Phimosis is a narrowing of the foreskin, in which it is difficult or impossible to remove the head of the penis. The symptoms are variable, depending on the severity of the phimotic ring. In children under 5 years of age, in most cases there are no unpleasant clinical manifestations, in adults, pain and microcracks appear due to mechanical compression of the penis head at the time of erection. During a violent attempt at retraction due to traumatization, blood is released. Diagnosis is based on examination data, PCR tests for STIs, smear microscopy from the urethra are used to determine the cause. Treatment can be conservative or operative — circumcision or performing prepucioplasty
ICD 10
N47 Excess foreskin, phimosis and paraphimosis
Meaning
Physiological phimosis is present in almost all newborn boys. The head begins to be exposed in 50% of cases in the first year of life, in 90% of children it is completely open by the age of 3 years without taking any measures. Only in 1-5% of patients, physiological phimosis persists up to 17 years. This nosological unit occupies the second place in the structure of diseases of the male genital organs after varicocele. The acquired form always accompanies some pathological process. Therefore, if the foreskin is immobile or narrowed in an adult male, and previously there was no phimosis, it is necessary to exclude persistent balanitis (balanoposthitis) of venereal etiology, diabetes mellitus and penile cancer.
Causes
Weakening of immune reactions of any nature, genetically determined pathology of connective tissue with excessive fibrosis are considered as the main predisposing factors. Anatomical prerequisites include a short frenulum, hypertrophied foreskin, and a congenital narrow phimous ring. Studies show that the probability of developing phimosis is higher in uncircumcised patients who practice free relationships without barrier protection. Conditions that can provoke phimosis:
- Nonspecific inflammation. Balanitis and balanoposthitis are complicated by recurrent infections of the bladder, urethra, prostate. Wetness, violation of the integrity of the epithelium against the background of inflammation leads to fibrotic-sclerotic tissue changes, scar formation and narrowing of the prepuce. A child may have phimosis after a viral infection that occurred in a generalized form involving the head of the penis and foreskin.
- Traumatization. Phimosis often develops against the background of prolonged functioning of urethral drainage, intermittent catheterization with neurogenic dysfunction of the bladder, bougie with urethral stricture. A frenulum tear during sex, during masturbation, is considered as prerequisites for phimosis. Insect and animal bites are complicated by a secondary inflammatory process and subsequent narrowing of the preputial sac.
- STIs. Sexually transmitted infections are a common cause of phimosis in men. Gonorrhea, trichomoniasis, chlamydia, left untreated, have less pronounced manifestations after a few weeks, which does not indicate recovery. Therefore, fibrotic-sclerotic processes in the prepuce appear after 2-3 months. Urogenital candidiasis (thrush) does not belong to sexually transmitted diseases, but can also be transmitted sexually.
- Lack of sexual activity. The foreskin is an elastic structure that stretches during erection and allows the head of the penis to come out. If the head is always covered, there is no sexual activity (especially with severe erectile dysfunction with the absence of spontaneous erections), then bacteria multiply in the smegma, and in the future the formation of scar phimosis is expected, in which the inner leaf of the foreskin grows to the head.
- Skin diseases. A number of skin diseases – psoriasis, lichen planus, sclerotrophic lichen, etc. – cause cracks, itching, redness on the skin, which leads to splices. At the initial stage, if you do not try to forcibly expose the head, there is no pain. Local therapy brings only temporary relief, meanwhile the disease continues to progress. Unpleasant manifestations can be avoided only after a radical operation – circumcision.
Pathogenesis
Gluing the inner sheet of the prepuce with the head of the penis in a newborn is a normal condition. The increase in the production of male hormones contributes to the development of smegma, the occurrence of spontaneous erections, by the age of 3-6, physiological phimosis passes independently. If there are prerequisites for pathological phimosis – congenital narrowed ring, excessive elongation of the foreskin, inflammation, short frenulum – spontaneous opening of the preputial sac does not occur, and thin epithelial adhesions become dense.
Against the background of sclerosis, the foreskin loses elasticity, cracks appear when it is stretched. In patients with DM, sugar is excreted in the urine. Constant irritation, a good nutrient medium, humidity and optimal temperature lead to the persistence of pathogenic and conditionally pathogenic microflora, which initiates and supports the inflammatory process. In a child, physiological phimosis turns into scarring due to an episode of balanitis and after a prepuce injury resulting from a sharp retraction.
Classification
The classification of phimosis is based on the degree of constriction of the constrictive ring and the possibility of exposing the head in a calm and erect state of the penis. There are four stages in modern andrology:
- First. There is difficulty and unpleasant sensations when exposing the head exclusively during an erection, there are no pathological changes in a calm form.
- The second. It is hardly possible to remove the head of only an erect penis, which is impossible with an erection because of the scar ring.
- Third. There are no pronounced problems with urination, because the foreskin does not block the external opening of the urethra (or it can be removed and the meatus can be released). The head is not displayed either in a calm or erect state.
- Fourth. There are pronounced violations of urination (urination in several stages), urinary retention, etc. Typically, the addition of complications.
Symptoms
A congenital or physiological condition is more often clinically asymptomatic, so it is not a cause for concern. In young children, phimosis is accompanied by inflating of the foreskin during urination, but the urine completely exits. The skin is elastic, stretches well, when using force and a sharp attempt at retraction, pain, radial cracks, blood appear.
