Clinical Guidelines for Phimosis
Last updated on 1st May 2008
The Management of PhimosisThese clinical guidelines have been drafted by NORM-UK for the guidance of medical practitioners and health authorities on the diagnosis and treatment of phimosis. These guidelines are the first in a series of guidelines which will include guidelines for the treatment of balanoposthitis and other conditions which may affect the foreskin.
Normal Anatomy and DevelopmentThe foreskin or prepuce is an integral, normal part of the penis that forms an anatomical covering over the glans. It is a specialised junctional mucosa with unique innervation enabling it to function as erogenous tissue [ 1 ]. Specialised sensory receptors of the prepuce include Meissner and Vater-Pacini corpuscles, Merkel cell discs, and thousands of nerve endings [ 2 ]. The sensory receptors of the ridged band of the preputial mucosa may form part of the afferent limb of the ejaculatory reflex [ 3 ]. The development of the prepuce is incomplete in the newborn male child. Separation from the glans and foreskin retractability occurs at a variable age. There is no deadline for this and often full retractability does not occur until well into the teenage years. A non-retractable foreskin in a pre-pubescent child is not a disease and requires no treatment.[ 5 ]
DiagnosisNon-retractability of the foreskin in childhood does not constitute phimosis. Ballooning during micturition is a harmless and transient phenomenon and is part of normal development requiring no treatment [ 6 ]. True phimosis has been defined as scarring of the tip of the prepuce, and is usually due to Balanitis Xerotica Obliterans (BXO) [ 7 ]. The incidence of pathological phimosis in boys has been recently reported as 0.4 cases/1000 boys per year, or 0.6% of boys affected by their 15th birthday [ 8 ]. The non-retractable foreskin in adult life may also be regarded as phimosis.
TreatmentThe normal non-retractile foreskin of childhood must be recognised and left alone. Patients and their parents should be advised not to attempt forcible or premature retraction of the foreskin, and to avoid excessive washing with soap.
Once phimosis is diagnosed, the available treatments include topical corticosteroids, manual stretching, preputial plasty and circumcision. Conservative treatments should be tried in the first instance and surgery used as the treatment of last resort. Details of the various treatment options are given below.
Topical SteroidsA number of studies show that phimosis can be safely and effectively treated by the application of topical steroids in 80-90% of cases.[ 9-16 ]. Betamethasone cream 0.05% should be applied to the exterior and interior of the tip of the foreskin 2-3 times daily. The treatment should be discontinued as ineffective after 3 months if the foreskin has not become retractile during this time.
Conservative SurgeryA number of plastic corrections are available for the adult or adolescent non-retractable foreskin.[ 19-32. ]. These include preputial plasty, in which a dorsal, longitudinal incision is made through the constrictive band of the foreskin. The underlying tissue is spread with artery forceps to expose the Buck's fascia and the incision is closed transversely with absorbable sutures. This procedure has less morbidity than circumcision, and allows the prepuce to be retained.
CircumcisionAs with any surgery, circumcision is very traumatic to a child. It is essentially irreversible and should be the treatment of last resort. Pathological phimosis due to BXO has been considered the one common absolute indication for circumcision.[ 33 ]. BXO however, is the same as Lichen Sclerosis Atrophicans (LSA) [ 34 ]. Circumcision has been reported to be ineffective in preventing or treating BXO.[ 35-37 ]. BXO does respond to topical corticosteroids,[ 38, ] topical testosterone,[ 39 ] or carbon dioxide laser treatment [ 40-41 ]. One report shows that long term antibiotic treatment is effective, but there is doubt as to whether this is due to antimicrobial activity.[ 42 ]
Cautions for CircumcisionCircumcision is essentially irreversible and should be the treatment of last resort. If a circumcision is to be performed, all the following patient criteria should be met.
02. Cold C and McGrath K. Anatomy and histology of the penile and clitoral prepuce in primates. In G Denniston et al (eds), Male and female circumcision: Medical, Legal and Ethical Considerations in Pediatric Practice (1999). NY Plenum.
