Makindo Medical Notes

Related Subjects: |Hypospadias |Phimosis |Paraphimosis |Balanitis (Children)

Phimosis is defined as the inability to retract the foreskin of the penis. While it is common for infants and young boys to have a naturally tight foreskin that gradually loosens over time, persistent phimosis in older children or adults may be pathological. Symptoms can include pain, swelling, discoloration, difficulty in maintaining proper hygiene, and interference with sexual activity.

Patient History

• Urinary Symptoms: Ask about pain during urination, difficulty voiding, or ballooning of the foreskin during micturition, which might suggest an obstruction.
• Sexual Function: Inquire whether the patient experiences discomfort or pain during sexual activity, which may indicate dyspareunia or hinder intercourse.
• Infection History: Determine if there is a history of recurrent balanitis or other infections affecting the foreskin or glans.

Physical Examination

It is normal to have a simple non-retractile foreskin up to the age of 4yrs. By 11yrs or older, prevalence is <8%

• Foreskin Retraction: Gently attempt to retract the foreskin. True phimosis is indicated by an inability to fully retract the foreskin without applying force, which should be avoided to prevent further trauma or scarring.
• Observation of Ballooning: During urination, look for ballooning of the foreskin, which can be a sign of urinary outflow obstruction.
• Skin Assessment: Evaluate the foreskin for signs of scarring, thickening, or white plaques that may indicate lichen sclerosus—a common cause of pathological phimosis.
• Signs of Infection: Check for erythema, swelling, or purulent discharge that could indicate ongoing or recurrent balanitis.
• Age Consideration: Note that physiological phimosis is typical in young children and often resolves naturally, whereas persistent phimosis in adolescents or adults is more likely to be pathological.

Investigations

• History and Clinical Examination: Often, a thorough history and physical examination are sufficient for diagnosis.
• Imaging: In some cases, ultrasonography may be used to evaluate underlying structures or complications.
• Laboratory Tests: If infection is suspected, swabs for culture or assessment of inflammatory markers (e.g., CRP, WBC count) can be helpful.
• Uroflowmetry: For patients with significant urinary symptoms, uroflow studies can help assess the degree of obstruction.

Causes

• Physiological Phimosis: Common in infants and young boys; typically resolves naturally as the foreskin gradually becomes retractable.
• Pathological Phimosis: May result from recurrent inflammation or infection (e.g., recurrent balanitis), traumatic injury, or scarring due to conditions such as lichen sclerosus.
• Congenital Anomalies: Some cases may arise from congenital factors that affect the normal development and elasticity of the foreskin.

Management

• Conservative Management:
  • Topical Steroids: Application of a high-potency topical steroid cream may help reduce inflammation and facilitate gradual foreskin retraction in cases of mild to moderate phimosis.
  • Gentle Stretching: Manual or device-assisted gentle stretching exercises can promote foreskin elasticity over time.
• Surgical Management:
  • Preputioplasty: A conservative surgical technique that involves making small incisions in the foreskin to relieve constriction while preserving most of the tissue.
  • Circumcision: Removal of the foreskin, which is indicated in severe or recurrent cases where conservative management has failed or when complications (e.g., recurrent infections or significant pain) are present.
• Post-Procedure Care:
  • Ensure proper hygiene and follow postoperative instructions to prevent infection and facilitate healing.
  • Follow-up assessments are important to monitor for complications and to evaluate the success of the chosen treatment approach.

Conclusion

Phimosis is a condition characterized by the inability to retract the foreskin, which may be physiological or pathological. A comprehensive evaluation—including detailed patient history, thorough physical examination, and targeted investigations—is essential for distinguishing between benign and pathological cases. Management strategies range from conservative methods, such as topical steroids and stretching exercises, to surgical options like preputioplasty or circumcision in more severe cases. Individualized care and proper follow-up are key to ensuring optimal outcomes and patient satisfaction.