Pathological, or true, phimosis is manifested by dysuria, skin irritation, bleeding when trying to open the head. Some patients have episodes of incontinence, in advanced cases, acute urinary retention develops. The main complaint for most men with phimosis is soreness during sexual contact. The appearance of radial cracks on the foreskin is more common in men with concomitant diabetes mellitus.
The skin of the prepuce is edematous, hyperemic, the nature of the discharge depends on the type of microflora: with gonorrhea, they are yellowish-green, and with phimosis, accompanied by candidiasis, the secret is whitish, with a sharp sour-milk smell. Erosive defects with plaque may form on the head and inner leaf. Urination disorders are typical for advanced stages of the disease and include discomfort, splashing of urine, the need for straining before urination.
Complications
At stage 1-2, complications are rare. With unjustifiably abrupt attempts, it is possible that the head is pinched by the ring of the foreskin – paraphimosis is a condition that requires seeking emergency help. Constant wetting of the skin due to the accumulation of urine leads to the development of contact dermatitis, balanitis, balanoposthitis. In 2% of cases, more often in asocial persons suffering from drug addiction, alcoholism, ischemia ends with necrotizing and self-amputation of the penis.
For patients with stage 3-4 phimosis, recurrent urinary tract infections, the addition of sexual dysfunction due to sharp soreness during frictions are typical. Prolonged contact of the mucosa with smegma and persistent inflammation is considered as a predisposing factor for the development of penile cancer, because mycobacterium smegmatis assimilates cholesterol that is part of the secretion and turns it into carcinogenic sterols.
Diagnostics
Changes characteristic of phimosis are visible to the naked eye. The andrologist makes a diagnosis when assessing the hard scarring of the foreskin, through which the head is either not removed, or is removed with difficulty. Consultations with a dermatovenerologist, an endocrinologist may be useful. If a secondary scarring process is suspected against the background of a penis tumor, an oncologist may prescribe a cytological examination. Ultrasound techniques are used to clarify the state of the prostate, bladder, kidneys. To find out the cause of phimosis, it is carried out:
- Inspection. The urologist clarifies the anamnesis (congenital condition or acquired), the connection of the development of phimosis with any event. During the examination, he pays attention to the discharge from the urethra, an increase in inguinal lymph nodes, the presence of concomitant rashes on the skin of the head, cracks. Often, it is already possible to determine the cause beforehand — a narrow ring, excessive foreskin, skin disease, etc.
- Examination for infections. The most informative are the results of analyses performed using the PCR method, but sometimes they are limited to microscopy of the separated urethra and prepuce. If genital warts are visualized during the examination, HPV infection tests are additionally prescribed, including quantitative determination of viral load.
Differential diagnosis
Differential diagnosis is carried out with a pinched, hidden penis. It is important to determine the correct diagnosis, since the approaches to treatment are diametrically opposed: with advanced stages of phimosis, the operation of choice is circumcision, and with a hidden penis, circumcision of “extra” tissue is unacceptable, since the foreskin is necessary for future reconstructive interventions. Primary balanitis and balanoposthitis due to edema and inflammation can limit the mobility of the foreskin, which is not yet a phimosis. When appropriate treatment is prescribed, the development of a pathological condition can be prevented.
Treatment
Therapeutic measures depend on the type and severity of the process. In children, small synechiae in the prepuce can be destroyed with the help of a special probe and a gauze buffer. Parents are also advised to refrain from abrupt shifting of the prepuce, but at the same time gradually (as carefully as possible, 1-2 mm each) during hygienic procedures to try to open the head of the penis. Background STDs are treated with the appointment of an antibacterial drug, taking into account sensitivity, both partners receive medications. Possible tactics for phimosis:
- Conservative therapy. Local treatment involves prolonged application of corticosteroid ointments to the head and foreskin. Under the influence of hormones, skin elasticity improves, inflammation and swelling decrease. At the same time, a soft massage of the head and the adjacent foreskin is performed. The method is suitable for men and boys with 1-2 stages of phimosis without the formation of adhesions. Unpleasant symptoms are well relieved by baths with decoctions of herbs (turn, calendula, chamomile).
- Circumcisio. In case of failure of conservative therapy or in the presence of dermatological pathology, scarring, frequent recurrence of infections, surgical treatment – circumcision is justified. The operation involves excision of excess foreskin, as a result of which the head remains always naked. This intervention is considered radical.
- Prepucioplasty. If it is important for a man to preserve the foreskin, it is possible to perform prepucioplasty (partial dorsal incision, Z-plasty) aimed at expanding its opening. Another low-traumatic method is stretching the phimous ring using dilators, as a result of treatment, a free space appears between the head and a sheet of flesh.
Prognosis and prevention
The prognosis is favorable. After performing plastic surgery, the probability of recurrence is 1.6 — 2.4%. The effectiveness of operations related to the removal of the foreskin is 99-100%. Recent studies have not found any differences in sexual sensitivity in circumcised and uncircumcised men.
Prevention implies daily hygienic measures aimed at removing the smegma, shifting the foreskin. Timely referral to a urologist with symptoms suspected of STDs, passing a course of therapy together with a partner help prevent the development of phimosis. It is impossible to prevent the development of physiological phimosis