Phimosis

Overview:

Phimosis is a medical condition in which the foreskin cannot be retracted from the tip of the penis.

As such, it is present in all newborn males due to the foreskin and glans being connected for the first few years of life. This connective tissue will gradually detach between 2 and 6 years of age. In some cases, male children may have phimosis until they are ten years old.

However, if the condition persists into the late teens or develops in adulthood, it is necessary to seek emergency medical care. In such instances, phimosis primarily occurs due to the following:

• Poor hygiene

• Bacterial infections

• Frequent Urinary Tract Infections (UTIs)

• Physical trauma or injury in the genital area 

• Inflammatory conditions such as balanitis (Inflammation of the glans)

• Scar tissue around the foreskin, resulting from recent surgical procedures

• Skin conditions such as eczema or psoriasis (red, flaky patches of skin that cause an itching sensation)

The listed causes are the most common factors that lead to the condition in male children. In adults, phimosis primarily occurs due to Sexually Transmitted Infections (STIs). Nonetheless, treatment for phimosis will not typically include advanced surgical procedures in the initial stages. Instead, doctors will rely on reducing the tightness around the foreskin with steroid creams or by gently pushing the foreskin back.

Symptoms:

Phimosis does not always produce symptoms. When it does, it may cause redness, soreness, or swelling. A tight foreskin may obstruct urine flow. In severe cases, this may prevent the person from completely emptying their bladder. Phimosis can cause inflammation of the penis (balanitis) or inflammation of both the glans and the foreskin (balanoposthitis). Both of these conditions are typically caused by poor hygiene. Symptoms of balanitis include soreness, itchiness, odour, redness, swelling, thick fluid buildup, and pain when urinating. Phimosis during sex can cause pain, skin splitting, and loss of sensation. Wearing a condom and applying lubricant can make intercourse more enjoyable.
 

Causes:

Pathologic phimosis (which is caused by some type of condition) can develop for a variety of reasons, including:

• Poor personal hygiene. This could be both the cause and the result of phimosis. It may be irritating and painful to attempt to thoroughly clean, but failure to do so may result in infection;

• Eczema, psoriasis, lichen planus, and lichen sclerosis are all skin conditions;

• When lichen sclerosis affects the penis, it is known as penile lichen sclerosis or balanitis xerotic obliterans;

• Preputial adhesions, or scar tissue, keep the foreskin connected to the tip (glans) of your penis;

• Injuries;

• Infections, including STIs.

Possible complications of phimosis:

Persistent pathologic phimosis, which doesn't resolve on its own and leads to issues such as penile irritation, bleeding, ballooning of the foreskin during urination causing difficulties, urinary retention, painful urination, painful erections, recurrent foreskin infections, paraphimosis, or urinary tract infections, might necessitate additional intervention. Your healthcare provider will direct your child to a pediatric urologist for further assessment. Phimosis, if left untreated it may lead to:

Penile Cancer: Medical researchers have found that phimosis patients have an increased risk for penile cancer. However, there needs to be more conclusive evidence to support this correlation. Nonetheless, if a patient does develop penile cancer as a direct result of phimosis, amputation of the organ may be the only viable solution.

Prolonged Bacterial Infections: Phimosis is known to lead to the growth of harmful bacteria in the associated area. This is especially concerning as a bacterial infection is one of the primary causal factors for the condition. If left untreated, this can result in a prolonged infection episode that causes severe damage to the penis.

Penile Gangrene: Rarely, recurrent bacterial infections in phimosis patients may lead to penile gangrene. This is a severe medical complication and involves tissue death in the penis and the surrounding genital area. Individuals who suffer from such a condition will typically experience immense physical pain or observe pus-filled sacs in the peripheral genital regions.

Ischemic Cascade (gradual tissue damage): Tightness around the foreskin may sometimes cause inflammation at the tip of the penis. In such cases, this will lead to reduced blood circulation. Subsequently, the tissues in the penis are deprived of oxygen.

All of this combine to cause an ischemic cascade. This is a medical condition which is characterized by gradual tissue damage. In addition, the initial inflammation may also make it difficult for an individual to clean his genitals, thereby increasing the risk of bacterial infections.

Prevention:

Phimosis is preventable with proper daily hygiene. Gently cleaning your penis on a daily basis can help prevent phimosis. Other ways to avoid a tightened foreskin include avoiding rough handling of your foreskin and practising safe sex to reduce the risk of sexually transmitted diseases.
 

