Phimosis classification

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Steven C. Campbell, M.D., Ph.D.

Classification

Phimosis in most but not all infants is physiological rather than pathological, whereas phimosis in older children and adults is more often pathological than physiological. Some have suggested that physiological infantile phimosis be referred to as developmental nonretractility of the foreskin to more clearly distinguish this normal stage of development from pathological forms of phimosis.[1] Different management is appropriate.

Note that women can suffer from clitoral phimosis.[2]

Infantile or Congenital Phimosis

It has been widely recognized by the medical profession for most of the last century that normal male infants have foreskins which are incompletely separated from the epithelium of the glans penis. They cannot be easily retracted. There have been four types of medical responses and attitudes toward this "normal" infant phimosis:

  1. Some physicians, especially in the first half of the twentieth century, recommended that the foreskin be repeatedly retracted, if necessary with some force, to free it from the glans. It was thought that ensuring separation early could prevent later (pathological) phimosis and urinary problems in older boys, since it permitted washing of the glans and foreskin. Poor hygiene was thought to predispose to pathological phimosis. This approach has not been recommended by physicians for many decades.
  2. Some physicians, particularly in the middle of the twentieth century, used avoidance of phimosis as justification for routine neonatal circumcision. Circumcision does prevent phimosis, although by some incidence statistics, at least 10 to 20 infants must be circumcised to prevent each case of potential phimosis. If one believes even lower phimosis incidence estimates, far more must be circumcised to prevent each case of phimosis. Although there are proponents of this view, it is not considered a compelling argument for routine neonatal circumcision by most pediatricians.[3]
  3. In the last three decades, as the circumcision rate in North America has declined, the most common official recommendations and guidelines from medical societies, as well as infant care books written by experts, have emphasized that it is normal not to be able to retract an infant's foreskin fully and that it need not be done. The American Academy of Pediatrics recommends gentle soap and water cleaning, but specifically recommends against forcible retraction.[3] There is now some suspicion that forceful retraction that results in inflammation may actually contribute to pathological phimosis at an older age. Although the rate of surgical treatment of phimosis (usually circumcision) is falling, somepediatric urologists have argued that many physicians continue to have trouble distinguishing developmental non-retractility from pathological phimosis, and that phimosis is overdiagnosed.[4][5][6]
  4. Phimosis is sometimes used as a justification for circumcision,[6] 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.[6]

Not all infantile phimosis is simply physiological. Though uncommon, phimosis can occasionally lead to urinary obstruction or pain. Causes of pathological phimosis in infancy 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.[7]

There are several management approaches to infant phimosis. Most cases of simple physiological phimosis need no "management" but will disappear with time or simple stretching of the foreskin. Various topical steroid ointments have been effective at hastening separation without surgery.[8] Several surgical techniques have been devised, which range from simple slitting of a segment of the foreskin to removal of it (circumcision).

Acquired Phimosis

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").

Because of the "elasticity" of the diagnostic criteria, there has been considerable variation in the reported prevalence of pathological phimosis. An incidence rate of 1% to 2% of the uncircumcised adult male population is often cited, though some studies of older children or adolescents have reported higher rates. Relative phimosis is more common, with estimates of its frequency at approximately 8% of uncircumcised men.[9]

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.

An important 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.[10] Infectious, inflammatory, and hormonal factors have all been implicated or proposed as contributing factors. Circumcision is usually recommended though alternatives have been advocated.

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

Images of phimosis.[1][2]

References

  1. Shankar KR, Rickwood AM.The incidence of phimosis in boys Brit J Urol Internat 84:101-102, 1999. This study gives a low incidence of pathological phimosis (0.6% of uncircumcised boys by age 15 years) by asserting thatbalanitis 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.
  2. Ezell C. Anatomy and Sexual Dysfunction Scientific American.com news item, October 31, 2000
  3. 3.0 3.1 Lannon CM, Bailey AGD, Fleischman AR, Kaplan GW, Shoemaker CT, Swanson JT, Coustan D.Circumcision Policy Statement Pediatrics 103:686-693, 1999. 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."
  4. Rickwood AM, Walker J. Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence? Ann R Coll Surg Engl 71:275-7, 1989. Authors review English referral statistics and suggest phimosis is overdiagnosed, especially in boys under 5 years, because of confusion with developmentally nonretractile foreskin.
  5. Spilsbury K, Semmens JB, Wisniewski ZS, Holman CDJ.Circumcision for phimosis and other medical indications in Western Australian boysMed J Austral 178:155-158, 2003. Recent Australian statistics with good discussion of ascertainment problems arising from surgical statistics. PMID 10444134
  6. 6.0 6.1 6.2 Van Howe RS. Cost-effective treatment of phimosis Pediatrics 102: 4 October 1998, p. e43. A pediatrician and anti-circumcision activist reviews estimated costs and complications of 3 phimosis treatments (topical steroids, praeputioplasty, and surgical circumcision) and 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.
  7. Babu R, Harrison SK, Hutton KAR.Ballooning of the foreskin and physiological phimosis: is there any objective evidence of obstructed voiding? BJU Internat 2004; 94:384-7
  8. Monsour MA, Rabinovitch HH, Dean GE. Medical management of phimosis in children: our experience with topical steroids J Urol 162:1162-4, 1999. Good description of topical steroid use as alternative to surgery.
  9. Stuart R. Encyclopedia of Phimosis Statisticsmale-initiation.net
  10. Laymon, CW, Freeman, C.Relationship of Balanitis Xerotica Obliterans to Lichen Sclerosus et Atrophicus Arch Dermat Syph 49:57-9, 1944

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