Phimosis

PEDIATRIC UROLOGY TREATMENTS

Phimosis

In many cases, phimosis may go unnoticed during the child's first months of age, reducing the possibility of prompt treatment.

Phimosis

Table of Contents

Definition

What is phimosis? Why does it occur?

Phimosis is the inability to retract the foreskin in children over the age of three. At birth, there is physiological phimosis due to the natural adhesions that exist between the foreskin and the glans. During the first years of life, the penis grows and the detritus from the epithelial scaling (whitish materials that are deposited in the folds of the external genital organs, called smegma) accumulates under the foreskin, gradually separating it from the glans. This separation mechanism is aided by intermittent erections of the penis that cause the foreskin to retract completely.

What causes phimosis?

Phimosis can originate from three mechanical conditions of the foreskin: an exaggerated narrowing of the tip of the foreskin on the glans, adhesion between the inner layer of the foreskin and the surface of the glans, or a short frenulum which makes normal retraction of the foreskin impossible.

Symptoms and diagnosis

The symptoms of phimosis in boys are mainly the difficulty (or impossibility) of trying to pull back the foreskin over the glans of the penis, and the bulge that is created while the boy is urinating. The latter will depend more on the degree of phimosis, that is, the more complicated it is to uncover the glans by the “cap” that covers it, the more difficult it will be for the urine stream to exit during urination.

In many cases, phimosis can go unnoticed during the first months of a child's life, reducing the possibility of timely treatment. It is usually the pain when urinating, the inflammation of the glans of the penis and the presence of smegma (whitish material with a very characteristic smell) that give warnings about a possible case of paediatric phimosis.

It is usually the parents of the child with this medical condition who first notice these problems. However, it will be a visit to the specialist doctor (paediatrician or urologist) by which the diagnosis of phimosis can be confirmed and thus, the most appropriate treatment can be found.

Therefore, no laboratory tests or complementary diagnostic images are required to confirm a case of phimosis, as visual examination by the specialist is sufficient.

Different types of phimosis

Phimosis is classified according to the degree of strangulation (or stenosis) of the foreskin:

Pointed phimosis

In which the hole left by the foreskin on the glans is so small that it barely allows urine to exit through the external urethral meatus. There may also be cases of phimosis that are so developed that they prevent urine from escaping, which is a urological emergency in newborns.

Non-retractable annular phimosis

This is where the skin of the foreskin, which surrounds the preputial orifice, is so thick that it does not allow even the slightest retraction movement.

Annular phimosis

This is the same as the previous one (skin of the foreskin thickened in the form of a ring around the preputial orifice) with the particularity that it is not as adhered as in the non-retractable one, allowing some retraction.

In addition to the degree of narrowing, phimosis can be classified according to the degree of foreskin retraction:

What is paraphimosis and how is it different from phimosis?

Paraphimosis is a pathology that occurs when a narrow foreskin (like the one that exists in phimosis) suddenly passes over the glans and is located behind it, producing a mechanical constriction in the body of the penis, like a ring.

This constriction of the penis decreases the blood supply to the glans and causes problems of tissue hypoxia (lack of oxygen to the cells) which, if not treated in time, can lead to gangrene and tissue destruction.

Phimosis 

Paraphimosis 

The treatment of paraphimosis consists of firmly compressing the tip of the penis for 10 minutes (to encourage the return of the blocked blood) and reducing the inflammation, thus allowing the foreskin to return to its original position.

Paraphimosis causes severe pain, marked swelling of the glans and foreskin and, in some cases, dizziness and nausea. It is considered a true medical emergency and differs from phimosis in that the constriction does not occur on the glans (but behind it) and can occur at any time in life, usually after trauma or injury during intercourse.

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Techniques and treatments

Phimosis treatment and solution

· Surgical treatments: Circumcision is not the only option ·

Circumcision is a common surgical practise, much more so among certain cultures and religious communities (such as Jews or Muslims) that consists of the partial or total removal of the foreskin, leaving the glans permanently exposed. It is a relatively simple surgical procedure that can even be performed in the child’s first months of life. Apart from circumcision, there are other surgical options in the treatment of phimosis:

Preputioplasty consists of a longitudinal incision over the constriction band of the foreskin, leaving it practically intact. It is less painful than circumcision and involves less recovery time.

