Phimosis is a condition where the foreskin cannot be fully retracted over the glans penis.
- Common in newborns and usually resolves by age 3-5 years
- Types: Physiological and Pathological
| Characteristic | Physiological Phimosis | Pathological Phimosis |
|---|---|---|
| Definition | Normal condition in newborns. Phimosis in newborn is rule. | Abnormal condition caused by scarring, infection, inflammation, or other medical factors. |
| Onset | Present at birth and usually resolves naturally as the child grows. | Develops later in life due to poor hygiene and recurrent balanitis (infection of glans penis), posthitis (inflammation of foreskin). Diabetes mellitus and Balanitisxerosisobliterans (BXO) are also causative factor. |
| Age of Resolution | Typically resolves by the age of 5-7 years or later in some cases. | Requires medical treatment and may not resolve on its own. |
| Causes | Natural development; no underlying medical causes. | Scarring, infections, inflammation, poor hygiene, injuries, skin conditions, or other medical factors. |
| Treatment | Usually no treatment required; resolves naturally. | Medical intervention is necessary, often involving topical creams, stretching exercises, or surgical procedures. |
| Retraction Test | Distal portion of foreskin is healthy and pouts with gentle traction. The narrowed part is proximal to the preputial tip. With physiologic phimosis, the preputial outlet is always closed and one cannot see the glans unless the foreskin is retracted. | Gentle traction leads to formation of a cone-shaped structure with the distal narrow part being white and fibrotic. The meatal opening is also pin-point. The glans and meatus are visible without any attempt at retraction, as the scarred ring holds the preputial outlet open. There is no inner mucosal eversion through the outlet |
History and examination
- Circumcision status, history of UTIs, balanitis, or penile trauma
| Symptoms | Signs |
| Pain during urination Difficulty urinating Ballooning during urination Recurrent balanitis Painful erections | Inability to retract foreskin Foreskin tightness Adhesions Scarring |
In physiological phimosis, only non-retractability of the foreskin seen, may be some ballooning during urination. But there is no pain, dysuria, and local or urinary infections.
In pathologic phimosis, there is usually pain, skin irritation, local infections, bleeding, dysuria, hematuria, frequent episodes of urinary tract infections, preputial pain, painful erection sand intercourse, and weak urinary stream. Occasionally, enuresis or urinary retention is noticed. The meatal opening is small and the tissue in front of the foreskin is white and fibrotic
Differential diagnosis (D/D) & Complication
| D/D | Complications |
| Balanitis (inflammation of glans and foreskin, erythema, discharge) Balanoposthitis (inflammation of both glans and foreskin) | Paraphimosis, urinary retention, recurrent UTIs, balanitis, sexual dysfunction |
Investigation
- Clinical evaluation is usually sufficient for diagnosis
- Urinalysis and culture (if UTI or balanitis is suspected)
Admission criteria
Admission is rarely required, except in cases of paraphimosis or severe infection
Management
Determine whether the problem is physiologic or pathologic. Management is determined by the child’s age, the type of nonretraction, the severity of the phimosis, the cause, and any associated morbid conditions.
Reassurance and Vigilance
- Reassure parents if phimosis is physiological
- Keep foreskin and its undersurface clean and hygienic
- Normal washing with lukewarm water and gentle retractions during bathing and urination
- Avoid strong soaps as it could lead to chemical irritant dermatitis and further phimosis
Topical Steroid
- Act via its local anti-inflammatory and immunosuppressive action
- Steroids also cause skin thinning
- Cream Betamethasone 0.05% LA BD x 4 Weeks Or Cream Hydrocortisone 1%
- Side effects: Perputial pain and Hyperemia
- Minimal systemic absorption
Use Topical Antibiotic or Antifungal if there is concomitant balanitis or balanoposthitis.
Treat Urinary tract infection
Rx:
- Cream Betamethasone 0.05% LA BD x 4 Weeks or Cream Hydrocortisone 1% LA BD X 4 Weeks
- Cream Fusidic Acid LA BD x 7 days ( If infection present)
- Syp/Tab Cefixime PO BD x 7 days (For UTI)
Dilation and Stretching
Instruct partent to retract and stretch the foreskin alternatively for 1-2 minutes after applying topical steroid.
Surgery
Circumcision (if conservative management fails or recurrent balanitis)
Preputioplasty (alternative to circumcision in selected cases)
Advices
- Teach proper hygiene and gentle retraction of the foreskin
- Avoid forceful retraction of the foreskin as it may lead to microtrauma, bleeding and infection
Referral
- Refer to a pediatric urologist if conservative management fails or if surgical intervention is required
Follow up
- Reassess in 4 weeks after completion of topical steroid therapy
- Regular follow-up with pediatrician if recurrent balanitis or UTIs occurs
References
- Morris, B. J., & Krieger, J. N. (2017). Management of phimosis: review of the literature and current recommendations. Sexual Medicine Reviews, 5(4), 529-534.
- Pippi Salle, J. L., Jesus, L. E., Lorenzo, A. J., Romao, R., Figueroa, V. H., Bägli, D. J., & Farhat, W. A. (2016). Glans amputation during routine neonatal circumcision: Mechanism of injury and strategy for prevention. The Journal of Pediatrics, 179, 192-198.