Delve into the intricacies of phimosis – causes, symptoms, and solutions. Your comprehensive guide, brought to you by Meri Sehat.

Tight Foreskin (Phimosis)

A. JABBAR DENTAL CLINIC

Sadia Khan

Overview

Tight foreskin, also known as phimosis, is the inability to retract the foreskin over the head of the penis (glans) in some children and adults who aren&rsquo;t circumcised. 
&nbsp;

The prevalence of phimosis varies depending on the population studied and the definition used. Generally, the condition is relatively common among newborns; almost all of them present with phimosis. However, the foreskin begins to change as they grow older.<a href="#accordion">[11]</a>&nbsp;In a typical development process, the foreskin may not fully separate from the glans until after puberty.

While some estimate that only 1% of 16-year-olds have phimosis, a study in Denmark reported an incidence of 10% in boys in their late teens.<a href="#accordion">[10][11]</a>&nbsp;Some research also shows that 2% of men have non retractable foreskins throughout their lives, even when they are otherwise healthy.<a href="#accordion">[12]</a> 
&nbsp;

There are two types of phimosis:

<ul>
	<li>Physiological Phimosis &ndash; Also called congenital or primary phimosis, this form is normally associated with infants and young children. It occurs naturally from the time of birth &ndash; 96% of males have it &ndash; and resolves on its own as they grow older. The process is aided by erections and keratinization of the inner epithelium.<a href="#accordion">[2]</a> 
	Gentle traction forms a pout given the distal portion of the foreskin is healthy. 
	&nbsp;</li>
	<li>Pathological Phimosis &ndash; Also called acquired or secondary phimosis, this form occurs as a result of infection, inflammation, or scarring. It is usually associated with balanitis xerotica obliterans (BXO). 
	Gentle traction leads to the formation of a cone-shaped structure and the distal narrow part is white and fibrotic. 
	&nbsp;</li>
</ul>

Note: Differentiating between the two is important as their treatment varies greatly. 
&nbsp;

Sign and Symptoms

These include:

<ul>
	<li>Soreness</li>
	<li>Redness and swelling when irritated or infected</li>
	<li>Difficulty urinating</li>
	<li>Painful urination</li>
	<li>Urinary retention</li>
	<li>Painful erection</li>
	<li>Thick discharge or bleeding underneath the foreskin or an unpleasant smell 
	&nbsp;</li>
</ul>

Causes

There are several causes of pathologic phimosis:

<ul>
	<li>Chronic infections, including sexually transmitted infections (e.g., <a href="https://merisehat.pk/disease/genital-herpes">genital herpes</a>, syphilis, and <a href="https://merisehat.pk/disease/gonorrhea">gonorrhea</a>)</li>
	<li>Repeated tears due to forceful foreskin retraction</li>
	<li>Inflammation, including balanitis and balanoposthitis</li>
	<li>Skin conditions, including psoriasis, eczema, lichen sclerosis, and lichen planus</li>
	<li>Scar tissue</li>
	<li>Insufficient foreskin removed during circumcision 
	&nbsp;</li>
</ul>

Diagnosis

The doctor begins by asking questions about the family and medical history of the patient, sexual activity, the symptoms they experience, and whether they have any injuries to the penis.

The diagnosis of phimosis is primarily based on a physical examination of the genital area. The healthcare provider may order a swab test, urine test, and blood test to check for underlying infection or other conditions. 
&nbsp;

Treatment

No treatment is usually needed for physiological phimosis in infants and young children, as the condition resolves naturally. However, pathological phimosis needs to be treated.

One common treatment option is the use of topical steroids, such as betamethasone or triamcinolone, which can help reduce inflammation and promote the stretching of the foreskin. These medications are typically applied to the affected area for two weeks, after which the doctor may recommend gently stretching the foreskin without hurting at all.