A dorsal slit or superincision consists of a single incision on the upper surface of the foreskin, from the tip to the crown, exposing the glans and reducing unnecessary tissue removal to zero. A ventral slit or sub-incision also exposes the glans but through an incision of the foreskin in its lower portion, which goes from the tip of the frenulum to the base of the glans, this operation is performed when phimosis is accompanied by a short frenulum.

Technical phimosis 

Technical phimosis 

pene circuncidado

Technical phimosis 

Surgical treatment of phimosis is indicated only after non-surgical methods (which we will see below) failed or were insufficient. Also, in cases where there is imminent danger of tissue loss (by cell necrosis) or total narrowing of the urinary meatus.

Dr Pedro Lopez Pereira, a renowned urologist who has treated hundreds of children at the Hospital de La Paz in the Community of Madrid in his long experience, is the head of our Paediatric Unit and performs all the interventions and monitors the results.

There are non-surgical ways to treat it, and in fact, they should be a priority.

Phimosis can be treated without the need for an operating room; the method of choice is topical application of corticosteroid cream (such as 0.05 per cent betamethasone, twice daily for a period of two to eight weeks).

These drugs work by decreasing the inflammatory immune responses at the site and improving the elasticity of the skin with the synthesis of new elastic and collagen fibres, allowing the progressive reduction of phimosis.

In addition to the application of these creams or ointments, skin stretching exercises are prescribed, which will gradually increase the degree of foreskin retraction on the glans.

Complications

Phimosis in young children: special features

The most frequent complications of phimosis in pediatric patients (whether newborns, infants or minors) include pain during urination due to glans inflammation or a decrease in the size of the opening of the urethra (external urethral meatus) through which urine is expelled, balanitis or inflammation of the balano-preputial sulcus (located between the glans and the site where the skin of the foreskin is inserted into the penis) due to the deposit of smegma and other cellular detritus, which increases the risk of urinary tract infections.

Also, a narrowing of the foreskin over the tip of the penis (phimosis) can lead to paraphimosis, a potentially serious and previously explained complication.

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complications

Phimosis in adults: special complications in adulthood

Almost 99% of phimosis problems are solved before (or during) the adolescent period, this due to the beginning of sexual practices such as masturbation or the same growth of the external genitals.

Although rare, persistent phimosis in adulthood can lead to serious problems such as difficulty in maintaining an erection or discomfort during intercourse; an inelastic foreskin can become bruised and painful, swollen, or in the worst-case scenario, cause small tears.

Another complication of phimosis in adult individuals is the increased risk of infection in the genital area, more specifically fungal or bacterial infections, which cause itching, odour, and burning during urination.

· Differences between adults and children ·

The main difference between phimosis in a child and in an adult is that the first ones are easier to treat and less likely to develop complications.

In addition, surgical interventions aimed at reducing phimosis (which is not very complex in itself) have a better evolution in paediatric patients.

It should be noted at this point that there are some adults who wish, for aesthetic reasons (and not medical) to have a circumcision because they like the appearance of a circumcised penis better. It is a choice like any other, but of course, it does not cover public health, it must be performed in a private centre like Andromedi.

Frequent questions

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How do I know if I or my child have phimosis?

If you have a child who is about two or three years old (maybe a few years older or younger) and you notice that he feels discomfort when urinating, has a swollen glans area, or has difficulty retracting the foreskin, your child may have phimosis. These symptoms may become visible even in the teenage years.

Or, you are the one who has trouble having sex (you feel pain during intercourse), you suffer from recurrent urinary infections or you simply find it hard to uncover the head of the penis, you are one of the few cases of phimosis that persist into adulthood.

In any case, the best thing to do is to go to a specialist doctor, according to the age (a paediatrician for your child or a urologist/andrologist for you).

Does phimosis affect fertility?

You can rest assured for the sake of your baby’s future that there is no direct association between the presence of phimosis and fertility problems; in theory, a problem with the male external genitalia (phimosis) should not impair the process of spermatogenesis (where sperm is produced), within the testicles.

However, in a very indirect way, absolute phimosis could make normal ejaculation, and therefore, eventual fertilization, more difficult in one way or another.

Is there a suitable age for this?

