Phimosis

Phimosis is inability to retract the foreskin behind the glans because the preputial opening is too narrow.

The critical distinction is:

Physiological phimosis

Normal developmental nonretractability without scarring.

Common in children and usually resolves spontaneously.

Pathological phimosis

A fibrotic scarred preputial ring prevents retraction.

Causes include:

• Recurrent balanitis
• Forced retraction with scarring
• Lichen sclerosus, also termed balanitis xerotica obliterans

Physiological nonretractability should not be treated as disease simply because the foreskin cannot yet retract.

Physiological phimosis:

• Soft nonfibrotic preputial ring
• No scarring
• Usually asymptomatic

Ballooning during urination can occur and does not automatically indicate urinary obstruction.

Pathological disease shows:

• White fibrotic ring
• Painful retraction
• Recurrent balanitis
• Painful erections
• Fissuring
• Progressive loss of previous retractability

Lichen sclerosus can also produce:

• Meatal stenosis
• Urethral involvement

Diagnosis is clinical.

Routine ultrasound, urine tests or imaging are unnecessary.

Do not forcibly retract the foreskin to establish the diagnosis because this can produce tears and secondary scarring.

Asymptomatic physiological phimosis requires:

• Reassurance
• Normal hygiene
• No forced retraction

Topical corticosteroid

For symptomatic primary phimosis:

Use a topical corticosteroid approximately:

Betamethasone 0.05% applied thinly to the tight preputial ring twice daily for 4 to 8 weeks

with gentle retraction exercises.

Topical steroid success exceeds 80% in appropriately selected disease.

Surgery

Circumcision is indicated for:

• Pathological phimosis refractory to steroid treatment
• Lichen sclerosus
• Recurrent severe balanoposthitis
• Patient preference after counselling

Preputioplasty is a foreskin preserving alternative in selected nonlichen sclerosus disease.

Do not perform routine simple circumcision before assessing associated penile anomalies such as:

• Hypospadias
• Epispadias
• Buried penis
• Significant congenital curvature

because foreskin can be required for reconstruction.