If the doctor suspects an underlying infection, they may prescribe antibiotics such as clotrimazole to treat it. Depending on the individual condition, they may also suggest over-the-counter pain relievers like ibuprofen. 
&nbsp;

In cases where conservative treatments are not effective, surgical interventions may be considered. Circumcision, the surgical removal of the foreskin, is a common procedure for the treatment of phimosis if the patient is a child or if they are an adult with lots of scar tissue. Circumcision is also preferred in the case of persistent balanoposthitis or balanitis and if steroid creams are ineffective.&nbsp;

Other surgical options include frenuloplasty or preputioplasty wherein the surgeon cuts the foreskin to loosen it. However, it may not always prevent the recurrence of the condition. However, as with any surgery, these interventions also carry a slight risk of infection and bleeding.<a href="#accordion">[12]</a> 
&nbsp;

These include: 
&nbsp;

<ul>
	<li>In cases of delayed treatment, phimosis can lead to restricted blood flow to the penis, causing gangrene and eventually loss of the penis.</li>
	<li>If left untreated, phimosis can lead to paraphimosis, a condition where the retracted foreskin becomes trapped behind the glans and cannot return to its original position covering the penile end. It is a medical emergency.</li>
	<li>Forceful retraction can also lead to psychological trauma for both the child and parent.</li>
	<li>Further, phimosis makes the individual more likely to get penile cancer. 
	&nbsp;</li>
</ul>

There are several risk factors, including:

<ul>
	<li>Advancing age as the skin loses its elasticity</li>
	<li>Poor hygiene</li>
	<li>Uncircumcised males</li>
	<li>Recurrent UTIs</li>
	<li>Repeated trauma to the foreskin 
	&nbsp;</li>
</ul>

While it may not be possible to prevent physiological cases, some preventive measures can help reduce the risk of developing pathological phimosis.

<ul>
	<li>Wash the penis with warm water and avoid chemicals to prevent the accumulation of smegma and reduce the risk of inflammation and infection.</li>
	<li>Seek prompt medical treatment for any skin conditions as they develop. </li>
	<li>Practice safe sex and use a lubricant during intercourse. 
	&nbsp;</li>
</ul>

Key Points

<ul>
	<li>Tight foreskin, also known as phimosis, is the inability to retract the foreskin over the head of the penis (glans).</li>
	<li>Phimosis can be physiological (congenital) or pathological (acquired).</li>
	<li>Symptoms of phimosis can include soreness, swelling, painful urination, and painful erections.</li>
	<li>Diagnosis is based on a physical examination of the genital area, and treatment options include topical corticosteroids, stretching exercises, or surgical interventions.</li>
	<li>Complications of phimosis can include gangrene and paraphimosis.</li>
	<li>Risk factors for phimosis include poor hygiene, recurrent infections, and previous trauma or scarring of the foreskin.</li>
	<li>Preventive measures for phimosis include good hygiene practices and prompt medical treatment for infections or inflammation of the genital area.</li>
</ul>

[1] Zampieri, N., Frigo, I., Caliò, A., & Camoglio, F. (2021). Histology and immunohistochemical evaluation of phimotic prepuce: the role of steroid therapy. Andrologia, 53(2).

[2] Shahid, S. (2012). Phimosis in children. Isrn Urology, 2012, 1-6.

[3] Dhungel, S., Dhakal, A., Koirala, K., Mukhia, R., Bhusal, N., & Thapa, A. (2022). Effectiveness of topical steroid in phimosis: a longitudinal observational study. Journal of Nepal Paediatric Society, 42(2), 26-29.

[4] Ghidini, F., Virgone, C., Pulvirenti, R., Trovalusci, E., & Gamba, P. (2020). Could a careful clinical examination distinguish physiologic phimosis from balanitis xerotica obliterans in children?. European Journal of Pediatrics, 180(2), 591-595.

[5] Russo, T., Currò, M., Barbera, A., Caccamo, D., Antonuccio, P., Arena, S., … & Romeo, C. (2016). Expression of transglutaminase in foreskin of children with balanitis xerotica obliterans. International Journal of Molecular Sciences, 17(9), 1551.

[6] Lee, C. (2013). Effect of topical steroid (0.05% clobetasol propionate) treatment in children with severe phimosis. Korean Journal of Urology, 54(9), 624.

[7] Morris, B., Gray, R., Castellsagué, X., Bosch, F., Halperin, D., Waskett, J., … & Hankins, C. (2011). The strong protective effect of circumcision against cancer of the penis. Advances in Urology, 2011, 1-21.

[8] Sneppen, I. and Thorup, J. (2016). Foreskin morbidity in uncircumcised males. Pediatrics, 137(5).

[9] Balaji, B., Jacob, T., & Gowri, M. (2020). Acceptability and outcomes of foreskin preservation for phimosis: an indian perspective. Journal of Family Medicine and Primary Care, 9(5), 2297.

[10] Morris, B., Waskett, J., & Gray, R. (2011). Does sexual function survey in denmark offer any support for male circumcision having an adverse effect?. International Journal of Epidemiology, 41(1), 310-326.

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