Phimosis

Phimosis is a constriction of the foreskin at which the glans penis cannot be opened at all or is opened difficultly and painfully. The foreskin is a skin fold that covers the glans penis.

Phimosis manifestations

Four stages of phimosis can be distinguished.

1 stage. In flaccid state the glans penis is uncovered easily, some effort is required during erection.

2 stage. During erection the glans penis is not uncovered at all, in flaccid state it is uncovered with or without effort.

3 stage. The glans penis is not uncovered at all or only in flaccid penis state and with significant efforts, although phimosis does not cause urination problems.

4 stage. Phimosis causes urination difficulties. At urination preputial sac is swelling first, then urine is excreted in thin stream or drop by drop. The glans penis cannot be uncovered even slightly.

Phimosis causes

Causes of the foreskin constriction are yet unclear. The disease is related to connective tissue insufficiency in the organism which has hereditary predisposition. At the same time mitral valves malformations, platypodia, varicose veins including varicocele and several other diseases or symptoms can be observed.

Infantile phimosis

Most children below 2-3 years have phimosis. Some researchers call this condition physiologic phimosis. However there is still no common opinion as to until which age the phimosis can be considered physiologic, when to plan surgical treatment of phimosis for children, etc. It should be also taken into account that physiologic phimosis has the same complications as common phimosis.

The question about advisability of surgery and its terms for children must be decided on an individual basis. It should be noted that most often infantile phimosis ends by itself, the glans penis starts to be uncovered and no further problems arise. Special attention should be given to hygiene of the glans penis until it can be uncovered. It is better to wash it daily with antiseptics (myramistin, chlorhexidine etc.)

Generally most specialists think that by 6-7 years the glans penis should be uncovered easily. If this does not happen, surgery is required.

Adult phimosis

Adult males can have phimosis since childhood or it can be developed during puberty. Heavy growth and development of genitals happens in this period. This can lead to inconformity between penis and the foreskin development. At that the foreskin is smaller than the glans penis, its opening is narrower and it is difficult or impossible to uncover the glans penis. Most often it can be 1 or 2 stage phimosis whereas phimosis that remains since childhood can be not less than 3 stage.

Disease progress

Phimosis of adolescents, youths and adult males does not remains unchangeable, the disease progresses steadily. It is related to appearance of erections, masturbation and sexual life.

During erection the glans penis is enlarged and the foreskin is tightly stretched. This leads to appearance of cracks and microcracks on the foreskin. Usually they are small, do not bleed and do not cause any inconvenience. However scars or microscars appear on these places after healing. Scar tissue is much less elastic than normal the foreskin tissue. Therefore with each new scar the foreskin constriction becomes stronger and the disease progresses.

This process is especially strongly pronounced during masturbation and sexual intercourse. The foreskin ruptures can be significant at these moments and be accompanied with profuse bleeding.

Phimosis and frenulum breve (short frenulum of prepuce)

Frenulum of prepuce is a skin fold below the glans penis that goes from outer urethral orifice to corona glandis. Normal frenulum is not stretched too much during erection at uncovering of the glans penis. If its tension is too high and the glans penis becomes bent during erection such frenulum is considered short.

Phimosis and frenulum breve are not directly connected but are caused by the same reasons, therefore they often happen at the same time. I have never encountered a case of phimosis without frenulum breve.

The most effective treatment of frenulum breve is a special surgery called a frenuloplasty. If frenulum breve is accompanied by phimosis, the surgery is performed simultaneously with circumcision.

Phimosis complications

Fusion of the foreskin with the glans penis

3 and 4 stages of phimosis when the glans penis cannot be uncovered can lead to fusion of the foreskin parts to mucous tunic of the glans penis. First a small area is fused, then it gradually increases and eventually the foreskin fuses with the gland penis along the whole length of it.

This condition does not cause particular inconvenience except for attempts to uncover the glans penis are accompanied with sharp pain and bleeding. Fusion of the foreskin can be only surgical. If the area of fusion is large, the surgery can be very difficult.

