What is Phimosis?
Phimosis is a medical term that comes from the Greek word for “muzzling.” It is used to describe a condition where a person finds it hard to pull back the foreskin. But sometimes, this term is used in different situations, and this can make people think there’s a medical issue when there isn’t one. Often, the main concern is that a person, or their parent or guardian, can’t pull back the foreskin. In such cases, it’s best to find out whether this is something natural or a sign of a disease.
What Causes Phimosis?
Physiological Phimosis
When a baby boy is born, the foreskin, or prepuce, of his penis doesn’t retract or pull back and this is normal. This foreskin first begins to develop when a baby is just eight weeks old in the womb, and it fully covers the tip, or glans, of the penis by the 16th week of pregnancy. At this point, the inner lining of the foreskin is stuck to the tip of the penis – this is a natural part of the developmental process. This connection begins to break down as the skin naturally sheds and forms small spaces, ultimately creating a space between the foreskin and the tip of the penis, known as the preputial sac.
Pathological Phimosis
Pathological phimosis refers to an abnormal tightening of the foreskin, which leads it to appear narrow, pale, and scarred. It is usually caused by a condition called balanitis xerotica obliterans (BXO). BXO is a skin condition that causes scarring and is very similar to another disease called lichen sclerosis. It’s a long-term, skin condition and there are some indications that it might be an autoimmune disease, which means the body’s immune system is attacking its own cells. There has been some debate about whether BXO might increase the risk of developing penile cancer in the future.
Risk Factors and Frequency for Phimosis
In the 1940s and 1960s, researchers found that the majority of boys develop a retractile foreskin as they mature into their teenage years. Their studies showed that 8% of 6 to 7-year-old boys, 6% of 10 to 11-year-old boys, and 1% of 16 to 17-year-old boys have phimosis, a condition where the foreskin can’t be pulled back. On the other hand, preputial adhesions, which involve the skin of the foreskin sticking to the penis itself, remain common throughout childhood and adolescence, but by the age of 17, only 3% have persisting adhesions.
True pathological phimosis, which is caused by a condition known as BXO (Balanitis Xerotica Obliterans), has a fairly consistent occurrence rate throughout all stages of life, with a spike in the third decade. It’s relatively uncommon in children under 5, peaking between the ages of 9 and 11, with 0.6% of boys affected at this stage. However, recent studies have questioned this, reporting varied rates from 5% to 52%, and suggesting that BXO can also affect children younger than 5 years.
Signs and Symptoms of Phimosis
Physiological phimosis is a common condition in childhood, usually between 2 and 4 years old. This often shows up as ballooning of the foreskin. The foreskin is non-retractile at this age, so you may notice this when a child’s foreskin balloons out when they urinate. You don’t have to worry, though. This is a self-limiting issue, which means it settles down as the foreskin naturally becomes more retractile. It doesn’t impact a child’s bladder function or their ability to urinate normally.
On the other hand, BXO (Balanitis Xerotica Obliterans), a different type of phimosis, starts gradually and stealthily. It can cause several problems including:
- Local irritation
- Infection
- Discomfort while urinating (dysuria)
- Bleeding
- Atrophy phimosis
- Urinary tract narrowing (meatal stenosis)
This condition may also come and go (in remission and flares). Rarely, it can cause serious problems like sudden inability to pass urine (acute urinary retention) or bedwetting at night (nocturnal enuresis) due to the urinary outflow being blocked over a long time.
Testing for Phimosis
If you’re being evaluated for phimosis (a condition where the foreskin can’t be pulled back from the head of the penis), usually there’s no need for labs or x-rays. Research shows that natural or “physiological” phimosis doesn’t block the flow of urine, so tests like these aren’t necessary.
If phimosis requires a surgery, the skin removed should be sent to a lab for examination. This process, called histology, can confirm the diagnosis of phimosis and check for any signs of cancer.
Treatment Options for Phimosis
If a boy is unable to pull back his foreskin, and it isn’t causing pain or interfering with normal urination, it’s generally not something to worry about. This condition, known as physiological phimosis, is quite normal and often resolves as the boy grows older. Parents concerned about this should be reassured that it typically improves on its own over time.
However, if the inability to retract the foreskin is causing discomfort or problems with urinating, it may be due to pathological phimosis. This condition requires treatment, and the most common method is circumcision, which is the removal of the foreskin. This procedure is generally the only reason a child would need a circumcision for medical reasons.
If a boy has balanoposthitis, an inflammation of the foreskin and head of the penis, treatments other than circumcision may be effective. This includes using a topical steroid cream on the foreskin. The cream can make the foreskin retractable sooner and is typically applied over a period of 4 to 8 weeks, during which time regular attempts at foreskin retraction are made. This treatment has a low risk associated with short-term use and can even be repeated if necessary.
There’s also a surgical procedure called preputioplasty that serves as an alternative to circumcision. This procedure changes the shape of the foreskin but doesn’t remove it. Initially, the penis may look like it has been partially circumcised, but with regular retraction of the foreskin after the surgery, it will take on a more normal appearance over time.
What else can Phimosis be?
Acute balanoposthitis is an infection of the foreskin that can cause swelling, redness, and minor bleeding. These symptoms can be accompanied by painful urination. The typical treatment for these episodes is antibiotics, with further treatment usually being unnecessary unless it happens repeatedly.
Paraphimosis is a condition where the foreskin can’t return to its original position after being pulled back. This can result in swelling and pain in the foreskin and the tip of the penis. This is not a disease and usually doesn’t require surgery unless it keeps happening, in which case circumcision may be considered.
Congenital megaprepuce is a rare condition where the outer skin of the foreskin directly meets the abdominal wall above and the scrotum below, with no visible penile shaft skin. This condition results in abnormal urination, with the foreskin filling with urine. A modified circumcision is needed to correct this; a standard circumcision would not be sufficient and would necessitate additional surgery due to the loss of outer foreskin.
Lastly, preputial adhesions, which are natural adhesions that form between the foreskin and the penis, usually resolve on their own over time. Surgery is rarely required and is mainly used in extreme cases.