Phimosis

Overview

Phimosis is a medical word that refers to difficulties retracting the penile prepuce. There are physiologic and pathologic variants of phimosis, which can make the term's use more difficult. The physiologic type, which is frequent in children aged 2 to 4, is self-limiting and dissolves as the foreskin becomes more retractile.

Balanitis xerotica obliterans (BXO), a cicatrizing skin disorder histologically similar to lichen sclerosis, is frequently the cause of the pathogenic form. BXO has a slow start and may be accompanied by discomfort, local infection, dysuria, and bleeding, all of which can precede atrophy and meatal stenosis.

 

Phimosis definition

The inability to retract the foreskin is referred to as phimosis. The name is of Greek origin, and its literal meaning is "muzzling." However, using it interchangeably in a variety of contexts can frequently lead to the perception of a pathological process when none occurs. Because non-retractile foreskin is frequently the presenting complaint of a patient or their parent/guardian, it is important to determine if the process is natural or pathological.

Physiologic phimosis, on the other hand, is characterized by a pliant, unscarred preputial opening. Physiologic phimosis is frequent in male patients up to the age of three, although it can also affect older people. On physical examination, these two distinct disorders are easily distinguished.

 

Penile Development and Anatomy

Penile development begins in the seventh week of pregnancy and is completed by the seventeenth week. The prepuce, or foreskin, is formed when the integument of the penis folds over itself in front. It includes the glans penis and the urinary meatus. It has various roles, the most important of which are defensive, immunologic, and erogenous. This 15-square-inch double-layered fold's inner mucous membrane connects with glans.

It is attached to the underside of the glans by a very sensitive tissue known as the frenulum, or "little bridle." Prepuce is well-vascularized and innervated. Prepuce has a lot of fine touch receptors. The majority of these sensitive regions are removed during traditional circumcision. Glans, unlike prepuce, has just pressure receptors and no fine touch receptors. Glands on the prepuce and glans release fluids that help in lubrication and infection defense.

Lysozyme, which is present in these secretions, inhibits the growth of pathogenic germs. Cathepsin B, chymotrypsin, neutrophil elastase, cytokine, and androsterone-like pheromones are also generated. Langerhans cells are found in prepuce and appear to give resistance to HIV infection. The inner component of the foreskin is glued to the glans at birth and during the first few years of life, making it nonretractile. This progressively separates over time, resulting in enhanced retractability.

 

Epidemiology

In the mid-twentieth century, the natural history of non-retractile foreskin and preputial adhesions was thoroughly recorded, first by Gairdner in 1949 and subsequently by Oster in 1968. Their combined research indicates that, with the exception of a tiny percentage of males, the foreskin will be retractile by the time they reach their adolescent years. According to these research, phimosis is present in 8% of 6- to 7-year-olds, 6% of 10- to 11-year-olds, and 1% of 16- to 17-year-old males. Preputial adhesions, on the other hand, are significantly more frequent throughout childhood and adolescence, but by the age of 17, just 3% will have persisting adhesions.

True pathological phimosis induced by BXO has a rather steady incidence across all ages, with a peak in the third decade. Relatively uncommon in children under the age of 5, the peak childhood prevalence occurs between the ages of 9 and 11, with 0.6 percent of boys afflicted by years of age. Modern studies call this notion into doubt, citing incidences ranging from 5% to 52% in infants under the age of five.

 

Causes for Phimosis

Physiological Phimosis

The prepuce is non-retractile at birth and stays thus for an unknown amount of time. The prepuce, which first appears as an epithelial ridge in the eighth week of gestation, is complete and encases the glans by 16 weeks of gestation. The glans and prepuce epithelial linings are continuous at this stage, and these preputial adhesions are essentially a normal developmental process. Separation occurs proximally with the process of desquamation, which results in the formation of tiny gaps that later merge to create the preputial sac.

Pathological Phimosis 

The pathological process causes stenosis scarring and pallor of the preputial aperture. Balanitis xerotica obliterans is the most common cause (BXO). BXO is a cicatrizing skin disorder that has the same histology as lichen sclerosis. It is a persistent skin disorder with an autoimmune origin, according to some research. There has been some debate over BXO as a possible cause of penile cancer later in life.

Exacerbating factors

Several causes may prevent a foreskin from fully retracting. The persistence of preputial adhesions most of the time prevents retraction. These adhesions are the remains of the fused layer that existed between the glans and the prepuce. Although they can initially hinder complete retraction, adhesions normally dissolve spontaneously with gentle foreskin retraction during bathing and periodic erections during infancy.

Boys with recurring bouts of balanitis or balanoposthitis are at risk of developing scarred preputial orifices, which can lead to pathologic phimosis. In about 80% of instances, applying a corticosteroid cream to the non-scarred preputial outlet loosens the tissues, allowing for better foreskin retraction.

Penile lichen sclerosis et atrophicus is a kind of balanitis xerotica obliterans. Pathologic phimosis is frequently caused by scarring caused by balanitis xerotica obliterans. Topical corticosteroid treatment is typically ineffective for Balanitis xerotica obliterans.

