Phimosis – Is circumcision the only option?

Phimosis

What is it and can it be solved without surgery?

Phimosis is described as a tightness of the foreskin, which prevents or limits its ability to retract over the glans. It is normal in boys during infancy, as the glans remains attached to the foreskin and then begins to shed as a normal part of development. About 96% of boys are born with a non-retractable foreskin, which resolves without intervention between birth and 18 years (often adolescents may have remnants of preputial adhesions, which usually separate and resolve during adolescence) .

Attempts to forcefully retract the foreskin should be avoided as this can cause damage and can be extremely painful. As the boy develops, increased erections and the individual’s curiosity may be enough to ensure that the foreskin retracts without the need for phimosis treatment; however, in about 2% of adult men, the foreskin remains non-retractable. This is usually physiological phimosis and stretching is commonly done to resolve the problem, provided the individual perseveres with stretching for a duration and frequency that is comfortable and non-aggressive. When phimosis develops on a previously retractable foreskin, this is known as pathologic phimosis and will show an element of scar tissue. Occasionally, phimosis can be secondary to other diseases such as circulatory problems, for example diabetes, and often patients with lichen sclerosus will encounter this problem. It goes without saying that the main objective in the circumstances of poor circulation and Lichen Sclerosus, must be the control of the factors that cause phimosis.

Regarding treatment options to resolve phimosis, clinical reasoning has been challenged in recent years, as the common consensus within the medical field was to circumcise. Unfortunately, this is likely to have been caused by a lack of appreciation of the function of the foreskin. Once deemed to have little function, the foreskin was often circumcised in the first case of phimosis, even in the developing boy. Fortunately, in more recent times, the treatment advice for physiological phimosis is usually to stretch the foreskin. However, in cases of pathological phimosis, there remains limited acceptance within the medical profession to accept that this too can be treated and circumcision avoided. This train of thought is driven by the fact that scar tissue has reduced elasticity, which is certainly correct, but before accepting this, we must first explore the scarring process.

When skin is injured, the repair process follows four stages which are described in very basic detail below.

1. Hemostasis: Blood vessels constrict to reduce blood flow. The platelets then stick together to seal the injured skin. Finally, coagulation occurs to form a blood clot.

2. Inflammatory stage – damaged cells, pathogens and bacteria are removed from the site of injury. Heat, pain, and redness are seen at this stage.

3. Proliferation stage: the wound contracts and new tissue is rebuilt (type III collagen)

4. Remodeling stage: This is a very important stage to consider regarding the healing that is observed in pathological phimosis. The type III collagen present is disorganized and thick, the scar has very little elastin, so it has inelastic properties. This is gradually replaced by type I collagen which forms a thinner, healthier scar, improving tensile strength. As the scar matures, an enhanced network of elastin improves its ability to stretch.

In a study by Roten et al (1996), elastic fibers were found to increase considerably during the remodeling stage, indicating significantly improved stretchability, when the initial injury has completed the healing process. Therefore, we can conclude from this, that as long as the scar has completely healed, stretching should be considered as a modality for the conservative treatment of phimosis. Of course, we need to adjust for any aggravating lifestyle factors that may have caused the original scarring, for example, if the tight foreskin is frequently injured by sexual activity, the activity should be modified to reduce the chance of further injury.

As we have noted, there is often a lack of appreciation of the functions of the foreskin, which has inevitably led to unnecessary circumcisions. If we were to break a finger it would be a ridiculous prospect to suggest amputation as we respect the function as part of our anatomy, however a tight foreskin is often resolved by circumcision without a doubt as its functions are often are ignored.

The foreskin is made up of skin, smooth muscle, mucous membranes, blood vessels, and neurons. Its functions include protecting the glans from trauma and abrasion, keeping the glans moist and lubricated, and enhancing sexual pleasure. Some may argue that sexual pleasure is not reduced after circumcision, however we just have to consider that the glans contains thousands of nerve endings, which after circumcision will eventually be covered by keratinized skin (since the glans is exposed to air). and abrasive materials such as clothing, the skin dries and thickens), so we can draw our own conclusions about the possibility of reduced sexual pleasure.

Inevitably, some people will require circumcision, due to the incidence of disease and anatomical dysfunction; however, we expect the shift in recent years toward more conservative phimosis correction to continue, and foreskin tightening to become more commonly accepted as a treatment.

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[Phimosis in children, Shahid. ISRN Urol. 2012; 2012: 707329. Published online 2012 Mar 5. doi: 10.5402/2012/707329] Access at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3329654/

Elastic fibers in scar tissue. J. Cutan Pathol. 1996 February; 23(1):37-42. Roten SV1, Bhat S, Bhawan J.

Van Howe RS (1998). “Cost effective treatment of phimosis”. Pediatrics. 102(4):e43-e43. doi:10.1542/peds.102.4.e43. PMID 9755280

Øster J. Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish schoolchildren. Arco Di Nino. 1968;43(228):200-3. doi:10.1136/adc.43.228.200. PMID 5689532

Spilsbury K, Semmens JB, Wisniewski ZS, Holman CD (2003). “Circumcision for phimosis and other medical indications in Western Australian boys”. Medicine. J. Aust. 178(4): 155-8. PMID 12580740

McGregor, tuberculosis; Lucius, JG; Leonard, MP (March 2007). “Pathological and physiological phimosis: approach to the phimotic foreskin”. Canadian Family Physician Canadian Family Physician. 53(3):445-8

What are the treatment options for phimosis?” PubMed Health. Institute for Quality and Efficiency in Health Care. October 7, 2015