International Scholarly Research Network

ISRN Urology
Volume 2012, Article ID 707329, 6 pages
doi:10.5402/2012/707329

Review Article
Phimosis in Children

Sukhbir Kaur Shahid

Consultant Pediatrician and Neonatologist, Shahid Medical Centre, Mumbai-400 077,

India Correspondence should be addressed to Sukhbir Kaur Shahid, s kaur

shahid@yahoo.com Received 22 November 2011; Accepted 19 December 2011

Academic Editors: T. Okamura and V.

Tzortzis

Copyright © 2012 Sukhbir Kaur Shahid. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Phimosis is nonretraction of prepuce. It is normally seen in younger children due to adhesions between prepuce and glans
penis. It is termed pathologic when nonretractability is associated with local or urinary complaints attributed to the phimotic
prepuce. Physicians still have the trouble to distinguish between these two types of phimosis. This ignorance leads to undue
parental anxiety and wrong referrals to urologists. Circumcision was the mainstay of treatment for pathologic phimosis. With
advent of newer
effective and safe medical and conservative surgical techniques, circumcision is gradually getting outmoded. Parents and doctors
should a be made aware of the noninvasive options for pathologic phimosis for better outcomes with minimal or no side-effects.
Also differentiating features between physiologic and pathologic phimosis should be part of medical curriculum to minimise
erroneous referrals for
surgery.

1. Introduction Penile formation starts from 7th week of gestation and is

complete by 17th week [8]. The integument of the penis
“Phimosis” is inability to withdraw the narrowed penile in front folds on itself to form the prepuce or foreskin.
fore- skin or prepuce behindthe glans penis [1]. It is a not It covers glans penis and urinary meatus. It serves many
so un-
common complaint for which a child is brought to
office
of paediatrician. Parents are often overtly anxious and
over-
concerned about this nonretractability in their infant or
toddler. Most of these cases end up in surgical
interventions in form of circumcision. Analyses of medical
records carried out in England and Western Australia
revealed that medically indicated circumcisions were
seven times more than the expected incidence of
phimosis in children less than 15 years of age [2, 3];
implying thereby that there is a high rate of unnecessary
circumcisions [4]. The operation of circumci-
sion is not devoid of adverse effects and also has a huge
economic impact [1, 5–7]. In order to avoid such
unindicated
expensive operations, it is important to elaborately redefine
phimosis and know about newer noninvasive cheaper and
safer treatment options.

2. Penile Development and Anatomy

functions; the main being protective, immunologic, and
erogenous. The inner mucous membrane of this 15 square
inches double-layered fold merges with glans [9]. It is
bound to under-surface of glans by means of a highly
sensitive tis- sue called frenulum or “little bridle”. Prepuce
is richly vascu- larised and innervated. Fine touch receptors
abound on pre- puce. Conventional circumcision
removes most of these sensitive areas [10]. Unlike the
prepuce, glans has only pres- sure receptors and no fine
touch receptors. Glands present on prepuce and glans
produce secretions, which aid in lubri- cation and defence
against infection. Lysozyme in these se- cretions acts
against harmful microorganisms. Cathepsin B,
chymotrypsin, neutrophil elastase, cytokine, and pherom-
ones such as androsterone are also produced. Langerhans
cells are present in prepuce and they seem to provide re-
sistance against HIV infection [9, 11, 12]. At birth and first
few years of life, inner part of foreskin is adhered to
glans and hence is nonretractile. This separates gradually
over time leading to increased retractability.

