Phimosis and paraphimosis
Phimosis derives from an ancient Greek word meaning “muzzled” and refers to a condition in which the foreskin cannot be drawn back to expose the glans. Nearly all babies have phimosis, which is the normal and proper condition of the infant penis, and in many boys the condition persists until puberty or his mid-teens. The idea that phimosis in childhood was in itself harmful and an “indication” for circumcision was an error committed by Anglo-American doctors in the Victorian period, who suddenly decided that it was an abnormality (“congenital phimosis”) which had to be surgically corrected. Up until that time doctors and midwives were more worried about a foreskin that was not long and tight enough, so much so that the Greek authority Soranus, author of a manual of baby and child care that remained in use for over a thousand years, gave instructions on how to lengthen an inadequate foreskin.
“If the infant is male and it looks as though it has no foreskin, she [the nurse of midwife] should gently draw the tip of the foreskin forward or even hold it together with a strand of wool to fasten it. For if gradually stretched and continuously drawn forward it easily stretches and assumes its normal length, covers the glans and becomes accustomed to keep the natural good shape.”
Soranus's Gynecology, trans. and ed. Owsei Temkin (Johns Hopkins University Press, 1956), p. 107
Soranus was the author of a famous manual of gynecology that remained in use for many centuries. His advice is consistent with the view of Greek and Roman physicians that a short or inadequate foreskin (one which did not provide ample coverage of the glans) was a physiological defect known as lipodermos. Their concern was to offer advice on how short foreskins could be lengthened.
For further details, see Frederick Hodges, Phimosis in antiquity, and his other study The ideal prepuce.
It was not really until the early eighteenth century that phimosis emerged as a disease concept, probably in response to observations that syphilis often caused scabs that tended to narrow the foreskin and gum it to the glans. But there was never any suggestion that a phimotic foreskin in an infant or child was at all abnormal or pathological. That idea had to wait until nervousness about boys handling their penis ("masturbation") led doctors to blame the foreskin for drawing their attention to it and to propose that an uncovered glans was more morally hygienic.
Further information on the history of phimosis on this site
Medical error
One of the three main reasons for the introduction of routine circumcision in the nineteenth century was thus based on a gross medical error, sudden amnesia towards previous knowledge, and ignorance of the normal development of the male genitals. In a baby boy the lower end of the foreskin (including the tapering spout or nipple which extends beyond the glans) can represent more than half the total length and bulk of the penis. This proportion decreases as the boy grows up and the rest of the penis grows into the foreskin. In infancy the foreskin is very tight and is normally fused to the glans, thus guarding the urethra (the urine passage) against the entry of dirt and protecting the glans from irritation by urine or faeces and from abrasion. It was never meant to be pulled back at this early stage; in most cases (unless there is a serious problem) the first person to pull back his foreskin should be the boy himself. It is suspected that one of the most frequent causes of genuine phimosis is injury caused by premature retraction.
Many men never have a fully retractable foreskin are perfectly happy with it, but persistent phimosis can be a problem. If it is and treatment is needed, there are several options before radical surgery. The most common of these is treatment with steroid cream.
Doctors in Australia, Britain and Canada are concerned that too many boys between the ages of four and ten are being circumcised because of a premature or otherwise incorrect diagnosis of phimosis. They warn that some of these diagnoses may be fraudulent and no more than excuse to get a boy circumcised. It should be stressed that the standard treatment for phimosis these days is application of steroid ointment, and that old surgical remedies such as circumcision are out of date and unscientific.
Doctors warn against false diagnosis of phimosis
Recent studies of the effectiveness of steroid cream in treatment of phimosis
Ashfield JE, Nickel KR, Siemens DR, MacNeily AE, Nickel JC. Treatment of phimosis with topical steroids in 194 children. J Urol. 2003 Mar;169(3): 1106-8.
PURPOSE: Topical steroids have been advocated as an effective economical alternative to circumcision in boys with phimosis. We evaluated the effectiveness of topical steroid therapy as primary treatment in 194 patients with phimosis.
METHODS: Between January 1996 and November 2000, 228 boys 16 years old or younger were referred for consideration of circumcision. When intervention was determined to be necessary, a 6-week course of topical steroids was used as primary treatment. Efficacy of treatment was evaluated at 3 months from initiation of therapy.
RESULTS: Of the 228 patients 15 had such a mild degree of phimosis that no intervention was believed to be necessary, 19 were scheduled directly for circumcision due to cosmetic reasons, parent wishes, or severe phimosis with associated voiding problems and the remaining 194 received topical steroids as primary treatment. Of these 194 patients 25 had coexisting balanitis and 4 had a history of urinary tract infection. Conservative treatment was successful in 87%, 88% and 75% of patients with phimosis alone, coexisting balanitis and history of urinary tract infection, respectively. Overall, circumcision was avoided in 87% of patients treated with topical steroids.
