Phimosis

Background & Causes

The foreskin (also known as the prepuce) is a normal part of the penis that covers the glans (the head). The outer prepuce is keratinized (like the external skin) whereas the inner prepuce is a mucosal surface (like the inside of the mouth). The foreskin contains nerves and glandular tissues.

Phimosis may be classified as physiologic or pathologic. These 2 conditions are largely differentiated by the presence of scarring and/or inflammation in pathologic phimosis.

Physiologic phimosis is a normal physiologic finding in children. The foreskin is normally adherent to the head of of the penis and gradually releases from the penis head over childhood. This is termed 'Physiologic Phimosis'. It should be noted that the timing of separation of the foreskin from the glans and complete retractibility is highly variable. The ability to completely separate the foreskin from the glans or completely retract the skin is not a disease in pre-pubescent males and should not be classified as phimosis.
Some doctors use the term 'physiologic phimosis' to distinguish this normal condition from 'pathologic phimosis'. Many children will not able to fully retract the skin until the teenage years.
Ballooning of the foreskin and splaying of the urinary stream do not usually indicate phimosis and may occur in perfectly normal males.
Physiologic phimosis does not cause scarring or infection.
Pathologic phimosis is a condition affecting uncircumcised males in which scarring of the foreskin produces a narrowing. The scarring may severe enough to block complete retraction of the skin over the head of the penis.
This is different than paraphimosis - this is when the skin is pulled back over the head of the penis to expose the glans but cannot be replaced back over the penis.
True phimosis is found in about 1 in 100 males at age 15, but most cases are 'physiological'. Post-pubescent males should be able to fully retract the foreskin for reasons of hygeine.
True phimosis is often due to an inflammatory condition called lichen sclerosis (LS) of the foreskin, also known as Balanitis Xerotica Obliterans (BXO). Characteristics of LS/BXO include the following:
- May occur in any age group but most common in middle-aged men. Thought to be uncommon occurring in about 1 in 200 to 1 in 1000 males.
- The cause is not known but related to chronic inflammation. Possible contributing factors include: accumulation of secretions under the foreskin, pooling of urine, the HPV virus (responsible for genital warts), autoimmune conditions (including type 1 diabetes, lupus and rheumatoid diseases). Hygiene is important.
- LS/BXO causes scarring of the foreskin which may fuse the head of the penis, extend onto the head and down the urethra causing significant complications including urinary retention.
- Repeated trauma (e.g. excessive force in trying to retract the foreskin leading to fissuring, bleeding and scarring) may promote a vicious cycle which worsens the condition.
- LS/BXO is considered a pre-malignant condition, that is, a strong risk factor for the development of penile cancer.
Comments on LS/BXO and Penile Cancer
As many as 1 in 20 men with this condition may have transformation to penile cancer (references are below).
Establishing the true nature of that relationship has been challenging, especially since it may be decades between the development of LS/BXO and penile cancer and the true incidence of LS/BXO is unknown. The studies on this subject should be interpreted with the knowledge that they have been reported in selected groups of patients (those referred to urologists who are likely to have the most severe forms of LS/BXO) and because LS/BXO is likely more common than is appreciated. This would have the effect of overestimating risk. Having said that, penile cancer is a serious life-changing disease. The remedy of circumcision combined with self-examination is likely to be much more attractive then the alternatives.
It is unclear if LS/BXO causes penile cancer directly. Between 1 in 3 and 1 in 2 men with penile cancer have a history of LS/BXO. Penile cancer is rare occurring annually in approximately 1 in 100,000 to 1 in 1,000,000 men.
Men with a history of LS/BXO should seek medical attention if they notice any change in the appearance of their foreskin, especially ulceration or nodular change (i.e. warty appearance).
References general: doi: 10.1111/ijd.14236, doi:10.1111/j.1464-410X.2012.11773.x, doi:10.1111/j.1464-410X.2006.06213.x, doi.org/10.1111/j.1464-410x.2011.10699.x
References penile cancer: DOI: 10.1016/s0190-9622(99)70245-8, DOI: 10.1046/j.1464-410x.2000.00772.x

Diagnosis & Evaluation

History and physical examination typically provide a diagnosis. As mentioned previously, ballooning of the foreskin and splaying of the urinary stream are not reliable symptoms of pathologic phimosis.