3. Defining Phimosis
Around 96% of males at birth are noticed to have a non-
retractile foreskin. This is due to naturally occurring adhe-
sions between prepuce and glans and due to narrow skin
of prepuce and “frenulum breve.” This is
physiological
2 ISRN
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ISRN
phimosis. The foreskin premalignant state painful erection 3
sand
Urology t
gradually becomes [28]. Repeated intercourse, and weak
i catherization could
retractable over a variable urinary stream.
period of time ranging o also lead to phimosis. Occasionally, enuresis or
from birth to 18 years of l urinary retention is
age or more. This is aided o 5 noticed. The meatal
by erections and g opening is small and the
.
keratinisation of the inner tissue in front of the
y
epithelium [13]. Thus foreskin is white and
preputial retractability C fibrotic [29–31]. Phimosis
improves with increasing o l due to BXO is severe with
age. But 2% of normal f i meatal stenosis, glanular
males continue to have lesions, or both [28].
non-retractability
n Phimosis in boys and
P i
throughout life even adults can vary in
though they are otherwise h c severity. Meuli
normal [14–18]. In i a et al. have graded
physiologic phimosis, the m l severity of phimosis into
distal portion of foreskin o following 4 grades [32],
is healthy and pouts with namely, Grade I— fully
gentle traction. The
s F retractable prepuce with
narrowed part is i e stenotic ring in the shaft,
proximal to the preputial s a Grade II—partial
tip. This differs from t retractability with partial
Physiologic phimosis is the exposure of the glans,
pathological phimosis u
rule in newborn males. Grade III—partial
wherein gentle
traction leads to formation
The pre- puce is adhered to r retractability with exposure
glans and this separates e of the meatus only, and
of a cone-shaped structure
with over time. Enthu- siastic Grade IV—no retract-
attempts to retract
s
the distal narrow part ability. There is another
foreskin in physiological The incidence
being white and fibrotic.
phimo- siscauses pathological phimosis of is classification of phimosis
The meatal opening is also 0.4 per 1000 boys per year severity invented by
microtears, infection, and or 0.6% of boys are
pin-point [4]. It is affected by their 15th Kikiros et al., which is as
bleeding with secondary birthday.
important to distinguish follows: Grade 0 is full
scarring and true This is much lesser than
between these two types of retractability, Grade 1 is
phimosis. Poor hygiene physiological phimosis,
phimosis because their full retraction but tight
and recurrent balanitis which is common in
treatment varies widely. behind glans, Grade 2 is
(infection of glans penis), younger children and
Whereas physiological partial exposure of glans,
posthitis (inflammation decreases with age [3].
phimosis only needs a Grade 3 is par- tial
of foreskin), or both Physiologic phimosis
conservative approach, retraction with meatus
could lead to difficulty in involves only non-
surgical management just visible, Grade 4 is
retraction retractability of the
seems justified in slight retraction but neither
of foreskin and consequent foreskin. There may be
pathological phimosis. meatus nor glans visible,
true phimosis. Diabetes some ballooning during
But medical doctors and Grade 5 is absolutely
mellitus urination. But pain,
are not trained enough to no retraction [15, 33, 34].
predisposes to these dysuria, and local or
distin- guish between these Based on state of the
infections due to high urinary infections are not
two types of phimosis [3, foreskin, phimosis is
glucose content of urine, seen in these cases. Even if
19–22]. Their misdiagnosis categorised in order of
which is conducive for urinary infection is
leads to unnecessary increasing severity as
bacterial proliferation [25– present, it is usually not
anxiety in parents and normal, “cracking,”
27]. Pathologic phimosis attributed to the phimosis.
over-referrals to urologists scarred, and balanitis
may also be due to On gentle traction, the
for circumcision. Of the xerotica obliterans [33, 34].
balanitisxerosisoblit- erans prepuce puckers and the
cases referred to a urology
(BXO), a genital form of overlying tissue are pink
clinic, it was found that
and healthy. In pathologic 6
only 8–14.4% of them had lichen sclerosus et
