(1)
Pediatric Surgery, Al Azher University, Cairo, Egypt
Abstract
The foreskin is usually still fused with the glans at birth. As childhood progresses, they gradually separate. There are different reports and a lot of debates about the age at which the foreskin can be retracted safely as there is no consensus about the time of complete separation between the glans and the inner prepuce. The other problem is the inability of many physicians to distinguish between physiological phimosis, pathological phimosis and paraphimosis, and their misdiagnosis that leads to unnecessary parents’ anxiety and over-referrals to urologists for circumcision or consultation. Of these cases referred to a urology clinic, in one study, it was detected that only 8–14.4 % had a “true” phimosis which necessitate surgical intervention.
Keywords
Physiological phimosisPathological phimosisPreputial stenosis and paraphimosisThe foreskin is usually still fused with the glans at birth. As childhood progresses, they gradually separate. There are different reports and a lot of debates about the age at which the foreskin can be retracted safely [1] as there is no consensus about the time of complete separation between the glans and the inner prepuce. The other problem is the inability of many physicians to distinguish between physiological phimosis, pathological phimosis and paraphimosis, and their misdiagnosis that leads to unnecessary parents’ anxiety and over-referrals to urologists for circumcision or consultation. Of these cases referred to a urology clinic, in one study, it was detected that only 8–14.4 % had a “true” phimosis needing surgical intervention [2].
Physiological phimosis, pathological phimosis and paraphimosis will be discussed separately and chronologically.
38.1 Phimosis
Definition:
Phimosis is defined as a narrowing of the preputial ring that prevents retraction of the foreskin over the glans penis. It could be physiological (congenital) or pathological (acquired). Physiological phimosis is almost invariably present at birth.
The term may also refer to clitoral phimosis in women, whereby the clitoral hood cannot be retracted, with a limiting exposure of the glans clitoris.
The word phimosis is from the Greek phimos (φῑμός) which means a muzzle.
Grades
There are many classifications of the grades or scores of phimosis with a great similarity. Kikiros et al. [3] classified phimosis to:
Score 5: Absolutely no retraction of the foreskin.
Score 4: Slight retraction, but some distance between tip and glans, i.e., neither meatus nor glans can be exposed.
Score 3: Partial retraction, meatus just visible.
Score 2: Partial exposure of glans, prepuce (not congenital adhesions) limiting factor.
Score 1: Full retraction of foreskin, tight behind the glans.
38.1.1 Physiological Phimosis
Nomenclature
Preputial Stenosis and Congenital Phimosis.
Definition
Physiological phimosis is an inability to withdraw the narrowed penile foreskin or prepuce behind the glans penis without any acquired disease in the glans or prepuce.
Incidence
Around 96 % of males at birth are noticed to have a nonretractile foreskin, and up to 10 % of males will have physiologic phimosis at 3 years of age, and a larger percentage of those will have only partially retractible foreskins. One to five percent of males will have nonretractible foreskins by age 16 years [4].
Etiology
Naturally occurring adhesions between prepuce and glans.
Narrow preputial tip.
Frenulum breve, (a congenitally short frenulum of varying degree, restricting the movement and gliding of the prepuce over the glans “comparable to tongue tie”).
38.1.1.1 Diagnosis
On gentle traction, the prepuce puckers and the overlying tissue are pink and healthy. There may be some ballooning during urination (Fig. 38.1). But pain, dysuria, and local or urinary infections are not seen in these cases. Even if urinary infection is present, it is usually not attributed to the phimosis. Diagnosis of phimosis is primarily clinical and no laboratory tests or imaging studies are required. These may be required for associated urinary tract infections or skin infections. Treating physician should be able to distinguish developmental non-retractability from pathological phimosis, and also to detect grading of severity of this phimosis.
Fig. 38.1
Inflamed oedematous preputial orifice after a forcible trial of retracting the prepuce in a neonate
38.1.1.2 Treatment
When it is certain that phimosis in the child is not pathologic, it is vital to reassure the parents on normalcy of the condition in that age group. They should be taught how to keep the foreskin and its undersurface clean and hygienic. Normal washing with lukewarm water and gentle retractions during bathing and urination makes the foreskin retractile over time.
The foreskin gradually becomes retractable over a variable period of time ranging from birth to 18 years of age or more. At least 2 % of normal males continue to have non-retractability throughout life, even though they are otherwise normal. In European countries the classical antecedents are focused on treating underlying pathology, maintaining foreskin function and preserving natural cosmosis, instead of doing circumcision [5]. In other areas, where ritual circumcision done routinely for almost all babies, many surgeons treating this type of phimosis by taking off the troublesome prepuce.
38.1.1.3 Complications
Patients with phimosis, both physiologic and pathologic, are at risk for developing paraphimosis when the foreskin is forcibly retracted past the glans and/or the patient or caretaker forgets to replace the foreskin after retraction, usually pain and swelling prevent reduction of a retracted foreskin (Fig. 38.1).
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