Phimosis

From Intactipedia
Jump to: navigation, search
THIS ARTICLE IS UNDER CONSTRUCTION

Phimosis (/fɪˈmoʊsəs/ or /faɪˈmoʊsəs/), from the Greek phimos (φῑμός ("muzzle")), also known as "true phimosis," is a stricture in the preputial orifice caused by scarified tissue, as a result of an infection caused by lichen sclerosus et atrophicos (LSA), also known as balanitis xerotica obliterans (BXO), which prevents normal retraction of the foreskin over the glans of the penis. It is a rare disease, occurring in less than 1% of males. [1]

Phimosis, or "true phimosis," is specifically a phenomenon caused by a disease, and should not be confused with normal developmental stages of the penis, or other conditions where the foreskin is narrow, or adhered to the glans of the penis.

In Britain, Rickwood et al. have successfully argued that the definition of phimosis should be divested of any notions of preputial non-retractability, physiological balanopreputial attachment, or preputial length.[2] The new definition of ‘‘true phimosis’’ refers to a condition where ‘‘the tip of the foreskin is scarred and indurated and has the histological features of Balanitis xerotica obliterans’’.[3] More recently, Rickwood has refined this to the formulas: ‘‘Phimosis = BXO’’, and ‘‘No BXO = No Phimosis’’.[4]

To determine whether or not a person is suffering a case of true phimosis, a learned doctor will order proper analyses to be conducted, in order to determine whether or not the narrowing of the foreskin has been caused by BXO (true phimosis), and/or whether or not surgical intervention is indicated.

Contents

Phimosis: Etymology

The word "phimosis" has become a vague term used to describe any condition where the foreskin has trouble retracting behind the glans, where the foreskin may be tight, retracting with difficulty, while in other cases, not retracting at all. The usage of the word "phimosis" to describe any of these conditions may be mistaken, as the original Greek medical term was used to describe a specific situation.

While from the 19th century onward, the usage of the word "phimosis" became vague and confused, the original Greek word had a clinically precise definition.[5] In its earliest usage, the term "phimosis" was first used to indicate inflammatory strictures of various parts of the body. Galen, Heliodorus, and Andromachus, for example, used the term to refer to inflammatory strictures of the anus or the eyelid, but not the foreskin.[6][7][8]

The earliest etymological association between the term "phimosis" and the genitals was made by the Greek physician Dioscorides of Anazarbus, who flourished under the reigns of Claudius and Nero (41-68 AD), in his Materia Medica.[9] Dioscorides does not specifically refer to the foreskin, and he does not indicate the genitals of what sex. Furthermore, he used the Greek term phimos, which, in this case, could, with equal validity, refer to an imperforate anus or a urethral stricture of either sex.[10]

It is Aulus Cornelius Celsus who finally says that the Greeks associated genitals and the idea of stricture in his great work De Medicina.[11] Celsus specifically indicates that such a stricture is due to pathological inflammation.[12]

The second known use of the word phimosis is found in the extant writings of the Greek physician Antyllus, who lived in the second century AD.[13] Proceeding where Celsus left off, Antyllus further refines the medical conception of phimosis to include reference to inelastic scar tissue and pathological granulations as the cause of symptomatic preputial nonretractability.[14]

Phimosis, then, strictly refers to a stricture of a part of the body, particularly one which is caused by a pathological inflamation.

Misuses of the term "Phimosis"

In their quest to make medical intervention indispensable, medical authors of the 19th century sought to pathologize natural attributes of male genital anatomy. To this end, they vilified defining characteristics of the developing juvenile penis, conflated them with actual medical conditions, and affixed the Greek term "phimosis" to them.[15]

Normal Development

Typically, when a baby boy is born, the prepuce is long with a narrow tip.[16][17] Retraction is not possible in the majority of infants because the narrow tip will not pass over the glans penis. Moreover, it is normal for the inner mucosal surface of the prepuce to be fused with the underlying mucosal surface of the glans penis,[18][19][20][21] further preventing retraction.