03. Taylor JR, Lockwood and Taylor AJ. The Prepuce: Specialised Mucosa of the Penis and its Loss to Circumcision. Brit J Urol 1996;77:291-295
04. Gairdner DM, MRCP. The Fate of the Foreskin. BMJ. 1949;2:1433-1437
05. Oster J, Further fate of the Foreskin. Arc Dis Child, 1968;43:200-36
06. Rickwood AMK and Walker J. Is phimosis overdiagnosed and are too many circumcisions performed in consequence? An Royal Coll Surg Engl, 1989;71:275-7
07. Rickwood AMK, Hemalatha V, Batcup G and Spitz L. Phimosis in boys. BJ Urol 1980;52:147-150
08. Shankar KR and Rickwood AMK. The incidence of phimosis in boys. BJU International 1999;84:101-2
09. Lang K. Eine konservative Therapie der Phimose. Monatsschr Kinderheilkd. 1986;134:824-5
10. Meyrick Thomas RH, Ridley CM, Black MM. Clinical features and therapy of lichen sclerosus et atrophicus affecting males. Clin Exp Dermatol. 1987;12:126-128
11. Fortier-Bealieu M, Thomine E, Mitrofanof P Laurent P, Heinet J. Lincehn sclero-atrophique preputial de l'enfant. Ann Pediatr (Paris).1990;3:673-676
12. Jorgensen ET, Svensson A. The treatment of phimosis in boys with a potent topical steriod (clobetsol propinate 0.05%) cream. Acta Derm Verereol 1993;73:55-6
13. Kikiros CS, Beasley SW, Woodward AA. The response of phimosis to local steriod application. Pediatr Surg Int 1993;8:329-32
14. Wright JE. The treatment of phimosis with topical steriod. Aust NZ J Surg 1994;64:327-8
15. Jorgensen ET, Svensson A. Phimosis hos pjkar kan behandlas med steriod salva (letter) Lakartidningen 1994;91:1291
16. Golubovic Z, Milanovic D et al. The conservative treatment of phimosis in boys. Brit J Urol 1996;78:786-788
17. Beauge M. Conservative Treatment of Primary Phimosis in Adolescents [Traitment Medical du Phimosis Congenital de L'Adolescent]. Saint Antione University, Paris VI, 1990-1991
18. Dunn HP. Non-surgical management of phimosis. Aust NZ J Surg. 1989;59:963
19. Diaz A, Kantor HI. Dorsal Slit. A circumcision alternative. Obstet Gynecol 1971;37:619-22
20. Parkash S. Phimosis and it's plastic correction. J Indian Med Assoc 1972;58:389-90
21. Holmland DE. Dorsal incision of the prepuce and skin closure with Dexon in patients with phimosis. Scan J Urol Nephrol 1973;7:97-9
22. Emmett AJ. Four V-flap repair of preputial stenosis (phimosis). Plast Reconstr Surg 1975;55:687-9
23. Gil Barbosa M, Aquilera Gonzalez C, Alipaz A, Garcia Sanchez JL. La balanolisis como sustituto de la circumcision. Salud Publica Mex 1976;18:893-9
24. Ohijimi T, Ohijimi H. Special surgical techniques for relief of phimosis. J Dermatol Surg Oncol 1981;7:326-30
25. Emmett AJ. Z-plasty reconstruction for preputial stenosis- a surgical alternative to circumcision. Aust Paediatr J 1982;18:219-20
26. Hoffman S. Metz P, Ebbehoj J. A new operation for phimosis: prepuce saving technique with multiple Y-V plasties. Br J Urol 1984;56:319-21
27. Moro G, Gesmundo R, Bevilacqua A, Maiullari E, Gandini R. La circoncisione con postoplastica. Nota di tecnica operatoria. Minerva Chir 1988;43:893-4
28. * Wahlin N. "Triple incision plasty". A convenient procedure for preputial relief. Scand J Urol Nephrol 1992;26(2):107-10.
29. Cuckow PM, Rix G, Mouriquand PD. Preputial plasty: a good alternative to circumcision. J Pediatr Surg 1994;29:561-3
30. de Castella H. Prepuceplasty: an alternative to circumcision. Ann R Coll Surg Engl 1994;76:257-8
31. Leal MJ, Mendes J. A circuncisao ritual e correccao plastica da fomise. Acta Med port 1994;7:475-481
32. Ohijim H, Ogata K, Ohijim T. A new method for the relief of adult phimosis. J Urol 1995;153:1607-9
33. Rickwood AMK, Medical indications for circumcision. BJU Intl. 1999;83 Suppl 1: 45-51.
34. Pasieczny TA. The treatment of balanitis xerotica obliterans with testosterone propinate ointment. Acta Derm Venereol. 1977;57(3):275-7
35. Freeman C and Laymon CW. Archs Derm Syph 1941;44:547
36. Laymon CW and Freeman C. Archs Derm Syph 1944;49:57
37. Catteral RD and Oates JK. Br J Vener Dis. 1962;38:75
38. Poynter JH, Levy J. Balanitis xerotica obliterans; effective treatment with topical and sublesional corticosteroids. Brit J Urol 1967 Aug 39(4);420-5.
39. Pasieczny TA. The treatment of balanitis xerotica obliterans with testosterone propinate ointment. Acta Derm Venereol 1977;57 (3):275-7
40. Ratz JL. Carbon dioxide laser treatment of balanitis xerotica obliterans. J Am Acad Dermatol 1984;10 (5 Pt 2):925-8
41. Rosemberg SK. Carbon dioxide laser treatment of external genital lesions. Urology 1985;25(6):55-8
42. Shelley WB, Shelley ED, Grunenwald MA, Anders TJ, Ramnath A. Long term antibiotic therapy for balanitis xerotica obliterans. J Am Acad Dermatol 1999 Jan;40(1):69-72
43. Williams N, Kapila L. Complications of circumcision. Br J Surg 1993;80:1231-36