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PHIMOSIS

What is Phimosis?

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Phimosis is a medical condition in which the foreskin of the penis of an uncircumcised male cannot be fully retracted. Phimosis is usually referred as male problem, but can also happen to women: women suffer from clitoral phimosis (in this article we will discus phimosis in men only). Phimosis can occur at any age, but the highest incidence is seen in infancy and adolescence ( approximately 1% of males older than 16 years suffers from phimosis)                      

         

The term  phimosis denotes both physiological stage of development (it is not referred as disease), and a pathological condition, when phimosis can cause problems for a person. In most but not all infants phimosis is physiological rather than pathological, whereas phimosis in older children and adults is more often pathological than physiological.

In the literature the true definition of phimosis has been confused. Essentially, there are two entities, and they are based on age and pathophysiology: congenital or primary phimosis, and acquired or secondary phimosis (or secondary phimosis of a lichenoid or fibrous type).

Both terms denote the inability to retract the distal prepuce over the glans penis; however once the foreskin

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can be retracted so that the glans penis partially appears, a phimosis is no longer present.

  Phimosis is not a disease- phimosis is a condition.        

Primary or congenital phimosis is the condition when subject had phimosis ever since he can remember. Treatment in this case usually includes gentle stretching, since there is a reason to believe that gentle stretching will mobilise the elastic capacity of the skin tissue.

Secondary phimosis of a lichenoid or fibrous type is a phimosis, when subject can remember developing phimotic ring. In these cases such types of phimosis are prone to degeneration and are generally difficult to stretch. In some cases steroids may help, but recurrent problems require surgery.  

There is one more term we have to define: paraphimosis. Paraphimosis is the entrapment of a retracted foreskin behind the coronal sulcus, and the condition occurs in the incorrectly circumcised or uncircumcised penis.

While primary and secondary phimosis denotes aggravated o impossible retraction of foreskin over the glans penis, typical of paraphimosis is edema, tenderness, and erythema of the glans or of the distal foreskin

Primary or congenital phimosis occurs on young children: infants and it is normal to have it into the  teenage years. Primary or congenital phimosis is physiologic, but does not cause any side problems, such as urinary obstruction, hematuria, or preputial pain. It is possible child suffers from congenital phimosis because of history of recent catheterization or of parents forcibly retracting the foreskin in an attempt to clean the glans.

Secondary or acquired phimosis also has several possibe causes: it most often occurs because of a history of poor hygiene, chronic balanoposthitis, but forceful retraction of a primary phimosis is also possible. Secondary or acquired phimosis is often followed by hematuria or preputial pain. Acquired phimosis is typical for both children and adults.   

Secondary or acquired phimosis, caused by poor hygiene and/or chronic balanoposthitis can eventually lead to paraphimosis.

Typical of paraphimosis is pain and edema of the uncircumcised or improperly circumcised penis. Even vigorous sexual activity has been reported to predispose one to paraphimosis. 

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Foreskin Contraction (phimosis)

How the Foreskin Develops in the First Couple of Years

The foreskin of a newborn boy is always closely contracted around the penis head (glans). Only a small passage allows the urine to pass through. In the first months the foreskin is stuck to the glans and cannot be pulled back and one should not attempt to do so.

During the first couple of years, the foreskin will become gradually looser and in many boys it can in time be pulled back without trouble. Half of all three-year-olds can pull back their foreskin.

It is not advisable to try pulling the foreskin back using force, since this may cause small cuts in the foreskin with scars which could finally cause a regular foreskin contraction.

Who Can Help?

A health visitor or GP will be able to give advice. If the foreskin is very contracted and stays so, causing recurrent infections and problems when urinating, then it may be necessary to operate.

Which Problems may follow Foreskin Contraction?

Foreskin contraction - also called phimosis - can last throughout life and not cause any trouble at all. It is a voluntary decision whether to have an operation or not. If any problems do arise they happen after puberty. The contraction may occur for the first time as an adult and usually requires an operation (circumcision).

  • There might be trouble urinating.
  • Infections may occur under the foreskin.
  • When infections are recurrent under the foreskin, a GP or health visitor should be consulted.
  • In many cases an infection can be avoided by cleaning regularly under the foreskin with lukewarm water.
  • At erection, a contracted foreskin may cause trouble by hurting when an attempt is made to pull the foreskin back. It may not go back over the glans before the penis is limp again.
  • Men may be able to have intercourse with a contracted foreskin but would probably manage better without this condition.
  • Very rarely, a malignant growth can occur in a long-standing foreskin contraction.

How is a Contracted Foreskin Treated?

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Many boys can be treated with a cream that contains a weak corticosteroid.

  • A GP can provide this treatment. The tip of the penis should be treated with the cream two to three times a day for two to three weeks at a time.
  • The foreskin must be pulled as far back as possible without using force before the cream is put on.
  • If this treatment does not work, an operation can help.

