Clinical Guidelines for Phimosis

Dr Peter Ball MB,B Chir

John Dalton Bsc,Msc

Last updated on 1st May 2008


The Management of Phimosis

These 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 Development

The 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 an requires no treatment.[ 5 ]

Diagnosis

Non-retractability of the foreskin in childhood does not constitute phimosis. Ballooning during micturition is a harmless and transient phenomenon and is part ofnormal 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.

Treatment

The
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 Steroids

A
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 Surgery

A 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.

Circumcision

As 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 Circumcision

Circumcision
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.

  • Have a genuine therapeutic indication for circumcision, conservative treatment having been tried and failed.
  • Have understood the implications of circumcision and be willing to have the operation.
  • Have understood that circumcision has at least a 2% chance of serious complications.[ 43 ]
  • Have a supportive friend or relative to stay with them overnight.

References (links will open in a new window)
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Emmett AJ. Z-plasty reconstruction for preputial stenosis- a surgical
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26.
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28. * Wahlin N. "Triple incision plasty". A convenient procedure for preputial relief. Scand J Urol Nephrol 1992;26(2):107-10.
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34.
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40. Ratz JL. Carbon dioxide laser treatment of balanitis xerotica obliterans. J Am Acad Dermatol 1984;10 (5 Pt 2):925-8
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43. Williams N, Kapila L. Complications of circumcision. Br J Surg 1993;80:1231-36