Pathologic and physiologic phimosis

Case description

A 3-year-old boy is brought to your office by his parents with the complaint of a “tight” foreskin (Figure 1A). They anxiously explain that their son’s foreskin has never retracted fully, despite several attempts over the past few months. Both parents believe that this is abnormal and ask whether you believe he needs a circumcision.

While taking the patient’s history, you find out that the patient’s foreskin balloons occasionally with voiding. He has had no urinary tract infections and is otherwise healthy.

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Figure 1 Tight preputial orifice on retraction of foreskin

A) Skin at preputial outlet is healthy with no scarring, and the inner preputial mucosa is starting to evert through the outlet. With physiologic phimosis, the preputial outlet is always closed and one cannot see the glans unless the foreskin is retracted, as the examiner has done in the photograph. B) In many cases of pathologic phimosis, 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.

Reproduced with permission from the Canadian Journal of Urology8.

Sources of information

This article is based on selected findings from a MEDLINE search for literature on phimosis and circumcision referrals and on our experience at the Urology Clinic at the Children’s Hospital of Eastern Ontario. The literature on this topic consists mainly of level II (cohort studies) and level III (retrospective reviews) evidence. The cohort studies performed in Europe are the studies most often cited in the urologic community when discussing phimosis.1,2 These cohort studies pioneered the way we approach phimosis, as they helped elucidate the natural history of the foreskin.

Fate of the foreskin

The prepuce (foreskin) is the retractile covering of the glans penis. It serves many functions, including protective, erogenous, and immunologic.3,4 During neonatal development the prepuce is normally non-retractile, as the inner epithelial lining of the foreskin and the glans adhere to one another.1,3 Non-retractile foreskins are common among young boys and are a normal part of preputial development. More than half a century ago, it was shown that the prepuces of newborns are non-retractile, while at 3 years of age, up to 10% of foreskins remain non-retractile.2 It should be noted that, in these small children, even retractable foreskins might not be fully retractable, as inner preputial adhesions are still seen in most boys at age 6.2 What of the 10% of 3-year-old boys with non-retractile foreskins? Oster1 answered this question in an elegant cohort study published in 1968. Oster extended the study and found that 8% of boys at the age of 6 years, and 1% at the age of 16 years, still had non-retractile foreskins.1 The foreskin gradually becomes retractable secondary to intermittent erections and keratinization of the inner epithelium.1,5 The moral of the story told by these 2 seminal studies is that, if one is patient and does not rush Mother Nature, most foreskins will become retractile by adulthood.

What is phimosis?

Phimosis is a condition in which the prepuce cannot be retracted over the glans penis. True pathologic phimosis exists when failure to retract is secondary to distal scarring of the prepuce. This scarring often appears as a contracted white fibrous ring around the preputial orifice. In contrast, physiologic phimosis consists of a pliant, unscarred preputial orifice. Physiologic phimosis is common in male patients up to 3 years of age, but often extends into older age groups.1,2,6,7 These 2 separate conditions are, by and large, clearly distinguishable on physical examination (Figure 1B).

Exacerbating factors

Several factors might prevent full retraction of a foreskin. Most of the time retraction is prevented by persistence of preputial adhesions. These adhesions are remnants of the fused layer between the glans and prepuce. Although these can initially prevent full retraction, adhesions usually spontaneously resolve with gentle retraction of the foreskin during bathing and during intermittent erections throughout childhood.

Boys who have recurrent episodes of balanitis or balanoposthitis are at risk of developing scarred preputial orifices, contributing to pathologic phimosis. Application of a corticosteroid cream to the non-scarred preputial outlet loosens the tissues in approximately 80% of cases, allowing for improved foreskin retraction. Balanitis xerotica obliterans is a form of penile lichen sclerosis et atrophicus. Scarring secondary to balanitis xerotica obliterans is a common cause of pathologic phimosis. Balanitis xerotica obliterans is usually resistant to topical corticosteroid therapy.

Common problems affecting the foreskin

A variety of conditions can affect the foreskin of a child. Many are benign, but might require medical attention.

Proper preputial hygiene

Proper care for an uncircumcised penis is simple and helps prevent pathologic foreskin conditions. The foreskin should be left alone until the prepuce demonstrates an ability to retract. If the foreskin does not yet retract, there is nothing to “clean under.” Once the prepuce can be retracted, foreskin hygiene may commence, with children learning to gently retract their own foreskins during voiding or bathing. Children normally stop retracting their foreskins if they have any discomfort. It is important to prevent forceful retraction. Forcefully retracting the foreskin creates microtears at the preputial orifice, leading to scarring that might eventually cause formation of a phimotic ring. Hence, the foreskin should be retracted gently to its maximum extent and no farther.

The foreskin can be cleansed during routine bathing. The foreskin should be pulled back gently and rinsed with soap and water. Once dried with a towel, the foreskin must always be brought back down to its original position to cover the glans.

Treatments for phimosis

Most patients who present with tight foreskins have physiologic phimosis.8 The best treatment for these patients is “tincture of time.” These patients require no more than reassurance of normalcy and reinforcement of proper preputial hygiene. A 6- to 8-week course of topical corticosteroids (eg, 0.1% triamcinolone topical cream), applied directly to the preputial outlet twice daily, can be tried to help speed up the process,9,10 but this is not needed in all cases. As discussed above, most foreskins will become retractable with time; only 1% of phimotic foreskins remain non-retractile once children enter their teenage years.1 Teenagers might experience painful erections secondary to phimotic foreskins. Although this is a rare presentation, it can cause considerable grief for patients; hence urologic consultation should be sought for residual phimosis among teenagers.

The one absolute indication for performing a circumcision remains pathologic phimosis. If the preputial orifice is scarred, consult a pediatric urologist for advice. While waiting for the referral appointment, a course of topical corticosteroids can be prescribed for children. Although this course is usually fruitless, some studies show that topical corticosteroids might help with mild scarring.8,9 Indications for urologic referral are listed in Table 1.