Makindo Medical Notes

Related Subjects: |Hypospadias |Phimosis

Phimosis is not usually a urological emergency.

About

• Phimosis is the inability to retract the foreskin behind the corona of the glans penis.
• If severe, it can obstruct urine flow and lead to localised balanitis.
• Surgery may be necessary for persistent balanitis or balanoposthitis causing painful tightness of the foreskin.

Development

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

Aetiology

• Commonly seen in children and may resolve with age.
• Pathological phimosis is more common in adults due to recurrent balanitis, STDs, or skin diseases like lichen sclerosus, eczema, or carcinoma in situ.

Clinical Presentation

• Symptoms may include:
  • Poor urinary stream, ballooning during urination, pain during intercourse in adults.
  • Infection predisposition under the foreskin causing itching, redness, and discomfort.
  • Phimosis may cause the foreskin to balloon with micturition if the meatus is narrowed.

Management

• In children under two with non-retractile foreskin or ballooning during micturition, routine circumcision is generally not required.
• Avoid forcible retraction of congenital phimosis to prevent scarring.
• Emphasize personal hygiene, including gentle cleaning under a retractable foreskin.
• Topical steroids (e.g., Betamethasone 0.025-0.1%) may be prescribed for up to three months.
• Circumcision may be indicated in severe cases or if the foreskin obstructs urinary flow.

Indications for Circumcision

• Pathological phimosis due to lichen sclerosis or balanitis xerotica obliterans (BXO).
• Recurrent balanitis or UTIs, especially in those with an abnormal urinary tract.

Additional Guidance

• Parents and patients should be informed of the risks and benefits of circumcision.
• Cultural circumcision is typically not NHS funded.
• For pain and lack of sensation during intercourse, using condoms and lubricants may help.
• In rare cases with retention or difficulty finding the meatus, use of plenty of instillagel or seeking urology advice is recommended.