Phimosis

Overview

Phimosis is the name given to a medical condition that occurs in boys when the foreskin is too tight and cannot be pulled back from the tip of the penis.  This condition is common among male uncircumcised infants.

By appearance, phimosis looks like a tight ring of foreskin surrounding the tip of the penis. It may look like a rubber band which hinders complete retraction of the foreskin. This condition usually settles down by the time the boys turn three years old. In some males, it may take longer, such as till adolescence for the condition to settle naturally.

Boys can experience phimosis naturally, or it can occur due to scarring. If the symptoms of phimosis become unbearable, such as if it begins to affect urination, treatment is necessary. Sometimes, even though the condition is present in childhood, the problems may not show up till much later in the growing years.

Men can experience phimosis at any age.Nearly 96% of males have a non retractile foreskin at birth. This gradually becomes retractable by the time they reach their adolescence.

Phimosis can result in a medical condition called balanitis, which means inflammation of the penis. Phimosis can also cause inflammation of both glans and foreskin, resulting in a medical condition called balanoposthitis.

Causes of phimosis

The cause of phimosis is not very clearly known, especially the reason why some boys experience it, while others do not. 

This condition is a natural occurrence in some boys while in some others it can happen if the foreskin is pulled back using force, especially before it is ready for retraction. This can damage the foreskin, causing scarring. This can also impair the ability of the foreskin to pull back from the tip of the penis.

Some of the causes of phimosis are:

• Infection of the glans (head of the penis)
• Inflammation of the glans, medically termed as Balanitis
• Infection and swelling of the foreskin which causes scar tissue on the foreskin. This reduces the elasticity or stretchiness of the skin making it tough to pull back
• Hormone imbalance
• Unusual immune reaction causing an infection, medically termed as lichen sclerosus which can result in balanitis
• Poor hygiene leading to inflammation and infection of foreskin
• Aging can cause the foreskin to loosen. This can also happen if the erections are fewer
• Medical condition such as diabetes, increases the risk of balanitis

Types of phimosis

Phimosis generally occurs in males that are uncircumcised but in certain cases can occur if excess skin becomes too rigid. Phimosis can be of two types – pathologic and physiologic.

Physiologic phimosis:  In this type of phimosis, infants are born with a tight foreskin. Over time, the foreskin loosens on its own. This is quite normal for uncircumcised male babies and usually sets itself right by the time the child is about 5-7 years old.

Pathologic phimosis:  This is the type of phimosis which occurs due to infection, scarring or inflammation. If the foreskin is forcefully pulled back, it causes pain, bleeding and scarring They may experience a problem during urination. Some experience ballooning of the foreskin. Such boys need treatment and need to consult a urologist. Children may go through trauma even at the emotional level due to this condition.Forceful attempts at rectifying congenital phimosis and improper hygiene elevates the risk of pathological phimosis.

What is paraphimosis?

Paraphimosis can affect males that have not undergone circumcision. It occurs when the foreskin is unable to be pulled over the penis tip. The foreskin gets stuck and inflamed. This is a painful condition as it retards or obstructs the blood flow to the tip of the penis. Paraphimosis needs immediate treatment as it can lead to complications in the absence of medical intervention.

Paraphimosis is a condition due to improper handling of the foreskin. This occurs if males do not put back the foreskin after washing.

While having sex, some patients may pull back the foreskin but not position it back. In case, the foreskin stays in that position for long, it could lead to swelling which might cause it to get stuck behind the head.

Penis ailments can also cause problems with the foreskin. For instance, phimosis can result in paraphimosis.

Treatment for paraphimosis can be in the following ways:

• Specialist may apply a solution to reduce inflammation. Later the doctor manually loosens the foreskin
• Another form of treatment is to manually make several holes in the foreskin, to permit escape of fluids. This lowers the swelling
• A small slit may be made in the foreskin to help loosen it
• Circumcision which may be full or partial, involves cutting the foreskin to provide relief to paraphimosis

Symptoms of phimosis

Uncircumcised boys may not be able to retract the foreskin by the time they are three years old. This is the most significant symptom of phimosis. Generally, with time, the foreskin tends to loosen, but in some boys this may take longer. By the time the boys reach the age of seventeen, the foreskin is able to naturally retract.

The following are common symptoms of phimosis.

• Some boys experience swelling of the foreskin during urination.
• Some patients may also have cysts. These usually become alright with genital retraction performed manually
• Patients with pathologic phimosis present with symptoms that do not resolve by itself over a period of time. They may suffer complications such as painful urination, medically called dysuria, irritation in the penis, and bleeding
• Urinary tract infections
• Painful erections
• Retention of urine
• Repeated infection of the foreskin

Diagnosis

Doctors diagnose uncircumcised males after evaluating the symptoms they present during consultation.

Specialist opinion from a urologist or a paediatric urologist helps in making a confirmed diagnosis.