Until now, specialists maintain the consensus that surgical interventions and non-surgical treatments aimed at reducing or eliminating phimosis problems have a higher success rate in paediatric patients. Also, the passage of years (for example, in persistent phimosis in adulthood) could aggravate the fusion of the foreskin with the glans, making treatment more difficult.

It is important to rule out this type of health problem at an early age so that treatment is timely and has a higher level of effectiveness.

Does phimosis affect the size of the penis?
There is no direct relationship between the size of the penis and the presence of phimosis, however, having a short, slightly retractable or very narrow foreskin could reduce the length by a couple of centimetres. It often happens that after phimosis surgery (or with the use of topical steroids), the penis may present a slight and apparent increase in size. Although extremely rare, we have also had cases opposite to our Seville practice: after an operation, the penis is shortened by a few centimetres and the existing tension in the erection shows that the stitches have been placed in the wrong (unnatural) place which must be corrected by phalloplasty (mainly by means of small grafts which reduce the tension in the tissues). This type of case is already closer to medical malpractice, and as we say is very unusual.
How long does the post-operative period last and when can the patient live a normal life?

The recovery period of circumcision (and other surgical interventions to treat phimosis) is usually, at most, about 10 days. That is, the time it takes for the wound to heal and absorb (fall out) the stitches.

During this period of time, it is advisable not to do intense physical activity (such as running or cycling) or have intercourse to prevent the wound from opening up again and the need of repeating the process (not to mention that it would be very painful).

Can you have sex while having phimosis?

You can have sex as long as you know your body well and the limits you can go to, otherwise, you could injure your foreskin or glans.

Many men with untreated phimosis have an active sex life without problems. Adequate lubrication is essential when having sex, and maybe even more so in this case.

Is phimosis the same as a short frenulum?

No, a short frenulum is a condition that occurs when the frenulum, a band of tissue that connects the ventral portion of the foreskin to the glans, is short or inelastic in length and for that reason, it is difficult to retract the foreskin.

In many cases, a short frenulum can be accompanied by phimosis aggravating the latter. The most commonly used treatment corresponds to surgical intervention: ventral slit or subincision.

Is it recommended to perform circumcision for balanitis or balanoposthitis?

Balanitis (inflammation of the glans) and balanoposthitis (inflammation of the glans and foreskin) are conditions that in most cases have infectious causes, i.e. produced by fungi or bacteria. These inflammatory diseases of the glans (and foreskin) can also be caused by trauma or injury.

Treatment is therefore usually ointment/cream or oral antibiotic.

A circumcision (surgical removal of the foreskin) would, therefore, have no relevant effect on the treatment of balanitis or balanoposthitis caused by infections. Unless this surgery can reduce the compression of these anatomical structures produced by a narrow foreskin, typical of the most chronic cases of these diseases.

Why perform it in a private medical centre instead of a Social Security centre?

The advantages of carrying out this type of surgery in private medical centres as opposed to public health centres are the short times for carrying out the treatment (around 24/48 hours, whereas in Social Security centres it could take weeks or months to begin) and the quality of the treatment, not only from a medical point of view but also from an aesthetic point of view, especially in cases where surgery is required.

Also, in a private medical centre they will be able to provide you with more personalised, confidential attention, adapted to your needs.

Does a partial circumcision have advantages over a total one? When is each one of them indicated?

A circumcision is partial when the foreskin is not cut completely, leaving a small portion covering the glans, or total when the entire foreskin is removed, leaving the glans completely exposed.

However, total circumcision is considered better than partial circumcision because there is less risk of developing a fibrotic ring around the glans over time.

Whatever the case may be, there are clinical and aesthetic criteria aimed at choosing the best option on an individual basis, as each case is particular and must be treated in consultation with the depth and care it deserves.

Dr. Natalio Cruz

Author

Dr. Natalio Cruz


El Dr. Cruz, con 25 años de experiencia médica, ha sido hasta 2016 Jefe de la Unidad de Andrología en el Servicio de Urología del Hospital Virgen del Rocío de Sevilla, Coordinador Nacional de Andrología de la Asociación Española de Urología (AEU) y Secretario General de la ESSM, cargos que ha delgado para centrarse de lleno en el ilusionante proyecto de ofrecer una consulta médica privada de alto nivel en Sevilla.

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