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Phimosis

Phimosis is the difficulty or the inability to retract the foreskin (prepuce) effortlessly over the glans penis. Many patients come up with the concern of tightness of the foreskin on attempted retraction. Tearing of the foreskin during sexual activity or erection often results in pain (dyspareunia) which ultimately leads to total avoidance of sexual activity. In exceptional cases, extremely tight phimosis can interfere with urination and resulting in a thin or spraying urinary stream The phimotic foreskin may be partially retractable and appears to be normal in the resting position or it may appear as a white, thickened, inelastic, non-retractile foreskin with a pinhole opening.


A vast majority of male babies are born with physiological phimosis. Over time, a progressive distal preputial enlargement occurs in most boys and is associated with the spontaneous release of the balanopreputial adhesions which allows exposition of the glans. However, when there is a persistence of adherence leading to functional difficulties, then it can be considered congenital. At birth or during early childhood, the prepuce is commonly referred to as the foreskin, which is attached by the adhesions to the glans. These nonpathological adhesions are responsible for physiologic phimosis or for the decreased retraction of the foreskin.


Generally, patients with phimosis can be divided into five different groups according to the degree of foreskin retraction.


● Normal: Exposure of the entire glans after retraction
● Type 1: Exposure to above the crown of the glans with the presence of adhesions with the foreskin
● Type 2 (intermediate): Partial retraction, with exposure from the apex to the middle of the glans
● Type 3: Exposure only of the external urethral meatus
● Type 4: Total absence of preputial retraction


COMPLICATIONS OF PHIMOSIS


Complications related to phimosis can occur at any point of time in life, and its surgical indications depend on the type of lesion present in the foreskin. Examples of complications related to phimosis are Balanoposthitis, Difficulty in urination, Urinary retention, etc.


MANAGEMENT OF PHIMOSIS


Classically, circumcision is considered to be the clinical treatment choice for true phimosis.


If the treatment for non-retractile foreskin is deemed necessary, then there are three non-invasive or less invasive alternatives to circumcision, especially in young boys. These include,


1. Topical application of steroids with gentle stretching
2. Manual stretching to accomplish tissue expansion
3. Minimally-invasive preputioplasty


Topical steroids more likely to experience


There have been numerous trials in several nations on the use of topical steroids for the treatment of non-retractile foreskin. However, most of these clinical trials have been performed in very young boys, when prepuce is still undergoing the natural developmental process, and thus no treatment is needed. Nevertheless, the treatment with steroids thins the foreskin. Often, few complications have been reported.


Steroid creams treat the prepuce with phimosis by decreasing inflammation, thinning the skin, and improving its elasticity. This allows non-traumatic retraction. Some patients with recurrent phimosis may not perform daily retraction after completing and maintain poor hygiene, favouring relapse.


In selected patients, application of 0.05%, betamethasone ointment on the phimotic ring (a distal aspect of the prepuce) with gentle traction is advised. A thin layer of cream is to be applied twice daily for a minimum of 30 days, with correct penile hygiene. Weekly follow-up may be advised and therapy was considered successful when the prepuce was fully retractable with total glans exposure. The treatment will be considered as failure only when it is not possible to achieve glans exposure and no alteration in the degree of stenosis after 3 months, and when there is infection during the treatment as well. In such cases, circumcision would be suggested, and patients may be advised to continue retracting the foreskin to maintain penile hygiene. We observed patient satisfaction when the decision to pursue conservative treatment was made.


Manual stretching


Manual self-stretching is also an effective method for the treatment of a retractile foreskin by tissue expansion. This is proved to be suitable for adolescents and adults and is cost-free too. There are several techniques which include daily manual stretching using forceps, masturbation techniques that mimic the dynamics of coitus, balloon dilation with local anesthesia, and retraction of the foreskin under anesthesia.


Preputioplasty


Preputioplasty is a minor surgery to alter the shape of the prepuce without removing the foreskin. European surgeons have reported using several variations of this minimally invasive operation with great success for more than a decade.


The above article has personal opinions from my experiences with my patients

Disclaimer: Name of the patients are changed to maintain privacy. Results and Treatments May Vary For Person to Person

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