atrophicus. phimosis, there is usually .
“true” phimosis needing
surgical intervention [23, This condition affects pain, skin irritation, local
both men and boys. Its infections, bleeding, D
24].
etiology is dysuria, hematuria, i
unknown; infectious, frequent episodes of
4 urinary tract infections, a
inflammatory, and
. hormonal causes preputial pain, g
have been implicated. It n
E may represent a o
s4 gil topical ISRN
Urology
i an
s ce
Diagnosis of phimosis is When it is certain that
primarily clinical and no phimosis in the child is not
laboratory tests or pathologic, it is vital to
imaging studies are reassure the parents on
required [35]. These may normalcy of the condition
be required for associated in that age group. They
urinary tract infections or should be taught how to
skin infec- tions. Treating keep the foreskin and its
physician should be able to undersurface clean and
distinguish devel- hygienic. Normal washing
opmental non- with lukewarm water and
retractability from gentle retractions during
pathological phimosis. bathing and urination
Grading of severity of makes the foreskin
phimosis should be done. retractile over time [36].
Determi- nation of etiology Mild soap can be used, but
of phimosis, if possible, avoid strong soaps as it
should be tried. could lead to chemical
irritant dermatitis and
7 further phimosis.
Reassurance and
. reinforcement of proper
preputial hygiene may
M need to be repeated at
a periodic intervals.
n
a 9
g .
e
T
m
o
e
p
n
i
t
c
When a child is brought a
with history of inability to l
retract the foreskin, it is
important to confirm
whether it is physiologic or S
pathologic. Management t
depends on age of child, e
type of nonretraction, r
severity of phimosis, cause,
and associated morbid o
conditions. i
d
8. s
Re Topical steroids have been
ass tried in cases of phimosis
ura since more than 2
nc decades. Overall, studies
using topical creams
e for phimosis have yielded
an dramatic results. Efficacy
d figures
Vi range from 65 to 95% [1].
Mechanism of action of
ISRN 5
Urology
6steroid therapy in
phimosis is not exactly
known. It is believed to
act via its local anti-
inflammatory and
immuno- suppressive
action. Mere moisturising
is not the mode of action
as prior use of
moisturizing agents has
failed to yield positive
results. Golubovic et al.
compared topical steroids
with vaseline and found
that 19/20 males
benefited with steroids,
whereas only 4/20 in
vaseline group improved
[37]. Steroids probably
act by stimulating
production of lipocortin.
This in turn inhibits
activity of phospholipase
A2 and hence arachidonic
acid production is
decreased. Steroids also
decrease mRNA and
hence interleukin-1
formation is diminished.
This causes anti-
inflammation and
immuno- suppression
[38]. Steroids also cause
skin thinning. Dermal
synthesis of
glycosaminoglycans
(especially hyaluronic acid)
by fibroblasts is reduced.
Epidermal proliferation
and stra- tum corneum
thickness is also decreased
[39]. Betametha- sone
0.05% applied twice a day
over a 4-week period has
consistently shown good
results [13, 34, 37, 40–45].
Success rate was higher
in older boys with no
infection [40, 43]. Poor
compliance was noted to
be cause of failures [44].
Studies carried out in
younger children have also
yielded good results [45].
0.1% betamethasone
cream usage also
generated comparable
results [46]. Dewan et al.
found an ef- ficacy of 65%
with 1% hydrocortisone
cream [47]. Other
steroids tried and found to
be effective in phimosis
include BXO respond poorly to If a ISRN patient has
topical steroids. This may Urology
clobetasol proprionate concomitant balanitis or
0.05%, 0.1% serve as a screening tool in balanoposthitis, depending
triamcinolone, and such cases [57]. on the etiology, he may
mometasone dipropionate In order to alleviate the be treated with topical
[42, 48–53]. The age of concern over side- antibiotics or antifungals
the patient, type and [60]. Proper serum glucose
effects of top-
severity of phimosis, control is vital in diabetic
ical steroids, nonsteroid
proper application of the anti-inflammatory patients [61].
ointment, compliance with ointment, diclo-
treatment, and the fenac sodium thrice daily
necessity of pulling back was evaluated and found 1
on the foreskin on a to be 0
regular basis contribute to 75% efficacious as .