In normal development, the foreskin usually separates from the glans and becomes retractable with age.[22] As the infant matures into a boy and the boy into a man, the tip of the prepuce becomes wider, and the shaft of the penis grows, making the tip of the prepuce appear shorter. The membrane that bonds the inner surface of the prepuce with the glans penis spontaneously disintegrates and releases the prepuce to separate from the glans. The prepuce spontaneously becomes retractable.

The prepuce of boys may be tight until after puberty.[23][24][25] This is an entirely normal condition and it is not phimosis. According to the experience in cultures where circumcision is uncommon, this tightness rarely requires treatment. Spontaneous loosening usually occurs with increasing maturity.[26][27][28] One may expect 50 percent of ten-year-old boys; 90 percent of 16-year-old boys; and 98-99 percent of 18 year-old males to have full retractable foreskin. Treatment is seldom necessary. If treatment should be necessary, it should not be done until after puberty and the male can weigh the therapeutic options and give informed consent.[29]

Normal Development Vilified

Both the transitory narrowness and balanopreputial attachment characteristic of normal development in the juvenile penis are often improperly diagnosed as "phimosis," when in fact, these are normal stages of development. To confuse things further, the term "phimosis" is also used to denote the pathological, ulcerative balanopreputial adhesions of an adult suffering the dermatological effects of a sexually transmitted disease.[30] No Greek writer ever confused the developmental, physiological, and transitory balanopreputial attachment of the juvenile penis with pathological adhesions.

A number of reports in the medical literature of the United Kingdom indicate that medical doctors are not trained to distinguish between normal developmental tight prepuce in boys and pathological phimosis.[31][32][33][34][35] This results in cases of misdiagnosis of normal developmental preputial tightness as pathological phimosis in the UK.[36][37][38][39][40]

Hypertrophic Phimosis: AKA "Redundant Foreskin"

One common misuse of the word phimosis by medical writers of the nineteenth-century as well as present concerns the length of the foreskin. Penises were and are frequently diagnosed with phimosis because the foreskin has arbitrarily been determined to be "too long", "redundant", or "hypertrophic". The Greeks, however, recognized no such disease. In antiquity, the problem was not having too much foreskin, but having too little. Consequently, classical medical writers were concerned with a deformity called lipodermos, a condition in which the foreskin was not long enough to cover the glans penis completely. Galen, Soranus, Dioscorides, and Antyllus, among others, published lengthy descriptions of lipodermus and made detailed recommendations for its correction.[41][42][43][44]

"Congenital Phimosis"

Authors of the 19th century perpetuated the mistaken belief that the foreskin was supposed to be retractable at the time of birth of the infant, which led to a characterization of the genitalia of most infant males as defective at birth.[45] Doctors could then diagnose a child with "congenital phimosis" and prescribe circumcision, when, in fact, the foreskin is developmentally normal, and no intervention is necessary.

The idea that the foreskin should be retractable at birth and that it should be forced back for hygiene is mistaken and dangerous misinformation. This is an old, outdated idea that, unfortunately, is still stubbornly being repeated today. The American Academy of Pediatrics cautions parents not to retract their son's foreskin, but suggests that once he reaches puberty, he should retract and gently wash with soap and water.[46] The Royal Australasian College of Physicians as well as the Canadian Paediatric Society emphasize that the infant foreskin should be left alone and requires no special care. [47] [48]

For more information, see Retraction of the foreskin.

"Phimosis" in Children and Adolescents

The first data on development of retractile foreskin were provided in 1949 by the famous British paediatrician, Douglas Gairdner.[49] According to Gairdner, 80 percent of boys should have a retractable foreskin by the age of two years, and 90 percent of boys should have a retractable prepuce by the age of three years.[50] Gairdner's research was groundbreaking at the time, as it destroyed the myth that a child's foreskin should be retractable at birth. However, inaccuracies in Gairdner's data would spawn new ones. Gairdner had collected no data on children beyond age 5, for example, which led some authors improperly to assume that children whose foreskin was not retractable by that age were suffering from "phimosis," and that circumcision was necessary.

