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%. 

Read full text at CIRP.

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. 

Read full text as PDF (52 kb)

 

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.

Read full text on CIRP.

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 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/

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


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