compared to petroleum
either success or failure of jelly, which was effective in
none of the cases used [58].
D
the medication [42, 44].
0.1% estrogen cream has il
Adverse also been tested and found
effects with topical steroids to be effective in 90% of a
were rare and mild and the
include preputial pain and
hyperemia. No significant c ti
side-effects a o
were reported even in s n
young patients [45]. e
Topical steroids s
a
are cheaper than n
circumcision by 27.4% [7, [ d
54, 55]. They are also less 5 S
harrowing and devoid of 9
]
t
psychological trauma
which is commonplace . r
with circumcision [56]. e
Studies have shown that t
retractability declines c
several months after h
completion of therapy
[33, 40]. However, a i
second course of topical n
steroids proves useful in g
such cases. Of concern to
parents and providers In this, gentle preputial
alike is the degree of risk retractions are carried out
of sys- temic absorption by a doctor on an
of steroid and outpatient basis. This
suppression of hypotha- nonsurgical adhesiolysis is
lamic-pituitary-adrenal found
(HPA) axis. But this risk to be effective, cheap, and
is minor considering the safe treatment for
fact that the amount of phimosis [23,
steroid cream used and 62–64]. Eutectic mixture of
surface area of application local anaesthetics (EMLA)
is small. Besides, steroids could
are used only for 4–6 be used prior to attempts at
weeks. Golubovic et al. release of the preputial
found that morning adhesions [65]. He and
cortisol levels were not zhou used a specially
significantly elevated in designed patented balloon
patients who received catheter with local
betamethasone ointment anaesthesia in 512 boys
versus controls [37]. and found it to be 100%
Topical steroids could be useful. The technique was
used as a first-line simple, safe, cheap, less
treatment for pathologic painful, and less
phimosis and is a viable traumatising then the
option prior to surgery. conventional circumcision.
However, patients with It was found to be more
 ISRN
beneficial in younger Hence they are not 7
Urologywith no fibrosis
children favoured much.
or infection [66].
Combination therapy using 11.2. Conventional Male
stretching and topical Circumcision. In this case,
steroids has also yielded the phi- motic foreskin is
excellent results [67, 68]. totally excised.
Circumcision is one of the
1 oldest elective operations
1 known in humans. It
started as a religious/ritual
. sacrifice [90]. But
gradually it became a rou-
S tine neonatal procedure in
u USA and in some
r countries of Euro pein
view of its reported hygiene
g and cancer-preventing
i benefits [91]. It cures
c phimosis and prevents
a recurrence [92]. It also
prevents further episodes
l of balanoposthitis and
These invasive measures lowers incidence of urinary
are to be reserved for tract infections [26, 93–
recalcitrant phimosis that 95]. But it is besot with its
fails to respond to medical own innumerable short,
management. and long-term
problems. Pain, difficult
11.1. Conservative Surgical recovery, bleeding,
Alternatives. It is a infection, psy-
conservative alternative to chological trauma, and
traditional circumcision high cost are seen with
circumcision
which is fraud with many
[96, 97]. The literature
complications, problems,
is full of reports of
and risk [7, 69–88]. Prepu-
morbidity and even deaths
tioplasty is the medical
with circumcision.
term for plastic surgery of
Besides, circumcision
the phi- motic prepuce.
could lead to keloid
This procedure has faster
formation. Possibility of
less painful recov- ery, less
decline in sex- ual
morbidity, less cost, and
pleasure for both
more preservation of fore-
circumcised males as well
skin and its various
as their
projectile, erogenous, and
sexual phys- iologic
functions [7, 86]. The
disadvantage is that
phimosis can recur [89].
Dorsal slit with transverse
closure is recom- mended
by many doctors due to
its simplicity and good
results [80]. The lateral
procedure described by
Lane and South provides
cosmesis [85]. Frenulotomy
and meatoplasty is also
beneficial. Some of the
procedures such as Y- and
V- plasties (The Ebbehoj
procedure) are complex
and require skilled hands.
8 ISRN
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ISRN
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