Gairdner's figures on percentage of retractability are now known to be too high.[51][52][53][54] Later studies have indicated that only about 40-50 percent of boys have fully retractable foreskins at age ten.[55][56][57][58]

Unfortunately, Gairdner's data have been incorporated into many textbooks and are still being repeated in medical literature today. Most medical curriculum still uses Gairdner's inaccurate data, so most healthcare providers are still being taught inaccurate data.[59] These outmoded figures are being used by many doctors to erroneously diagnosis phimosis in normal, healthy boys, leading to false indications of circumcision.

For further reading, see Retraction of the foreskin.

"Phimosis" in Adults

Occasionally, a male reaches adulthood with a non-retractile foreskin. The non-retractability is not caused by any pathogen or adhesion, and is merely a failure of the preputial opening to dilate to allow passage of the glans. The term for a narrowing of the foreskin which is not caused by any pathogen is "preputial stenosis," and should not be confused with true phimosis, which is actually caused by a disease.

Unlike phimosis, which is pathological, preputial stenosis is a true narrowing of the foreskin which is caused by a lack of hormones in the body.[citation needed] Of these 2%, 85-95% will respond to topical steroids. Of those who fail this, at least 75% will respond to stretching under local anesthesia, either manually or with a balloon. The arithmetic is simple: At the very most 7 boys in 10,000 may need surgery for preputial stenosis.

Non-retractability in Children

The rare condition of difficulty in retracting the foreskin in adult men must not be confused with the natural state of the penis in neonates and pre-pubecent boys. In newborns and young children, the foreskin is adhered to the glans by means of a membrane called synechia, also known as the balano-preputial membrane or balano-preputial lamina and will not retract.[60] Forcibly retracting the foreskin of a child can cause damage to a child's penis. (Please see article on forced retraction.)

For more information regarding the normal development of the intact penis through childhood, see the article on the Retraction of the Foreskin.

Adhesions

There are three types of adhesions that occur between the foreskin in the glans. The first are, natural, transitory adhesions that occur as part of normal development. The second are iatrogenic adhesions that occur as a result of external tampering of a developing child's penis, such as the forced, premature retraction of the foreskin; forcibly tearing away the synechia causes wounds, whereby actual adhesions are caused to grow between the foreskin and glans. The third are pathological, ulcerative balanopreputial adhesions of an adult suffering the dermatological effects of a sexually transmitted disease.[61]

Adhesions that occur as a normal part of a child's development will begin to disappear by themselves as the child nears puberty. Adhesions that were iatrogenically induced, however, may require surgical intervention later on. Adhesions that occur as a symptom of a sexually transmitted disease may also require surgical intervention. Surgical intervention to alleviate adhesions may or may not entail circumcision.

It is a mistake to classify the non-retractability of the foreskin caused by adhesions (be they the transitory adhesions a developing child encounters, or pathological adhesions that occur as part of a sexually transmitted disease) as "phimosis," however, as phimosis refers strictly to stricture, or muzzling at the end of the foreskin caused by BXO.

Phimosis Caused by Circumcision

Phimosis can actually be caused by circumcision. Phimosis with a trapped penis is an infrequent but important complication of circumcision. This condition is more likely to occur in older infants and those with poor attachment of the penile skin to the shaft.

True Phimosis

The only condition that can therefore be described as "true phimosis," is one such where an infection caused by balanitis xerotica obliterans (BXO) results in a stricture in the foreskin caused by scarified tissue. It should not be confused with normal developmental stages of the penis, or with other conditions where the foreskin is narrow or adhered to the glans.

To determine whether or not a person is suffering a case of true phimosis, the doctor should order that the proper analyses be conducted to determine whether or not the narrowing of the foreskin has been caused by BXO, and/or whether or not surgical intervention is indicated.