CONCLUSION: Topical steroids are becoming the standard conservative measure for treating phimosis. Our study supports this trend, with an overall efficacy of 87%.
Ng WT, Fan N, Wong CK, Leung SL, Yuen KS, Sze YS, Cheng PW. Treatment of childhood phimosis with a moderately potent topical steroid. ANZ J Surg. 2001 Sep;71(9): 541-3.
BACKGROUND: Recently, topical steroid application has been shown by a small number of studies to be an effective alternative to circumcision for the treatment of phimosis. However, only potent or very potent corticosteroids have been more thoroughly studied in this treatment option. A prospective study was conducted to determine whether comparable results could be achieved using a weaker steroid cream.
METHODS: Boys, 3-13 years of age, with non-retractable foreskin due to a tight ring at the tip were offered the regimen of twice-daily preputial retraction and topical application of 0.02% triamcinolone acetonide cream. The degree of preputial retractability was assessed at presentation and at 4 and 6 weeks of treatment. Success was defined as full retraction or free retraction up to agglutination of the foreskin to the glans.
RESULTS: Eighty-three boys completed the treatment. Successful retraction was achieved in 48/83 (58%) patients after 4 weeks and 70/83 (84%) patients after 6 weeks of application. The overall response rate aggregated from six published series using 0.05% betamethasone was 87% at 4 weeks and 90% on completion of treatment. Thus, the results appear inferior when analysed at 4 weeks but compare favourably with those reported for a more potent steroid on completion of the full course of treatment.
CONCLUSIONS: Even though the triamcinolone cream used in the present study is less potent than the more commonly used 0.05% betamethasone valerate cream, it could effect comparable improvements in foreskin retractability after 6 weeks of treatment.
Berdeu D, Sauze L, Ha-Vinh P, Blum-Boisgard C. Cost-effectiveness analysis of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect. BJU Int. 2001 Feb;87(3):239-44.
OBJECTIVE: To compare the cost-effectiveness of surgery and topical steroids as treatments for phimosis (defined as a clinically verifiable, pathological, cicatricial stenosis of the prepuce) and to evaluate the financial basis of these treatments.
METHODS: Data on treatment using topical steroids was obtained from published reports and those for circumcision from claims by private hospitals for children <13 years old registered at the health insurance department of our facility. The estimate of the French national financial cost of the treatments for 1998 was calculated from public and private institutional information.
RESULTS: Treatment with topical steroids for 4-8 weeks was successful in approximately 85% of patients (mean age 5 years) and had no side-effects; the remaining 15% were treated by circumcision. Topical steroid therapy costs (in French francs) F 360 per patient. For those primarily treated by circumcision (81 boys, mean age 4.3 years) and diagnosed as having phimosis, the cost was F 3330 per patient in the private sector. The total number of circumcisions performed in France, regardless of sector (public or private) for 1998 was estimated to be 51 080, which represents an annual cost of F 195.7 million.
CONCLUSION: As topical pharmacological treatment avoids the disadvantages, trauma and potential complications of penile surgery, including anaesthesia-related risks, the use of topical steroids as a primary treatment appears to be justified in boys with clinically verifiable phimosis. This treatment could reduce costs by 75%, which represents a potential annual saving of approximately F 150 million.
Further studies of phimosis treatment on this site
Phimosis in adolescents and adults
Another non-surgical method of treating an uncomfortably tight foreskin that makes sexual activity difficult or uncomfortable in adolescents and young men (i.e. after puberty) is to adopt a method of masturbation that loosens the foreskin and helps it to slide easily over the glans. This procedure has been described by the French physician Dr Michel Beaugé, and has the great advantages of being free, enjoyable and suitable for those odd moments when a boy is by himself with nothing much to do. (Oh those naughty French! How they must scandalize prudish Americans, who would much prefer to force a boy to get it all cut off!)
Details of the Beauge method here.
Cases of phimosis in adult men can usually be resolved by application of steroid cream, as described in many articles about the success of such treatment in children.
Dutch sex therapists suggest that a tight foreskin in adult men may be more of a psychological phenomenon than a physical problem, arising from sexual inhibition and reluctance to handle his penis when young - a process that nearly always results in the loosening of the foreskin. In these cases they suggest that gentle stretching exercises and psychological counselling may fix the problem.