Paraphimosis

Paraphimosis is a condition when the foreskin becomes trapped behind the glans penis. Most often paraphimosis is caused by attempts to open the foreskin at 2 or 3 stage of phimosis. Entrapment can occur during sexual intercourse or masturbation.

Paraphimosis quickly causes the glans penis edema, it quickly enlarges which makes paraphimosis reduction impossible after some time. This condition is accompanied with sharp pain and the glans penis turns blue.

The glans penis should be reduced in case of paraphimosis. Sometimes it is easy, sometimes reduction is very difficult or impossible. If the reduction is unsuccessful, emergency surgery of circumcision or dorsal slit is necessary.

Balanoposthitis

Balanoposthitis is an inflammation of the glans penis and foreskin. Hygiene of the glans penis is difficult at phimosis of 2 and latter stages. It often leads to smegma congestion in preputial sac, its infection and development of inflammation.

Pronounced balanoposthitis combined with phimosis requires emergency dorsal slit of the foreskin. After the inflammation is eliminated planned circumcision is possible.

Phimosis treatment

Out of several ways of phimosis treatment only one exists in reality, namely the surgery of circumcision. However we shall review here other methods or attempts of phimosis treatment in order to destroy the myths and not to withhold the facts.

Corticosteroid therapy

The essence of the method is in regular and prolonged application of corticosteroid ointments on the glans penis and the foreskin. Corticosteroid ointments insignificantly increase foreskin tissue elasticity which may lead to its stretching and decrease of the disease stage. In addition application of glucocorticoids abates edema and inflammation and precipitates microcracks healing.

However in practice all these processes are pronounced very slightly. Therefore even application of corticosteroid ointments during several months does not produce any effect. If phimosis is prone to progression the disease continues to development even against the background of such treatment although more slowly.

Generally this method of phimosis treatment should be considered ineffective and should not be recommended for use.

Stretching of the foreskin

The essence of this method is clear from its name. A man should systematically stretch stenosing foreskin ring with his fingers or appliances to make it wider after some time. This method really helped some people to get rid of phimosis. Sometimes it is used in combination with corticosteroid therapy.

Effectiveness of this method does not equal zero but does not differ much from it. To get real effect from stretching of the foreskin one must practice such exercises for 1-2 hours a day during several months or even years. Not many people have enough patience to make all these manipulations to achieve real effect. Furthermore on 3 and 4 stages of phimosis the foreskin cannot be stretched enough to achieve any significant effect.

Stretching of the foreskin cannot be recommended as a method of phimosis treatment just because of its extreme inconvenience. More than 99% of attempts to get rid of phimosis in this way fail.

Circumcision

The quickest and most effective method of phimosis treatment is the surgery of circumcision. The foreskin is removed completely or partially and no problems with uncovering of the glans penis appear as a result. Circumcision is indicated at any stage of phimosis. Contraindication to circumcision is balanoposthitis, pronounced inflammation of the glans penis and the foreskin.

Dorsal slit of the foreskin

This surgery is performed during phimosis only in two cases – if phimosis in 3 or 4 stage is complicated with acute balanoposthitis or if paraphimosis has been developed. In first case it is necessary to achieve uncovering of the glans penis but it is impossible to perform full-fledged circumcision because of the risk of inefficiency of sutures. In case of paraphimosis the ring that squeezes the glans penis needs to be cut but blood circulation disturbance does not allow to perform the circumcision immediately.

In such situation dorsal slit of the foreskin is performed. After this surgery the glans penis uncovers and it is easy to cure balanoposthitis. After the inflammation of the glans penis is cured, normal circumcision can be performed. It is not necessary to perform the circumcision after the dorsal slit to treat phimosis, but this surgery is required for cosmetic purpose.

Phimosis prophylaxis

Phimosis progress is in many respects caused by hereditary predisposition to this disease so there is no serious phimosis prophylaxis. Boys need to pay attention to the glans penis daily and uncover it during washing. If phimosis has already developed it is necessary to immediately go to urologist and settle the day of surgery. This will allow you to avoid a lot of problems