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Phimosis

Definition of Phimosis

Phimosis is a congenital or acquired narrowing of the prepuce, which hinders (relative phimosis) or prevents (absolute phimosis) the retraction of the prepuce. Natural adhesions (without scarring) during the first years of life between the prepuce and the glans penis have to be distinguished from phimosis.

Epidemiology of Phimosis

The prevalence of adhesions between prepuce and glans is age-dependent: 90% after one year of life and 10% after six years of life. The prevalence of true phimosis (with scarring) is 8% in 6-year-old boys and 1% at 16 years of age.

Etiology (Causes) of phimosis

Natural adhesions:

The prepuce is formed by a fold of skin surrounding the glans by the fifth month of fetal development. Initially, the inner sheet of the prepuce is connected to the glans with adhesions. Penile growth, epithelial debris (smegma), and intermittent erections lead to a separation of the prepuce from the glans during childhood, see epidemiology.

Scarring of the Prepuce

Recurrent inflammation (balanitis) leads to scarring and narrowing of the prepuce, which itself predisposes to recurrent balanitis. Additional risk factors for scarring are diabetes mellitus, obesity, or catheterization.

Complications of Phimosis

Frequent complications are urinary tract infections, paraphimosis, or recurrent balanitis. Obstructive voiding dysfunction and urinary retention are possible. The risk of sexually transmitted diseases is higher in uncircumcised men.

Phimosis is a risk factor for penile cancer. With a good standard of hygiene care, penis cancer is uncommon. The risk for cervical cancer is increased in women with uncircumcised men.

Signs and Symptoms

• Difficult of missing retractability of the prepuce
• Poor hygiene (smegma)
• Obstructive voiding symptoms, urinary retention
• Complications like paraphimosis or balanitis

Treatment of Phimosis

Circumcision

Complete (radical) or incomplete (prepuce sparing) circumcision is the cornerstone of phimosis treatment, see circumcision: technique and complications. Contraindications for circumcision are untreated balanitis, coagulation disorders, or hypospadias with possible repair in the future.

Newborn circumcision:

After local anesthesia of the penis, circumcision is performed using a Gomco clamp, Mogen clamp or with the Plastibell technique.

Conservative Treatment of Phimosis

Local cortisone treatment for 6–12 weeks can lead to a healing of the phimosis, e.g., betamethasone 0.06% cream. The success rate of conservative therapy (avoidance of circumcision) is around 75–90%. Contraindications to conservative treatment are recurrent urinary tract infections and obstructive voiding dysfunction due to phimosis.

Prophylactic Newborn Circumcision

Worldwide, 37–39% of men are circumcised, primarily because of religious observance. There is disagreement regarding prophylactic neonatal circumcision, especially when religious affiliation does not mandate circumcision. Prophylactic circumcision is e.g. very commonly performed in the United States. Since the diseases that can be reduced by prophylactic circumcision are uncommon, endorsement of routine circumcision is critical.

Arguments for a prophylactic newborn circumcision:

• Prevention of scarring phimosis and surgery in the phallic phase
• Reduced risk for urinary tract infections or sexually transmitted diseases
• Prevention of invasive penile cancer or cervical cancer of future sexual partners

Arguments against prophylactic newborn circumcision:

• Painful procedure with rare but potentially serious complications
• Circumcision does not provide any reliable protection against sexually transmitted diseases
• The incidence of penile cancer is very low with adequate hygiene care (Overtreatment),

References

EAU Guidelines: Paediatric Urology

  Deutsche Version: Phimose