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Review literature: (Riedmiller et al, 2001).
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 are age dependent: 58% after 1 year of life, 10–35% after 3 years of life. The prevalence of true phimosis (with scarring) is 8% in 6-year old boys and 1% with 16 years of age.
Etiology (Causes) of phimosis
The prepuce is formed by a fold of skin, which surrounds 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: 50% after the first year of life, 90% after third year of life.
Scarring of the Prepuce
Recurrent inflammation (balanitis) leads to scarring and narrowing of the prepuce, which itself predisposes to recurrent balanitis.
Complications of Phimosis
Frequent complications are urinary tract infections, a 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 very rare. 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 dysfunction, urinary retention
- Complications like paraphimosis or balanitis
Treatment of Phimosis
Complete (radical) or incomplete (prepuce sparing) circumcision is the cornerstone of phimosis treatment. Please see section circumcision: technique and complications. Contraindications for circumcision are untreated balanitis, coagulation disorders or hypospadias with possible repair in the future.
After local anesthesia of the penis, circumcision is performed using a Gomco clamp, Mogen clamp or with the Plastibell technique. The complication rate for newborn circumcision is 0.2–3%. Most complications are minor, but also devastating complications like partial glans removal or ablative penile injury have occurred. See below for arguments pro or contra prophylactic newborn circumcision.
Conservative Treatment of PhimosisLocal cortisone treatment for 6–12 weeks can lead to a healing of the phimosis, e.g. betamethasone 0.06% cream. The glucocorticoid steroid cream is applied twice daily for six weeks. With insufficient widening of the prepuce, the treatment can be continuated for another 6 weeks. The success rate of conservative therapy (avoidance of circumcision) is around 75–90%. Contraindications to conservative therapy are recurrent urinary tract infections and obstructive voiding dysfunction due to phimosis.
Prophylactic Newborn Circumcision
Prophylactic newborn circumcision is the most common surgical procedure in the United States. Controversies exist about the benefit and harm regarding the prophylactic newborn circumcision, especially if the religious affiliation does not mandate circumcision. Since the diseases, which can be reduced by prophylactic circumcision are very rare, endorsement of routine circumcision is critical.
Arguments for a prophylactic newborn circumcision:
- Avoidance the need for surgery of scarring phimosis in the phallic phase
- Reduction of urinary tract infections
- Reduced risk for transmission of sexually-transmitted diseases
- Prevention of invasive penile cancer
- Prevention of 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
- Incidence of penile cancer is very low with adequate hygiene care
- Many circumcisions are not necessary (overtreatment), since preventable diseases are rare.
Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
- Riedmiller u.a. 2001 RIEDMILLER, H. ; ANDROULAKAKIS, P. ; BEURTON, D. ; KOCVARA, R. ; GERHARZ, E.:
- EAU guidelines on paediatric urology.
In: Eur Urol
40 (2001), Nr. 5, S. 589–99
Deutsche Version: Phimose