Makindo Medical Notes.com

Phimosis is not usually a urological emergency

About

• Phimosis is an inability to retract the foreskin behind the corona of the glans penis
• If severe this can obstruct urine and can also lead to localised balanitis
• Surgery may be needed if a child or adult has severe or persistent balanitis or balanoposthitis that causes their foreskin to be painfully tight.

Development

• The proportion of partially or fully retractable foreskin by age is at:
  • Birth 4%
  • 6 months 20%
  • 1 year 50%
  • 11 years 90%
  • 12-13 years 95%
  • 14+ years 99%

Aetiology

• Phimosis is seen most commonly in children and may resolve with age. True pathological phimosis is rare in those under 18 year old and must be distinguished from physiological adherence of the foreskin to the glans, which is normal.
• Pathological phimosis is more common in the adult population. This may be due to scarring due to recurrent balanitis, sexually transmitted diseases (STDs) and skin diseases such as eczema, psoriasis, lichen sclerosus, Zoons balanitis, carcinoma in situ, and frank squamous carcinoma.

Clinical

• Phimosis (true or physiological) may cause poor stream ballooning of foreskin on micturition, 'spraying' or poor stream on micturition, recurrent attacks of balanitis, pain on intercourse in adults in severe cases, hydronephrosis
• The foreskin is tight and cannot be retracted however it can be normal to not be able to retract the foreskin until 6 years of age
• Phimosis can predispose to infections such as balanitis with a collection of material below the foreskin
• The glans becomes itchy, red and inflamed and painful with associated hygiene issues
• Sometimes if the meatus is small the foreskin balloons with micturition

Management

• A non-retractile foreskin and/or ballooning of the foreskin during micturition in a child under two, do not routinely need to be referred for circumcision. Avoid forcible retraction of congenital phimosis, as this can result in scar formation and an acquired phimosis.
• Cultural circumcision is generally not NHS funded. Parents and patients should be made aware of the risks and benefits of circumcision.
• Personal hygiene is very important. Advise cleaning under a retractable foreskin and always reduce it to cover the glans after cleaning.
• Topical steroid application to the preputial ring to treat 'phimosis' has reported success rates between 33-95%. A prescription would not normally exceed three months and should have achieved maximal therapeutic benefit within this time. A topical steroid such as Betamethasone (0.025-0.1%) is commonly prescribed
• Phimosis can cause pain, skin splitting, or a lack of sensation during sex. Using a condom and lubricants while having sex may make your penis more comfortable.
• It may be an issue in the rare scenario if the patient is in retention and needs a catheter and meatus difficult to find. Use plenty of instillagel. Seek urology advice if not possible and catheter needed.
• Circumcision may be indicated electively but should not be performed on children with hypospadias as the foreskin may be useful for surgical reconstruction

Indications for Circumcision

• Pathological phimosis - The commonest cause is lichen sclerosis, balanitis xerotica obliterans (BXO ) Recurrent episodes of balanitis
• Relative indications for circumcision or other foreskin surgery: Prevention of urinary tract infection in patients with an abnormal urinary tract
• Parents and patients should be made aware of the risks and benefits of circumcision

Revisions