 

Pathophysiology

Physiological phimosis causes an apparent constriction ring a few millimeters proximal to the preputial opening when the foreskin is retracted. On retraction, the opening is characterized as like a flower, with a moist, supple, and unscarred look with pouting of the inner mucosa.

In contrast, BXO has a sclerotic constricting band 1 to 2 cm proximal to the distal end, and there may be glans involvement in a scattered pattern, with pathognomonic white staining of the peri-meatal region and an erythematous area.

 

Phimosis symptoms

Ballooning of the foreskin is a frequent appearance of physiological phimosis in children while the foreskin is still non-retractile. It is a self-limiting syndrome that disappears as the foreskin becomes more retractile, which usually occurs between the ages of 2 and 4 years. Parents may be confident that this has no influence on their child's bladder or capacity to urinate.

BXO has a slow start and may be accompanied with discomfort, local infection, dysuria, bleeding before atrophy phimosis, and meatal stenosis. The illness can also progress in a cyclical pattern with intervals of remission. Patients with chronic outflow blockage may appear with acute urine retention or nocturnal enuresis on rare occasions.

In the uncircumcised or partially circumcised patient, paraphimosis often manifests as a painful, swollen glans penis. A preverbal newborn may just exhibit irritation. Occasionally, paraphimosis is discovered as an unintentional finding by a caregiver for a disabled patient.


Physical

Phimosis includes the following:

  • The foreskin is not retractable proximally over the glans penis.
  • The preputial orifice is unscarred and seems healthy in physiologic phimosis.
  • A tight white fibrous ring around the preputial opening may be observed in pathologic phimosis.

 

Phimosis in boys and adults can vary in severity. Meuli et al. have graded severity of phimosis into following 4 grades, namely, 

  • Grade I— fully retractable prepuce with stenotic ring in the shaft, 
  • Grade II—partial retractability with partial exposure of the glans, 
  • Grade III—partial retractability with exposure of the meatus only, and 
  • Grade IV—no retractability. 

 

There is another classification of phimosis severity, which is as follows: 

  • Grade 0 is full retractability, 
  • Grade 1 is full retraction but tight behind glans,
  • Grade 2 is partial exposure of glans, 
  • Grade 3 is partial retraction with meatus just visible, 
  • Grade 4 is slight retraction but neither meatus nor glans visible, and
  • Grade 5 is absolutely no retraction . 

 

Phimosis is classified as normal, "cracking," scarred, or balanitis xerotica obliterans based on the status of the foreskin.

 

Diagnosis

Laboratory testing and radiography are not routinely used to diagnose phimosis, and studies have shown no indication of blockage from physiological phimosis.

Any surgically removed skin from pathological phimosis should be referred for histology to confirm the diagnosis and rule out any indication of cancer.

 

Phimosis treatments

Treatment of physiological phimosis is not recommended, and anxious parents should be offered comfort and an explanation of the natural history of the healthy non-retractile foreskin. Circumcision is the primary therapy for pathological phimosis in youngsters, and it is the only absolute indication for this operation.

Circumcision alternatives are not suited for treating phimosis caused by BXO, but are intended to obtain a completely retractile foreskin. These therapies can be very beneficial for those suffering with balanoposthitis. Topical steroids have been thoroughly researched, and topical administration to the foreskin can cause it to retract earlier.

A normal therapy period lasts 4 to 8 weeks, with retraction efforts made on a regular basis. Given the minimal risk of short-term topical steroid usage, this can be repeated if necessary. 

 

Emergency Department Care

Patients with phimosis rarely require emergency treatment and should be referred to a urologist on an outpatient basis before irreparable penile damage develops.

A paraphimosis is a urologic emergency that must be treated right away. Many paraphimosis-reduction techniques have been described in case studies, but none have been tested in randomized controlled trials. The basic purpose of each approach is to manipulate the edematous glans and/or the distal prepuce to return the foreskin to its normal position over the glans penis.

When required, any of the following treatments can be aided by local anaesthetic, a penile block with lidocaine hydrochloride without epinephrine, or, especially in youngsters, conscious sedation. All invasive operations should be performed using a sterile method.

The authors advise seeking to diminish paraphimosis in the order listed below, from least to most intrusive. In all cases of paraphimosis that require more than minimally invasive treatment, the urologist should be consulted early on.

 

Manual reduction

Both index fingers are placed on the dorsal border of the penis behind the retracted prepuce, and both thumbs are placed on the end of the glans. With steady thumb pressure, the glans is forced back through the prepuce, while the index fingers draw the prepuce over the glans.

This procedure may be aided by the use of cold and/or hand compression to the foreskin, glans, and penis prior to manual reduction to reduce glans edema. It has been claimed that soaking the penis in a glove full of ice for 5 minutes before trying manual reduction works 90% of the time.

