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Phimosis is a condition where the male foreskin cannot be fully retracted from the head of the penis. The word derives from the Greek phimos (φῑμός, "muzzle"). As most boys are born with a non-retracting foreskin, the term is confusing because it denotes both a normal stage of development, and a pathological condition (i.e. a condition that causes problems for a person). This confusion is particularly pronounced in regard to infants. Conflicting incidence reports and widely varying post-neonatal Circumcision rates reflect looseness in the diagnostic criteria. Phimosis has become a topic of contention in circumcision debates.
It is normal for a baby's foreskin not to retract, but as the child grows the foreskin is expected to become retractable. 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. Different management is appropriate. In other words, there are different degrees of phimosis, and treatment may vary on the degree of phimosis.
Women can suffer from clitoral phimosis.
For most of the Twentieth Century, most of the medical profession has recognized that most male infants have foreskins which are still attached to the Epithelium of the glans Penis and cannot easily be retracted. There have been four types of medical responses and attitudes toward this fact:
Pathological phimosis (as opposed to the natural non-retractability of the foreskin) in childhood is rare and the causes 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.
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.
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.
One 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. 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.
Phimosis may also sometimes be brought on by diabetes, due to high levels of sugar being present in the Urine of some diabetics, which creates the right conditions for bacteria to breed, under the foreskin.
Beaugé noted that unusual Masturbation practices, such as lying face down on a bed and rubbing the penis against the mattress, may cause phimosis. The Patient should stop the unnatural masturbation techniques and be encouraged to masturbate in the normal fashion by moving the foreskin up and down so as to mimic more closely the action of sexual intercourse. After giving this advice Beaugé noted not once did he have to recommend circumcision.
Chronic complications of acquired (pathological) phimosis can include discomfort or pain during urination or sexual intercourse. The urinary stream can be impeded, resulting in dribbling and wetness after urination. Harmful urinary obstruction is possible but uncommon. Pain may occur when a partially retractable foreskin retracts during intercourse and chokes the glans penis. A totally non-retractable foreskin is rarely painful. There is some evidence that phimosis may be a risk factor for penile cancer.
The most acute complication is Paraphimosis (Paraphimosis image). In this acute condition, the glans is swollen and painful, and the foreskin is immobilized by the Swelling in a partially retracted position. The proximal penis is flaccid.
Phimosis in infancy is nearly always physiological, and needs to be treated only if it is causing obvious problems such as urinary discomfort or obstruction. In older children and adults phimosis should be distinguished from frenulum breve, which more often requires surgery, though the two conditions can occur together.
If phimosis in older children or adults is not causing acute and severe problems, nonsurgical measures may be effective. Choice of treatment is often determined by whether the patient (or doctor) views circumcision as an option of last resort to be avoided or as the preferred course. Some adults with nonretractile foreskins have no difficulties and see no need for correction.
There is a school of opinion among the medical profession that advocates and promotes a number of alternative methods where surgery, with all the attendant risks, can be avoided.
High rates of success have been reported with several nonsurgical measures:
A number of medical reports of phimosis incidence have been published over the years. They vary widely because of the difficulties of distinguishing physiological phimosis (developmental nonretractility) from pathological phimosis, definitional differences, ascertainment problems, and the multiple additional influences on post-neonatal circumcision rates in cultures where most newborn males are circumcised. A commonly cited incidence statistic for pathological phimosis is 1% of uncircumcised males., When phimosis is simply equated with nonretractility of the foreskin after age 3 years, considerably higher incidence rates have been reported. Others have described incidences in adolescents and adults as high as 50%, though it is likely that many cases of physiological phimosis or partial nonretractility were included.