References

  1. Øster J. Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child. 1968;43:200-3.
  2. Rickwood AMK, Hemalatha V, Batcup G, Spitz L (1980) Phimosis in boys. Br J Urol 52:147-150
  3. Rickwood AMK, Walker J (1989) Is phimosis overdiagnosed in boys and are too many circumcision performed in consequence? Ann Roy Coll Surg Eng 71:275-277
  4. Rickwood AMK (1997) The foreskin. Presented at the British Association of Paediatric Urologists 1997 Course. Churchill College, Cambridge (11 September)
  5. Hodges FM. Phimosis in antiquity. World J Urol 1999;17(3):133-6.
  6. Hippocratis de medici officina liber et galeni in eum commentarius II, 2.31. In: Kühn DCG (ed) (1830) Medicorum græcorum, vol 18, part 2. Cnobloch, Leipzig, p 812
  7. Heliodorus apud oribasium, 44.20.72. In: Raeder I (ed) (1964) Oribasii. Collectionum medicarum reliquiæ, vol 3. Adolf M. Hakkert, Amsterdam, p 141
  8. 1 Andromachus apud galenum, Galeni de compositione medicamentorum secundum locus, 9.6. In: Kühn DCG (ed) (1827) Medicorum græcorum. vol 13. Cnobloch, Leipzig, p 311
  9. Hodges FM. Phimosis in antiquity. World J Urol 1999;17(3):133-6.
  10. Hodges FM. Phimosis in antiquity. World J Urol 1999;17(3):133-6.
  11. Celsus. De medicina, 7.25.2. In: Spencer WG (ed and trans) (1938) Celsus. De medicina, vol 3. Harvard University Press, Cambridge, p 422
  12. Celsus. De medicina, 6.18.2. In: Spencer WG (ed and trans) (1938) Celsus. De medicina, vol 2. Harvard University Press, Cambridge, p 269
  13. Hodges FM. Phimosis in antiquity. World J Urol 1999;17(3):133-6.
  14. Celsus. De medicina, 6.18.2. In: Spencer WG (ed and trans) (1938) Celsus. De medicina, vol 2. Harvard University Press, Cambridge, p 269
  15. Hodges FM. Phimosis in antiquity. World J Urol 1999;17(3):133-6.
  16. Gairdner D. The fate of the foreskin. Brit Med J 1949:2:1433-7.
  17. Spence J. On Circumcision. Lancet 1964;2:902.
  18. Deibert GA. The separation of the prepuce in the human penis. Anat Rec 1933;57:387-399.]
  19. Gairdner D. The fate of the foreskin. Brit Med J 1949:2:1433-7.
  20. Øster J. Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child 1968;43:200-3.
  21. Catzel P. The normal foreskin in the young child. (letter) S Afr Mediense Tysskrif [South Afr Med J] 1982 (13 November 1982) 62:751.
  22. Øster J. Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child 1968;43:200-3.
  23. Jakob Oster. Further fate of the foreskin: Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys.. Arch Dis Child (published by the British Medical Association), April 1968. p. 200-202.
  24. Kayaba H, Tamura H, Kitajima S, et al. Analysis of shape and retractability of the prepuce in 603 Japanese boys. Journal of Urology, 1996 Nov, V156 N5:1813-1815.
  25. Warren JP: NORM UK and the Medical Case against Circumcision. In: Sexual Mutilations: A Human Tragedy; Proceedings of the 4th Intl Symposium on Sexual Mutilations , Denniston GC and Milos MF, Eds. New York, Plenum, 1997) (ISBN 0-306-45589-7)
  26. Jakob Oster. Further fate of the foreskin: Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys.. Arch Dis Child (published by the British Medical Association), April 1968. p. 200-202.
  27. Kayaba H, Tamura H, Kitajima S, et al. Analysis of shape and retractability of the prepuce in 603 Japanese boys. Journal of Urology, 1996 Nov, V156 N5:1813-1815.
  28. Warren JP: NORM UK and the Medical Case against Circumcision. In: Sexual Mutilations: A Human Tragedy; Proceedings of the 4th Intl Symposium on Sexual Mutilations , Denniston GC and Milos MF, Eds. New York, Plenum, 1997) (ISBN 0-306-45589-7)