The operation for phimosis is usually done under general anaesthesia without any serious problems. The doctors may try to retain the foreskin in the operation where often a small cut is enough to loosen it up sufficiently for it to be pulled back without trouble.

An actual circumcision where the foreskin is removed completely is more often required in adults where the foreskin is thickened and scarred.

Check your Symptoms

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We want to make sure that you are definitely suffering from a tight foreskin and that the Homecure Program is going to be suitable for you.

Please compare yourself to the symptoms below to confirm that you suffer from tight foreskin/phimosis and to assess the severity of your symptoms:

Unable to completely pull back foreskin when flaccid and/or erect

Pain when pulling back or attempting to pull back foreskin when flaccid and/or erect

Foreskin dry, red, slightly swollen and/or tender

Foreskin is infected

If your symptoms are simliar or identical to those mentioned above not including the red then you will be able to cure yourself using the Homecure Program. The Homecure Program contains everything you need to know in order to cure yourself quickly, painlessly and discreetly from home. It is explained in great detail with annetations and photographs where appropriate. As customer satisfaction is our highest priority all customers receive free support via email for any questions that may arise and you are also protected by our 100% moneyback guarantee in the unlikely event you do not see results                 

What You Should Know?

If the foreskin of the penis is so tight that it can't be pulled back, the condition is known as phimosis (fim-O-sis). It is seen most frequently in children.

Care

If the boy is unable to urinate, seek medical attention at once. The doctor may need to thread a tube (catheter) into the tip of the penis, through the urinary canal (urethra), and into the bladder to drain the urine. If the boy can urinate, he may not need treatment right away. The usual remedy is circumcision to remove the foreskin.

What You Should Do?

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  • Do NOT use force to pull the foreskin back. This can cause scarring and make the condition worse. Clean under the foreskin regularly if possible.
  • In uncircumcised babies, the foreskin is normally tight. It usually doesn't start to loosen enough to be pulled back until the baby is at least 18 months old. Until then, leave the foreskin alone. Later, you may gently pull back the foreskin during bathing.

Call Your Doctor If...

  • There is redness, swelling, or drainage from the foreskin. These are signs of infection.
  • The boy has pain when urinating.
  • The boy gets a high temperature.

Seek Care Immediately If...

  • The boy has not urinated in 24 hours.

Treatment of Phimosis

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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.

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Although it is in generally- a common condition- not too many people have heard about the condition called phimosis. What exactly is phimosis? Well, it is defined as the inability of the prepuce, also called -the foreskin, to be retracted behind the glans penis. Of course- we are talking about uncircumcised males. What’s also interesting-a great majority of all males are born with congenital phimosis but this represents a benign condition that resolves in the great percentage of infants in their early childhood. It is also extremely important to point out that the phimosis in most infants is physiological rather than pathological, whereas phimosis in older children and adults is more often pathological than physiological. Although, it is mostly a condition that affects the males, women can also suffer from a similar condition called the clitoral phimosis. The most common symptoms are:

·          inability to retract foreskin

·          straining during urination

·          thin stream of urine

·          recurrent urinary infections

Good thing is that uncomplicated pathologic phimosis is usually acceptable to conservative medical treatment but patients should know that every failure of medical treatment is a secure indication for surgical intervention, usually in the traditional form of a circumcision or preputioplasty.

Relevant Anatomy

Everyone should know that the foreskin or prepuce is an integral, normal part of the penis. It normally forms an anatomical covering over the glans. It is interesting that the sensory receptors of the ridged band of the preputial mucosa may form part of the afferent limb of the ejaculatory reflex and that’s why it is important that all of these structures are fully functional. Like it was been told- the development of the prepuce is incomplete in the newborn male child. Separation from the glans and foreskin retractability occurs at a variable age.

Incidence of the Condition

Important thing to point out is that a commonly incidence statistic for pathological phimosis is 1% of uncircumcised males. Others have described incidences in adolescents and adults as high as 50%. Several researches done in the past have showed that only 4% of infants had a fully retractable foreskin at birth but that 90% did by age 3 years. This means that this condition could be, in certain occasions and age, considered to be physiological. Beside this, primary type- experts are saying that adult phimosis may also occur secondary to poor hygiene or an underlying medical condition.

Types of Phimosis & Possible Treatments
 

1. Infantile or Congenital Phimosis

Like it was already mentioned- this infantile phimosis has been widely recognized by the general practitioners for most of the last century. It is extremely important to point out that this foreskin cannot be easily retracted. There are several approaches to this type of phimosis and the most famous one where foreskin is being repeatedly retracted to free it from the glans. If this isn’t being done- later in life, a boy could experience pathological phimosis and urinary problems. Poor hygiene was thought to predispose to pathological phimosis. Oppositely to this approach- there are some experts that claim that forceful retraction that results in inflammation may actually contribute to pathological phimosis at an older age.