When To Consult A Doctor?

On Manifestation of Symptoms: Typically, phimosis can be left untreated in young males, with the condition getting resolved on its own. However, if the inability to retract the foreskin is causing urinary irritation or interfering with healthy erections, it is necessary to consult a general physician or a urologist. In addition, phimosis can lead to recurring infections, which cause other related issues such as penile inflammation, rashes and discolouration of the foreskin. When these symptoms manifest, it is critical to seek emergency medical care.

Adults with Type 2 Diabetes: Males with type 2 diabetes have an increased risk of developing phimosis. This usually occurs due to diabetic patients being prone to fungal infections. Repeated episodes of such issues lead to inflammation (balanitis) or fibrosis (residual scarring from the infection). Both of these factors increase the likelihood of an individual developing the condition.

Frequent Physical Examinations: Regular visits to a general physician can enable individuals to pre-emptively identify the clinical markers for phimosis. Regardless, not all physical examinations include a genital inspection. Thus, it’s vital to proactively convey any information related to discomfort near the foreskin or other associated symptoms.

Diagnosis:

General Physical Examination: A clinical diagnosis of phimosis does not require doctors to administer advanced tests or assessments. Instead, medical professionals will conduct a standard physical examination upon being informed of the issue by a patient. This will involve a clinical inspection of the penis, the surrounding area and the foreskin.

In some cases, individuals may undergo a swab test to check for bacterial infection while providing their medical history or additional information regarding any symptoms.

Note that diabetic patients may have to undergo supplementary urine and blood tests. However, these assessments are not directly related to a diagnosis of phimosis and are primarily done to determine if there are any irregularities with their blood sugar levels.

Treatment:

Home Remedies: For male children and teenagers, phimosis can usually be resolved by pulling the foreskin back regularly. However, it is essential to be gentle while doing so, as too much pressure may cause the connective tissue between the glans and the foreskin to tear. It is also advisable to maintain good personal hygiene as, in most cases, the condition is a direct result of bacterial infections. As such, doctors recommend using lukewarm water to wash the associated area. If there is any inflammation, ice packs can reduce some swelling.

Medication & Steroid Creams: Medical professionals may prescribe medications or creams based on the underlying causal factor. For example, if the condition is due to a bacterial or fungal infection, doctors will recommend antibiotic drugs. In more severe cases, physicians or urologists could prescribe steroid creams like Betamethasone valerate. These ointments soften the foreskin and make it easier to retract.

Surgical Treatment: If available home remedies and medications are ineffective, surgical treatment may be the only viable option for phimosis patients. In such cases, doctors will suggest circumcision to remedy the issue permanently.

However, if a patient is not suited for circumcision for any reason, medical professionals will recommend a dorsal slit. This emergency procedure involves making a small incision at the top of the foreskin. Subsequently, any tightness in the surrounding area is alleviated instantly. Note that this procedure does not eliminate the chance of recurrence.

Urologists may rely on a hyaluronidase injection for phimosis patients with severe penile inflammation. These injections contain enzymes that reduce any swelling. In rare cases, it may be necessary to use sterilized needles to drain any built-up fluids or pus (due to bacterial infections).

Additional Information

Prognosis for Phimosis

While phimosis does have various uncomfortable symptoms associated with it, the condition is not life-threatening. In most cases, medications and steroid creams are highly effective in treating the issue.

There is some existing evidence that a tight or non-retractable foreskin increases the risk of penile cancer. However, more conclusive research is required to substantiate this finding.

Difference between Phimosis and Paraphimosis

Paraphimosis is the opposite of phimosis, meaning that the foreskin is retracted and can’t be moved back into its original position. The causes, risk factors and treatment for the two are relatively similar except for phimosis being a naturally occurring condition in some cases.

In addition, as mentioned earlier, phimosis patients have a relatively high chance of developing penile cancer.

Management of Phimosis

Gentle daily retraction is sufficient to loosen the foreskin in most cases. It is also advisable to pull the foreskin back when urinating or bathing to prevent any issue with genital hygiene.

Parents and caregivers must also note the significant variability in how children develop. As such, just because an older male sibling had phimosis up until a specific age does not mean that the younger one will develop it similarly.