Friday, October 31, 2014

Definition

Phimosis is tightness of the prepuce (foreskin) of the penis that prevents the retraction of the foreskin over the glans. The condition is usually congenital but it may be the result of an infection.

Description

True phimosis - that is, not just non-retractability - may rarely be a primary and congenital anomaly, but is much more commonly secondary to repeated attacks of infection that cause scarring and narrowing of the preputial ring.

Difficulty with voiding and ballooning of the prepuce are the commonest reasons for patients seeking treatment, though recurrent bacterial infections (balano-posthitis) may also occur.

Causes

Phimosis begins with an infection of the foreskin. If untreated, the infection spreads and the foreskin swells up. Eventually, the foreskin becomes so large that it cannot retract. It is swollen and tight, and cannot be moved back away from the glans.

Phimosis is the result of repeated foreskin infections such as balanitis. It is linked to neglected hygiene. Germs breed under the foreskin with its enclosed glans. The delicate tissues undergo a process of partial healing/partial flare-up/partial healing again. Scar tissue keeps building up and breaking down. Eventually, the scar tissue becomes fibrous - hard, tough and inelastic. It contracts the meatus, pulling the infected foreskin tightly inwards. At the same time, nearby healthy tissue strives to form new scabs and becomes infected. This adds to the spread of germs.

Symptoms

The foreskin may be red, swollen, and tender.

Diagnosis

Diagnosis is made by a physical examination.

Treatment

Some men accept the chronic irritation and the red, swollen foreskin. They sometimes complain of phimosis and visit the doctor only when there is pain or an odorous discharge.

Antibiotics may control the infection. Hot soaks may help separate the foreskin from the glans. If they fail, a small incision is made to release it. Circumcision is generally advised when the inflammation clears.

For some pliant, unscarred foreskins, a preputial stretch may be used. This can even be done under local anesthesia with, for example, EMLA cream. Some surgeons may perform a preputioplasty, with the aim of increasing the diameter of the preputial ring but without excising the prepuce (foreskin).

Circumcision is typically performed under general anesthesia. The foreskin is pulled back as far as it will go. It is slit along its upper surface and then all around so that it can be removed. The raw edges of the inner and outer layers are stitched, and a dressing is applied. The patient usually goes home the same day.

Immediately after circumcision, the patient may find that the appearance of the penis has changed considerably. Until healing is complete, there will be some pain but this can be controlled by painkillers. Urination may be painful and the urine should be kept away from the incision.

For some days, walking or any movement is discouraged that may cause penile contact with clothes or thighs while the previously very sensitive glans loses some of its sensitivity through constant exposure to air. At the end of that time, however, there should be no pain, the stitches should be healing, and interest in sex will have been re-established. While healing is taking place, there is very little risk of the stitches splitting or pulling out because of an erection. The good blood supply to the area also means the chance of infection is rare.

Questions

Is there an infection of the foreskin?

Will antibiotics be prescribed?

What are treatment options?

Do you recommend circumcision?

What are the benefits and risks of the procedure?