of the foreskin can be accomplished manually. Skin that is under tension expands by growing additional cells. There are different ways to stretch the phimosis. If the opening of the foreskin is already large enough, the foreskin is rolled over two fingers and these are carefully pulled apart. If the opening is still too small, flesh tunnels can be used. These are inserted into the foreskin opening and should preferably be made of silicone so that they can be folded when inserted and so that they do not interfere when worn. The diameter is gradually increased until the foreskin can be retracted without difficulty. Even phimosis with a diameter of less than a millimetre can be stretched with these rings. Rings in different sizes are also available as stretching sets. Studies involving treating phimosis using topical steroids in conjunction with stretching exercises have reported success rates of up to 96%. However, other sources claim "wildly variable reported failure rates (5 – 33 %) and lack of follow-up to adulthood." File:Stretching of foreskin to cure phimosis.jpg, Stretching the foreskin opening with two fingers File:Stretching of foreskin to cure phimosis using silicon ear plugs.jpg, Stretching the foreskin opening with

flesh tunnel A plug (sometimes earplug or earspool), in the context of body modification, is a short, cylindrical piece of jewelry commonly worn in larger-gauge body piercings. Modern western plugs are also called flesh tunnels. Because of their size—which ...

of different diameters

Surgical

Surgical methods range from the complete removal of the foreskin to more minor operations to relieve foreskin tightness: *

Dorsal slit A dorsal slit (often referred to in anthropology as superincision or supercision) is a single incision along the upper length of the foreskin from the tip to the corona, exposing the glans without removing any tissue. An ancient practice, it has ...

(superincision) is a single incision along the upper length of the foreskin from the tip to the corona, exposing the glans without removing any tissue. * Ventral slit (subincision) is an incision along the lower length of the foreskin from the tip of the frenulum to the base of the glans, removing the frenulum in the process. Often used when

occurs alongside the phimosis. *

Preputioplasty Preputioplasty or prepuce plasty, also known as "limited dorsal slit with transverse closure", is a plastic surgical operation on the prepuce or foreskin of the penis, to widen a narrow non-retractile foreskin which cannot comfortably be drawn ba ...

, in which a limited dorsal slit with transverse closure is made along the constricting band of skin, can be an effective alternative to circumcision. It has the advantage of only limited pain and a short healing duration relative to circumcision, while also avoiding cosmetic effects. *

Circumcision Circumcision is a procedure that removes the foreskin from the human penis. In the most common form of the operation, the foreskin is extended with forceps, then a circumcision device may be placed, after which the foreskin is excised. Top ...

is sometimes performed for phimosis, and is an effective treatment; however, this method has become less common as of 2012. While circumcision prevents phimosis, studies of the incidence of healthy infants circumcised for each prevented case of phimosis are inconsistent.

Prognosis

The most acute complication is

. In this 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. Some studies found phimosis to be a risk factor for

urinary retention Urinary retention is an inability to completely empty the bladder. Onset can be sudden or gradual. When of sudden onset, symptoms include an inability to urinate and lower abdominal pain. When of gradual onset, symptoms may include loss of bladd ...

and

carcinoma of the penis Penile cancer is cancer that develops in the skin or tissues of the penis. Symptoms may include abnormal growth, an ulcer or sore on the skin of the penis, and bleeding or foul smelling discharge. Risk factors include phimosis (inability to retr ...

Epidemiology

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. 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. When phimosis is simply equated with nonretractility of the foreskin after age 3 years, considerably higher incidence rates have been reported. 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. 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.

History

According to some accounts, phimosis prevented

Louis XVI of France Louis XVI (''Louis-Auguste''; ; 23 August 175421 January 1793) was the last King of France before the fall of the monarchy during the French Revolution. He was referred to as ''Citizen Louis Capet'' during the four months just before he was ...

from impregnating his wife,

Marie Antoinette Marie Antoinette Josèphe Jeanne (; ; née Maria Antonia Josepha Johanna; 2 November 1755 – 16 October 1793) was the last queen of France before the French Revolution. She was born an archduchess of Austria, and was the penultimate child a ...

, for the first seven years of their marriage, but this theory was later discredited. 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 (such as Vincent Cronin and Simone Bertiere) assert that surgical repair would have been mentioned in the records of his medical treatments if this had indeed occurred. Non-retractile prepuce in adolescence is normal, common, and usually resolves with increasing maturity. US president

James Garfield James Abram Garfield (November 19, 1831 – September 19, 1881) was the 20th president of the United States, serving from March 4, 1881 until his death six months latertwo months after he was shot by an assassin. A lawyer and Civil War gene ...

was assassinated by Charles Guiteau in 1881. Guiteau's autopsy report indicated that he had phimosis. At the time, this led to the speculation that Guiteau's murderous behavior was due to phimosis-induced insanity.

References

External links

Phimosis
by the

University of California, San Francisco The University of California, San Francisco (UCSF) is a public land-grant research university in San Francisco, California. It is part of the University of California system and is dedicated entirely to health science and life science. It ...

Urology department {{Male diseases of the pelvis and genitals Circumcision debate Penis disorders Wikipedia medicine articles ready to translate