Phimosis & Circumcision
What is phimosis?
Phimosis refers to tight foreskin of penis.
 
What are problems associated with phimosis?
Phimosis or tight foreskin of penis is a common complaint for which parents seek medical attention for their kids. Most of the times it is physiological i.e. which occurs during normal phase of development. In newborn boys the inner layer of foreskin is fused to the glans penis. Gradually the layers separate and the skin cells are shed off which may be seen as whitish material under the foreskin called ‘Smegma’. Sometimes smegma deposits may be fairly large and seen or felt as a plaque across the skin.
Phimosis is physiological in young babies especially till 3-4 years of age. By that age the layers should separate and foreskin should become retractable to allow for daily cleaning. Pathological (abnormal) phimosis is seen when it causes problems or persists beyond 5 years of age. Unnatural pulling back of the skin in a small child may lead to more tightening and also psychological trauma.
Common symptoms of a clinically significant phimosis are:
  • Local irritation and itching due to smegma deposits
  • Difficulty in passing urine
  • Ballooning of foreskin when the child tries to pass urine
  • Local infection and pus discharge- Balanoposthitis
  • Urinary tract infection
 
How is phimosis treated?
  • In children presenting with urinary infection, a urine examination is done and antibiotics are prescribed accordingly.
  • In children presenting with balanoposthitis warm compresses locally, antibiotic ointments and a short course of a broad spectrum antibiotic usually suffice.
  • In children who come with straining during passage of urine and are diagnosed to have phimosis as the probable cause, various forms of therapy are available depending on the severity of phimosis.
  • In those also where phimosis presents with urinary or local infection, one of the alternatives is eventually required to tackle the tight foreskin.
The treating doctor should grade the phimosis and document it.
The various treatment options are
  • Preputial dilatation - Preputial dilatation is a short procedure done in office whereby the foreskin is forcibly dilated with an instrument so that retraction becomes easy. It may be useful in children with ballooning and those with milder grades of phimosis.
  • Steroid ointments are a recent management strategy for this problem and have cut down the surgical rates for this condition by almost 80%.  Steroid ointments are very effective in those with mild to moderate degree of phimosis especially if the foreskin is soft and there have been no repeated attacks of local infection. It is applied locally twice daily for 2-4 weeks, it is very important to choose the correct steroid compound and concentration otherwise side-effects may be seen.
  • Circumcision and preputioplasty are the surgical alternatives for severe grades of phimosis and in those children where the foreskin is thickened and the above strategies have failed.
 
How do you care for the uncircumcised penis?
Care of the uncircumcised infant is easy. We do not recommend pulling back on the foreskin to expose the tip of the penis (glans penis). As the boy gets older, the natural processes of erections and accumulation of old skin remnants between the inner foreskin and glans cause the foreskin to eventually separate from the tip of the penis. By age 4-5 years the foreskin should pull back easily, but it is not until puberty that it is necessary for boys to pull the foreskin back daily to clean the penis except when symptoms of infections or irritation are seen.
 
When is circumcision recommended?
  • Certain medical reasons: vesicoureteral reflux, kidney or bladder infections - The foreskin may be a source bacteria for urinary tract infections, and circumcision may be a good idea in boys with any underlying kidney abnormality.
  • Posthitis (inflammation of the foreskin)
  • True phimosis (narrowing of the foreskin) which has not responded to medical therapy.
  • Parents for family, cultural, or religious reasons may request circumcision.
Although circumcision is often done shortly after birth, the procedure may be delayed for certain reasons:
  • the newborn infant may be too ill, in which case an elective circumcision when the infant is well can be arranged
  • the infant may have an abnormality of the penis such as hypospadias or chordee, in which case the foreskin should be left in place for use in later reconstructive surgery
 
Can Phimosis be managed medically?
Yes, for selected cases with phimosis medical treatment with ointments and daily cleaning may work and avoid a surgery. This can be decided only after a thorough history and clinical examination. We have personally treated more than 200 babies with phimosis successfully with medical therapy.
 
How is circumcision done?
Circumcision is a minor surgical procedure which is done in operating room under a mild anesthesia. After excising the excess skin and ensuring hemostasis (control of bleeding), fine absorbable stitches are used to approximate the layers of skin. A transparent plastic wrap dressing is placed over the penis and it generally falls off in 3-4 days. The child is discharged to home the same day.
 
How is the penis cared for after circumcision?
We suggest antibiotic ointment or Vaseline be applied to the glans with every diaper change after circumcision. Bathing can be given (including warm tub baths) 4-5 days after surgery, this will also help the dressing to ease away in case it has not fallen off by itself in 3-4 days. We like to see the patient 1-2 weeks after circumcision. Penis tends to swell up a little for some days and then gradually comes back to normal shape in a weeks time.
 
Cases Case 1
 
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