Another approach is presented in some physicians is based on routine neonatal circumcision. How come? Well, the fact is that circumcision really does prevent phimosis, although by some incidence statistics, at least 10 to 20 infants must be circumcised to prevent each case of potential phimosis. Although, so far, this infantile phimosis is mentioned only as physiological, the thing is that this isn’t the only case because not all infantile phimosis is simply physiological. Possible causes of these, pathological congenital phimosis, are:

¨        balanitis (inflammation of the glans penis)

¨        preputial stenosis or narrowness that prevents retraction

¨        a condition called- Frenulum breve

There are several management approaches to infant phimosis and some of the most common are topical steroid ointments and several other surgical techniques.

2. Acquired Phimosis

Reasonably- not all phimosis are the same! They can vary in severity, with some men able to retract their foreskin partially, condition called relative phimosis, and some completely unable to retract foreskin, condition called full phimosis. Of course- this first type- relative phimosis is more common, with estimates of its frequency at approximately 8% of uncircumcised men.  Exact medical graduation is next:

¨        Grade I - Fully retractable prepuce with stenotic ring in the shaft

¨        Grade II - Partial retractability with partial exposure of the glans

¨        Grade III - Partial retractability with exposure of the meatus only

¨        Grade IV - No retractability

Potential Complications of Acquired Phimosis

It is reasonable that acquired phimosis, if left untreated, can lead to several complications! Chronic complications of acquired (pathological phimosis) include: discomfort or pain during urination or sexual intercourse. How come? Well, it is simple- the urinary stream can be impeded, resulting in dribbling and wetness after urination. During sexual intercourse, or even during simple erection, patient could experience strong pain because of over-extension of the foreskin! Pain may occur when a partially retractable foreskin retracts during intercourse and chokes the glans penis. Although nothing of this is proven –the fact is that there is some evidence that phimosis may be a risk factor for penile cancer. Of course, all patients should know that the worst acute complication is paraphimosis. Paraphimosis is one acute condition characterized by the glans swollenness and strong pain. During this condition the foreskin is immobilized by the swelling in a partially retracted position. The contraction may occur for the first time as an adult and usually requires an operation (circumcision).

Review of possible complications:

·          There might be trouble urinating

·          Problems and pain during intercourse

·          Infections may occur under the foreskin

·          Frequent and recurrent infections under the foreskin which can be avoided by cleaning regularly under the foreskin with lukewarm water

·          At erection, a contracted foreskin may cause trouble by hurting when an attempt is made to pull the foreskin back

·          Although very rarely, there is a chance that a malignant growth can occur in a long-standing foreskin contraction.

Circumcision – Health Benefits 

Urinary Tract Infections

One of the most beneficial things about the circumcision is the fact that it has been promoted as a means of reducing the risk of urinary tract infections, which are more common in uncircumcised males younger than 6 months. Several researches have proven

that the risk in circumcised kids is approximately 1 in 1000, while the risk in uncircumcised kids is about 1 in 100.

Sexually Transmitted Diseases

Another very serious indication for circumcision is prevention of STDs. Although not too many people know about this- the fact is that a large number of case-control studies concerning the relationship between the foreskin and HIV infection have confirmed the present but not definite link. Another fact is that the United States has one of the highest rates of STDs, HIV infection, and male circumcision. Strange!

Penile Cancer

Timing of circumcision could also be amazingly important! Although it may sound impossible- the fact is that infant circumcision seems to decrease the risk of penile cancer, while the same thing but only -done later does not. Good thing is that penile cancer is a rare disease in the United States, with an incidence of 1.5 per 100,000 people. Direct proof of this the fact that the lowest incidence has been reported in Muslims and Jews and we all know that both of these groups have high rates of neonatal circumcision.

Diabetes Mellitus

Experts are claiming that this condition may be a presenting symptom of early diabetes mellitus. Where is the connection between these two conditions? Well, it is simple- when the residual urine of a patient with diabetes mellitus becomes trapped under the foreskin, the combination of a moist environment and glucose in the urine may lead to a proliferation of bacteria which can then progress to phimosis.

Circumcision & Sex

Experts today know that the presence of the foreskin actually enhances the sexual experience for men because it constantly moves over the head of the penis causing more friction and pleasure. Therefore, it is logical to assume that men will also lose much sensitivity to the glans if circumcised. Not only that- it is also proven that circumcised men will have to deal with discomfort and dry glans. The foreskin has many needed functions: protective, erogenous, sensory, and sexual physiologic.

 Treatmnet

Treatment for Phimosis by Dr. &  Hakeem Tariq Mehmood Taseer

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Complete Treatment of Phimosis

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