The specialist checks for problems such as ballooning of the foreskin during urination. Further, the specialist evaluates the patients for the presence of symptoms that have not resolved on its own over a period of time.

If patients suffer from bleeding while urinating, or dysuria, the specialist probes further to make a confirmed diagnosis. If patients present with recurrent urinary tract infections, or have a problem of urine retention, the specialist will begin the treatment for phimosis.

Treatment

Phimosis treatment is different for individuals depending upon the symptoms they present and the severity. Treatment for phimosis is as follows:

Regular or daily manual retraction without force

Patients will be taught to slowly retract the foreskin manually on a daily basis to reduce the symptoms. In time, the problem should in all likelihood, settle on its own.

Topical corticosteroid ointment application

Specialists advise the application of topical steroid ointment as a remedy for phimosis in children. These ointments help lubricate and soften the tight foreskin around the head or glans of the penis. This ointment helps to manually retract the penis.

This ointment treatment can go on twice daily for about 6 to 8 weeks alongside foreskin manual retraction exercise. During this period, the patient can experience full retraction of foreskin easily. The ointment is discontinued when patient finds relief.

Circumcision procedure

Circumcision means surgical removal of the foreskin. Usually, circumcision may not always be needed to treat phimosis. This surgery is performed only if the treatment with the steroid has not worked, or it is a case of pathologic phimosis, or paraphimosis. The procedure may involve partial or complete removal of the foreskin depending upon the severity of the condition.

Doctors perform circumcision using the following techniques. Laser circumcision is the most popular technique in use due to lesser risks, faster recovery and negligible risk of damage to the tissues surrounding this area.

• Open surgery or traditional circumcision
• Laser circumcision
• Stapler circumcision

During traditional circumcision surgery, the specialist uses a scissors to remove the foreskin. The incision is stitched using dissolving sutures.

Laser technique uses laser energy, which is more focussed on the specific area. The laser cuts the foreskin and the tissues around this area are intact without any injury.

Stapler circumcision makes use of a stapling instrument which cuts the foreskin. Stainless steel staples in the same instrument helps close the incision.

Post op care and things to keep in mind

• After surgery, patients especially new-borns experience uneasiness and discomfort. Those handling babies must ensure proper handling such that there is no pressure on the genital region
• The tip of the penis may give out a yellow discharge and feel sore
• It takes about seven to ten days for the redness to heal and the inflammation slowly lessens by this time
• Patients must dress the area regularly. For babies, it is good to change the dressing during diaper change. Petroleum jelly at the tip of the penis will protect the area from sticking to the bandage
• Wash the penis regularly
• Use soap and water to wash the area after complete healing

Cost of surgery to remedy phimosis  

The cost of surgical treatment for phimosis will vary depending upon the type of surgery and the hospital location.  

The major factors that go into the cost of treatment for phimosis in India is as follows:

• Circumcision technique
• Type of anaesthesia
• Specialist’s consultation charges with fee for both pre- and post-surgical sessions
• Cost of diagnostic tests
• Medicines cost

In India, an open circumcision surgery will be about INR 47,000.

The cost of stapler circumcision surgery in India can be anywhere between INR 30,000 – INR 45,000.

For a laser circumcision procedure in India, the expenditure will be in the range of INR 25,000 and INR 65,000.

Prevention

In most of the cases, prevention strategies can help offset the risk of penis disorders.

Boys must wash the foreskin and head of the penis regularly. It is important to keep this area dry. It is also important to handle the foreskin in a gentle manner to pull back the skin. The foreskin must be back in position after the daily hygiene ritual.

If the symptoms of phimosis are severe, then circumcision is a good option to prevent some of the symptoms.  

What are the risks of untreated phimosis?

Patients suffering from phimosis have an increased risk of penile cancer. In the absence of treatment, the risk of inflammation of the foreskin and infection is higher. In very serious cases, it can cause gangrene, which might result in amputation of the penis.

What is the best way to take care of an uncircumcised penis?

During infancy, there is no requirement of additional care. Do not use force to retract the foreskin. However, it is okay to gently pull back the foreskin.

Pull back the baby’s foreskin gently and clean below the skin. Perform this cleaning ritual during bathing or change of diaper. Gradually, when the child is older, and the foreskin is able to pull back fully, a hygiene schedule of retracting, cleansing and drying below the foreskin is necessary.

After cleaning, pull back the foreskin over the glans.

Best option

There are many hospitals and healthcare facilities that offer advanced treatment technique for phimosis which is effective, safe, minimally invasive with fewer risks and complications.

Patients prefer to gain easy access to all the healthcare facilities such as consultation before surgery, support with diagnostic tests, help with logistics during surgery, post-op care, everything under one roof.

goficure enables all these services as a complete solution package for patients that wish to undergo treatment for phimosis. The service also handles the transportation for the patients before and after surgery as well as puts a dedicated team to handle all the paper work related to medical insurance.

References