Abstract Patients use different words to express their sexual concerns. Some problems will be presented as dysfunctions, some as physical complaints, some as a disturbance in sexual feelings and emotions. Men, in general, tend to emphasize the dysfunctional and the physical aspects, rather than the emotions. A tight foreskin will be experienced as a purely physical condition by most patients. Yet quite often the medical sexologist will find a psychosomatic explanation. At birth, almost all boys will have a tight foreskin. During childhood and early puberty, sexual experiments and masturbation will be effective in stretching the prepuce to its adult size. If a man at the age of 20 still has a tight foreskin, it will often be a sign of sexual inhibition. Genital manipulation has been avoided, because this activity has been linked to guilt feelings or fear of doing damage to the genital organs. In adulthood the problems related to a tight foreskin in the absence of organic disease can be solved by the patient himself, by doing stretching exercises. Circumcision can be avoided, if the consulting physician only recognizes the psychosomatic nature of the problem.
Source Jelto J. Drentha & Jelto J. Drbnth M.D., The tight foreskin: A psychosomatic phenomenon, Sexual and Marital Therapy, Volume 6, Issue 3, 1991, 297-306.
Further information
Further information on treatment of phimosis from CIRP
Further information on phimosis from Circumstitions.
Further information from Norm-UK.
Phimosis information at Essential Kids
Phimosis information at the BubHub
There is also a website where adult men discuss their individual efforts to overcome phimosis without surgery: http://www.network54.com/Forum/244184/
Video with advice on home treatment of phimosis and paraphimosis from Norm-UK
Paraphimosis
Paraphimosis refers to a condition in which the foreskin has been retracted from the glans but becomes trapped there and cannot be brought forward to cover it again. In most cases the problem can be solved by gently compressing the glans by squeezing it and allowing the foreskin to fall forward, but in rare cases (where the condition has persisted for a long time and the foreskin has become swollen and threatens to strangle the penis), urgent medical attention is needed. In the meantime ice may help.
Paraphimosis in infants and young boys is often caused by attempts at premature retraction, and can easily be prevented by observing the golden rule of foreskin care: leave it alone; don't try to pull it back. Some pro-circumcision websites urge uncircumcised men to draw their foreskins back and wear them retracted, so as to get the feel of a bare glans, which is supposed to be pleasantly like being circumcised. Quite apart from the fact that such a condition is nothing like being circumcised (the foreskin, after all, is still there), the exercise is very risky and can induce a genuine paraphimosis (inability to return the foreskin to its normal, position) that may require surgery. The eighteenth century English physician William Buchan reported the case of a "foolish young man" who tried this trick to keep his glans cool, but whose foreskin became inflamed and suffered permanent damage. The foreskin is meant to cover the glans, and attempts to keep it back are likely to end in tears.
Further information
Useful information on handling cases of paraphimosis is given at Circumstitions
Information on treatment of paraphimosis from CIRP
Advice from Royal Children's Hospital, Melbourne
Phimosis (tight foreskin): Advice from British National Health Service
Balanitis Xerotica Obliterans
Balanitis xerotica obliterans (BXO) is a rare condition in which the foreskin becomes inflamed and hardened and covered with a dry whitish film. In adults the problem can result in progressive tightening of the foreskin, making retraction difficult and painful. The condition is poorly understood and the cause(s) unknown: it could be a viral, bacterial or fungal infection or (more probably) some sort of auto-immune response (where the body’s antibodies attacks its own tissue). The symptoms of BXO are similar to those of several other minor penis inflammations, so that its presence must be confirmed by appropriate specialist advice and finally established by laboratory analysis. Where BXO is confirmed, treatment options are limited: application of of steroid medications may help, but if they do not circumcision will be necessary. BXO is one of the very few conditions where therapeutic circumcision is warranted.
The most recent comprehensive survey of the medical literature reached the conclusion that, although rare, BXO may be increasing in frequency; that diagnosis is difficult and often mistaken; and that the principal treatment is circumcision, possibly assisted by appropriate anti-inflammatory medications. The abstract of the paper reads as follows:
OBJECTIVE Balanitis xerotica obliterans (BXO) is a chronic inflammatory disease that is considered as male genital variant lichen sclerosis. The incidence varies greatly in different series; diagnosis is mostly clinical but histopathological confirmation is mandatory. Various treatments are described, but there is no consensus that one is the best.
MATERIALS AND METHODS A literature review was made of BXO and lichen sclerosis in boys under 18 years of age, between 1995 and 2013, analyzing demographic dates, treatments and outcomes. In addition to that, we reviewed BXO cases treated in our centers in the last 10 years.