Significant aspects of symptomatic phimosis include recurrent urinary tract infections, infections of the foreskin or penis or trips to the emergency room as the child is unable to pee.

In adults, symptoms include restriction in erections, difficulty with hygiene, recurrent infections or any redness, urinary symptoms, recurrent fissuring or pain.

Management Options

Physiologic phimosis can often be addressed with proper hygiene and may sometimes benefit from topical cream. Circumcision is usually reserved for recalcitrant cases. Pathologic phimosis, especially if there is lichen sclerosis (balanitis xerotica obliterans) is best treated with circumcision but a trial of topical therapy may be attempted first.

Intervention may be undertaken if there are issues with any of the following:

Hygiene issues.
Recurrent inflammation or infection of the foreskin (balanoposthitis).
Recurrent urinary tract infection.
Difficulty with urination.
Lichen sclerosis.

In deciding on the most appropriate treatment, the severity of the complications, the tightness of the foreskin and the presence of scarring (such as lichen sclerosus) are considered. If significant scarring and fissuring is present, a circumcision is likely to be required. Patients with lichen sclerosus must bear in mind the increased risk of developing penile cancer.

It is not unusual for boys to have an unretractable foreskin until puberty. So long as they are not having issues with the foreskin, they can safely be observed. Some parents have difficulty leaving the non-diseased but not yet retractable foreskin alone - especially if the father or other males in the family have been circumcised.
No attempt should be made to forcibly retract the foreskin or clean the area excessively with soap. Forcible retraction may produce fissuring and scarring, in which case surgery may be required.
The foreskin should be gently pulled back until there is some tension. This should be done with urination and with bathing.
Topical creams and ointments soften the skin and makes it more elastic so that he can be retracted.
80% of children will respond to topical betamethasone when it is applied correctly 3 times per day for 2-3 months.
Topical treatments should be applied sparingly to the affected area and this is best done when the foreskin is retracted and the tight area easily identified.
Diligent application is necessary to have any chance of success: 2-3 times per day for 2-3 months. Reassessment is usually undertaken to ensure the desired result has been achieved.
Topical options:
- Betamethasone 0.1% ointment (Betnovate, Celestone; 15 and 45 gram tube). Topical steroid. Usually applied to the foreskin 2-3 times per day. It may take a few months of application before a response is seen.
- Clobetasol 0.05% ointment (Dermovate; 15, 30, 45 and 60 g tubes). Topical steroid. Similar to betamethosone. Apply one fingertip unit of the medication daily for 1-3 months.
- Viaderm-K.C. ointment. Combination cream: triamcinolone, neomycin, gramicidin and nystatin. Used to address concurrent infection - covers bacteria and fungus.
- Tacrolimus (Protopic) 0.03% (or 1% for severe cases) twice daily x 3-4 months (30 g supply). Can transition to maintenance a few times a week. Use sparingly.
Application:
- Retract the foreskin until it is tight and shiny. The cream is then applied to the foreskin. The foreskin should he held in the retracted position for 20 seconds to allow the head of the penis to gradually dilate the foreskin.
- THE SKIN SHOULD ALWAYS BE RETURNED TO THE RELAXED POSITION (NORMAL ANATOMIC POSITION) after the gentle retraction. Failure of return of the skin to the anatomic position can result in the skin becoming stuck behind the head of the penis (paraphimosis) which is an emergency.
Indicated when LS/BXO is present or the condition fails to respond to topical therapy.
Read information on the circumcision here.