To reduce edema, an elastic bandage can be applied from the glans to the base of the penis for 5-7 minutes. To provide moderate continuous symmetrical traction, noncrushing clamps can be put at the 3- and 9-o'clock locations on the constricting region of the foreskin.


Osmotic method

Prior to physical reduction, substances with a high solute concentration can be employed to osmotically extract fluid from the edematous glans and foreskin. Granulated sugar applied for 2 hours to the glans and foreskin has been demonstrated to aid in manual reduction. Alternatively, before trying reduction, a swab soaked in 50 mL of 50% dextrose (more readily available in the ED) can be wrapped over the glans and foreskin for an hour. One significant disadvantage of these approaches is that they are time demanding.

 

Puncture method

This procedure involves inserting a 21- to 26-gauge needle into the foreskin to allow edematous fluid to escape from the puncture sites during manual compression. Successful reductions have been reported with as few as one and as many as twenty punctures.

 

Hyaluronidase method

The puncture approach can be improved by injecting 1-mL aliquots of hyaluronidase into one or more areas of the edematous prepuce with a tuberculin syringe. Hyaluronidase is hypothesized to disperse extracellular edema by altering the permeability of intercellular material in connective tissue.

The use of this procedure is not advised in people who have an illness or cancer, since it may result in the spread of germs or malignant cells. The risks of allergy and shock, as well as the absence of hyaluronidase in many EDs, are disadvantages of this technique.

 

Aspiration

The shaft of the penis is cinched with a tourniquet. The glans is then aspirated with a 20-gauge needle parallel to the urethra to get 3-12 mL of blood. This decreases the volume of the glans enough to allow for manual reduction.

 

Vertical incision

If none of the preceding approaches work, the restricting band of the foreskin should be incised using a 1-2 cm longitudinal incision between two straight hemostats inserted in the 12-o'clock position for hemostasis. This releases the restricting ring and enables for simple decrease of the paraphimosis. The incised edges can then be reapplied with 4/0 nylon sutures.

 

Differential Diagnosis

Acute balanoposthitis is the most severe type of posthitis, characterized by a purulent, pyogenic infection of the prepuce. These disorders cause prepuce erythema and edema. Dysuria is prevalent, and mild bleeding is possible. Unless recurring episodes occur, these episodes usually resolve with antibiotic therapy and do not require additional intervention.

The term "phimosis" refers to the failure to return the foreskin to its normal position after manipulating it. Pain and edema of the prepuce and glans are usual presentations. Paraphimosis is not a disease condition, and single episodes, once treated, do not necessitate surgical intervention. Recurrent incidents are rare and should be circumcised.

Congenital megaprepuce is an extremely unusual disorder. The outer preputial skin immediately touches the abdominal wall dorsally, the scrotum ventrally, and there is no penile shaft skin. Micturition is usually aberrant, with urine filling the whole preputial sac. This can be conveyed to give the illusion of being more normal.

This disease requires a modified circumcision; any effort to cure it with a conventional circumcision will result in the need for revision surgery, which will be compounded by the loss of outer preputial skin.

Preputial adhesions are a natural physiological trait that resolves on its own. Except in extreme circumstances, surgical intervention has a small role.

 

Complications

Complications of phimosis or paraphimosis may include the following:

  • Recurrence
  • Posthitis
  • Necrosis and gangrene of the glans 
  • Autoamputation

Human papillomavirus (HPV) was found in 46.66 percent of 30 patients who underwent circumcision owing to phimosis in a Brazilian research, with 50 percent having high-risk HPV genotypes. Only 16.36 percent of 100 asymptomatic individuals were positive for HPV, with only one showing high-risk HPV.

According to a Taiwanese research, phimosis with preputial fissures may be an indication of undetected diabetes mellitus. Diabetes was verified in all 28 patients with acquired phimosis and preputial fissures, compared to just 2 patients out of 28 with acquired phimosis without preputial fissures. Body mass index, random plasma glucose, glucosuria, and glycosylated hemoglobin levels were shown to be statistically significant, but not age, family history of diabetes, hypertension, or characteristic hyperglycemic symptoms.

 

Conclusion 

Phimosis is a disorder that causes the prepuce to be unable to retract over the glans penis. True pathologic phimosis occurs when the inability to retract is caused by distal scarring of the prepuce. Scarring around the preputial opening is commonly seen as a constricted white fibrous ring.

The treatment of phimosis involves a multidisciplinary effort. Although the main caregiver or nurse practitioner is generally the first to meet the patient, a referral to a urologist is often recommended. Treatment of physiological phimosis is not recommended, and anxious parents should be offered comfort and an explanation of the natural history of the healthy non-retractile foreskin. Circumcision is the primary therapy for pathological phimosis in youngsters, and it is the only absolute indication for this operation.

Circumcision alternatives are not suited for treating phimosis caused by BXO, but are intended to obtain a completely retractile foreskin. These therapies can be very beneficial for those suffering with balanoposthitis. Topical steroids have been thoroughly researched, and topical administration to the foreskin can cause it to retract earlier.