  29. Warren JP: NORM UK and the Medical Case against Circumcision. In: Sexual Mutilations: A Human Tragedy; Proceedings of the 4th Intl Symposium on Sexual Mutilations , Denniston GC and Milos MF, Eds. New York, Plenum, 1997) (ISBN 0-306-45589-7)
  30. Hodges FM. Phimosis in antiquity. World J Urol 1999;17(3):133-6.
  31. Rickwood AMK, Walker J. Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence? Ann R Coll Surg Engl 1989;71(5):275-7.
  32. Griffiths D, Frank JD. Inappropriate circumcision referrals by GPs. J R Soc Med 1992; 85: 324-325.
  33. Andrew Gordon and Jack Collin. Save the normal foreskin. Br Med J 1993;306:1-2.
  34. Nigel Williams, Julian Chell, Leela Kapila. Why are children referred for circumcision? Brit Med J 1993; 306:28.
  35. Shankar KR, Rickwood AM. The incidence of phimosis in boys. BJU Int 1999 Jul;84(1):101-2.
  36. Rickwood AMK, Walker J. Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence? Ann R Coll Surg Engl 1989;71(5):275-7.
  37. Griffiths D, Frank JD. Inappropriate circumcision referrals by GPs. J R Soc Med 1992; 85: 324-325.
  38. Andrew Gordon and Jack Collin. Save the normal foreskin. Br Med J 1993;306:1-2.
  39. Nigel Williams, Julian Chell, Leela Kapila. Why are children referred for circumcision? Brit Med J 1993; 306:28.
  40. Shankar KR, Rickwood AM. The incidence of phimosis in boys. BJU Int 1999 Jul;84(1):101-2.
  41. Galeni de compositione medicamentorum per genera, 7.7. In: Kühn DCG (ed) (1827) Medicorum græcorum, vol 13. Cnobloch, Leipzig, p 985
  42. Sorani gynæciorum, 36.103.19-27. In: Rose V (ed) (1882) Sorani gynæciorum. Teubner, Leipzig, p 278
  43. Dioscuridis. De materia medica, 2.82.2. In: Wellmann M (ed) (1907) Pedanii dioscuridis anazarbei de materia medica, vol 1. Weidmann, Berlin, p 166
  44. Antyllus apud oribasium, 50.2. In: Raeder I (ed) (1964) Oribasii collectionum medicarum reliquiæ, vol 4. Adolf M. Hakkert, Amsterdam, p 55-56
  45. Hodges FM. Phimosis in antiquity. World J Urol 1999;17(3):133-6.
  46. American Academy of Pediatrics: Care of the uncircumcised penis, 2007
  47. Fetus and Newborn Committee, Canadian Paediatric Society (CPS)
  48. Royal Australasian College of Physicians. (2010) Circumcision of Infant Males.
  49. Gairdner D. The fate of the foreskin: a study of circumcision. Br Med J 1949;2:1433-7.
  50. Gairdner D. The fate of the foreskin: a study of circumcision. Br Med J 1949;2:1433-7.
  51. Wright JE. "Further Fate of the Foreskin." Med J Aust 1994;160:134-5.
  52. Hill G. Circumcision for phimosis and other medical indications in Western Australian boys. Med J Aust 2003;178(11):587.
  53. Hill G. Circumcision for phimosis and other medical indications in Western Australian boys (Letter). Med J Aust 2003;178(11):587.
  54. Hill G. Triple incision to treat phimosis in children: an alternative to circumcision (letter). BJU Int 2004;93(4):636.
  55. Øster J. Further Fate of the Foreskin: Incidence of Preputial Adhesions, Phimosis, and Smegma among Danish Schoolboys. Arch Dis Child, April 1968. p. 200-202.
  56. Kayaba H, et al. Analysis of shape and retractability of the prepuce in 603 Japanese boys. Journal of Urology, 1996;156(5):1813-1815.
  57. Imamura E. Phimosis of infants and young children in Japan. Acta Paediatr Jpn 1997;39(4):403-5.
  58. Morales Concepción JC, Cordies Jackson E, Guerra Rodriguez M, et al. ¿Debe realizarse circuncisión en la infancia? Arch Esp Urol 2002;55(7):807-11.
  59. Hill G. Circumcision for phimosis and other medical indications in Western Australian boys. Med J Aust 2003;178(11):587.
  60. Gairdner D. The fate of the foreskin: a study of circumcision. Br Med J 1949;2:1433-7.
  61. Hodges FM. Phimosis in antiquity. World J Urol 1999;17(3):133-6.
Personal tools