RESULTS After literature review, only 13 articles matched the inclusion criteria. Analyzing those selected, the global incidence of BXO is nearly 35% among circumcised children. Described symptoms are diverse and the low index of clinical suspicion is highlighted. The main treatment is circumcision, with use of topical and intralesional steroids and immunosuppressive agents.
CONCLUSION BXO is a condition more common than we believe and we must be vigilant to find greater number of diagnoses to avoid future complications. The main treatment for BXO is circumcision, but as topical or intralesional treatments are now available with potentially good outcomes, they may be considered as coadjuvants.
NOTE: The reference to 35% does not mean that 35% of children experience BXO, but that the condition was confirmed in 35% of the children referred with suspected BXO. The condition itself is quite rare.
Soledad Celis et al. Balanitis xerotica obliterans in children and adolescents: A literature review and clinical series. Journal of Pediatric Urology 10 (1) February 2014, 34-39. Full text available here.
Advice from paediatric surgeon
A paediatric surgeon has sent a letter to Circumcision Information Australia, explaining that while he is strongly opposed to routine, non-therapeutic circumcision of boys, BXO is one of the few pathological conditions where circumcision is usually necessary.
Throughout my training I have always been taught that BXO was the only absolute indication for circumcision. I am aware of some reports of steroid use and covered for a colleague in the UK once who used this as the first line of treatment. My experience was that this did not work, and that the disease usually progressed rapidly, making circumcision urgently necessary.
I did a quick Google search, and also a search of the Journal of Pediatric Urology, with BXO and steroid as the search strategy. The only article I found that helped much was a review of the literature and case series from UK (St George's, London) Ireland (Dublin) and Chile by Celis et al [referenced above]. The main findings were that the incidence of BXO is increasing. Also that circumcision is the main treatment, with steroids and other treatments having a supporting role.
Reading through the paper a couple of things caught my eye:
1. The correlation between clinical suspicion and histological diagnosis is not great — meaning that some clinically suspicious BXO turns out to be other scaring / inflammation.
2. Steroids, if they do work at all, only work with early inflammation affecting the prepuce and no scaring. I get the impression these patients had not had their diagnosis confirmed histologically
3. In a few patients who had trial of “tissue sparing surgery” (preputioplasty presumably) in a cohort from Chile there was a 100% relapse rate, needing to progress to circumcision.
4. Reinforcement of complications of inadequately treated BXO leading to progressive disease and significant morbidity needing complex surgical fixes as a result.
My summation is therefore that there may be cases of early clinically suspicious BXO which may respond to steroids, but that this probably is not BXO anyway. For those patients with established scaring the only treatment that is reliably effective is a circumcision and that failure to do this exposes the patient to considerable risk of really significant complications of progressive scaring. The role of steroids, therefore, is as a way of excluding non-BXO in patients with inflammation that has not developed established scaring, to temporise and limit disease progression until a definitive circumcision is carried out by an appropriately trained surgeon under a general anaesthetic with adequate analgesia / penile block etc. I would also use post-operative steroids to further reduce the risk of meatal scarring when the inflammation has already spread onto the glans (which I have also seen), despite adequate circumcision.
It would seem that whilst histologically it shares features of lichen sclerosis, the clinical behaviour of BXO is different to the disease seen in females. Sadly, at present, I do not think the strategy of primary treatment of established BXO with topical or intra-lesional drugs can be recommended. In the present state of medical knowledge the only sure cure for BXO is circumcision — though we may hope that medical treatments will eventually be developed.
The surgeon adds that he is concerned by the number of Queensland boys who have been subjected to unnecessary Plastibel circumcision in infancy.
I find it distressing how many boys are still subjected to the Plastibel circumcision. I see so many incidentally in my clinic (when looking at hernia, undescended testes etc) who have obviously had the Plastibel, with their shaft skin reaching only half way up the penis; and on occasions we get children referred with other complications — including buried penis, meatal stenosis and adherent preputial remnants.
In Scotland the National Health Service policy was to provide cultural circumcisions (almost entirely for the Muslim population), performed by paediatric surgeons in hospital under general anaesthetic, on the basis that the state had to respect religious/cultural beliefs and that we had a duty of care to minimise the trauma and suffering experienced by the children who were going to get the operation anyway. I do not agree however with “prophylactic” or essentially cosmetic circumcisions, and I am signed up to the international opinion of paediatric surgeons that there is no place for “routine” neonatal circumcisions in the developed world [Referenced in circinfo.org website]. On the few patients that do have persisting symptoms associated with phimosis I will discuss the alternative of a preputioplasty [a surgical operation on the foreskin that loosens it with minimal loss of tissue].
