Επιστημονικά Άρθρα

PHIMOSIS

Does phimosis need surgery?

 

Complete retraction of the foreskin often becomes a stressful subject for families and family doctors alike. It is not uncommon for parents to receive contradicting information from different sources.

In early life physiologic phimosis is the expected state of the foreskin. It is defined by the glans (penile head) not being visible, because the foreskin / prepuce (the excess of skin covering the glans) is tightly adhered to it via preputial adhesions (incomplete joining of the preputial skin to that of the glans). These two components of the joining are meant to eventually separate completely. Spontaneous erections (beginning very early in life), unavoidable urination within the foreskin and family handling of the penis e.g. during washing / bathing etc. help towards that direction.

  • Is the separation of the foreskin adhesions already delayed in my child?

There is no upper age limit after which this process would be considered delayed. Especially before potty training in a child in nappies there is no need for concern about the progression of adhesion separation. Every child progresses differently. Most 15 yr olds will have a separated fully retractile foreskin without any particularly active involvement by the family.

  • So, do we ignore the whole process completely?

Reasons to monitor this process definitely exist. The area needs to be cleaned in order to avoid irritation from urine remains. Irritation may take the form of “burning” or “stinging” or even swelling and redness, ofttimes reaching further down the shaft of the penis (BALANOPOSTHITIS).

Monitoring also ensures training in proper urination technique. Every boy gradually learns to grasp the penis with both hands in a fashion that allows the urethral opening on the glans to be uncovered enabling the stream of urine to be directed away from the foreskin and thus keeping the area dry from urine remains on the glans / prepuce skin.

Concerning the risk for urinary tract infections or other serious conditions due to physiologic phimosis in healthy boys, it is worth mentioning that in modern societies that is for all practical reasons not true.

  • What are the main steps of this monitoring process?

The single most important message here is to avoid injury to the prepuce skin by any means!! Even repeated microinjuries (single drops of blood) may lead to scar formation (pathologic Scar Phimosis). This is characterised by thick, whitish, sclerotic scar tissue surrounding a deformed or even slit-like skin opening.

Prefer using gentle movements to stretch the foreskin as much as the child permits, in order to wash the area clean, similar to other body parts. Furthermore, as the child grows we make sure that the proper urination technique is followed, as outlined above.

  • Some things become evident I am unfamiliar with…is it worrisome?

Gradual adhesion separation need not happen uniformly around the glans. Sometimes an area becomes freed up, whilst neighbouring areas are still attached. Other times a white caseous (cheesy) substance appears. That is called smegma i.e. dead skin cells, keratin and skin secretions. Newly freed prepuce will often release that or deeper pockets may form leading to an appearance on the outside of the foreskin resembling a “pearly” cyst. Smegma accumulates when the foreskin is not fully retractable and thus not permitting proper cleaning of the glans.

  • When should I seek Paediatric Surgery advice?

It should be made clear that adhesion lysis (separation with an instrument) by a surgeon is not necessary. On occasion this separation can be augmented – if a doctor so deems necessary – by means of local therapy via cream application.

  • An operation under general anaesthesia is indicated for pathologic Scar Phimosis. This can be the result of repeated trauma or a chronic form of inflammation (BXO).

Other surgery indications:

  • Multiple recurrent episodes of balanoposthitis.
  • Persistent preputial stenosis (when the retracted foreskin forms a tight band under the glans resembling an hourglass) especially when it has been complicated by episodes of paraphimosis. Paraphimosis is the inability to replace the retracted foreskin back over the glans, resulting in pain, swelling and redness under the glans. This is a potential medical emergency and families are advised to seek immediate medical attention!
  • Failure of the foreskin separation process despite medical advice and long-standing follow-up due to difficult cooperation with the boy or any other reason.
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