PHIMOSIS IN BOYS

PHIMOSIS

Phimosis is defined as the inability to retract the foreskin or prepuce covering the glans of the penis.(Fig 1) Phimosis is divided into two types: physiologic and pathologic.

Phimosis is normal in uncircumcised babies and toddlers, as the foreskin is still attached to the glans. It will start to detach naturally between 2 and 6 years of age, though it might happen later. It can happen at up to around 10 years old, in some boys. The foreskin can be pulled back behind the glans in about 50 percent of 1-year-old boys, and almost 90 percent of 3-year-olds. Phimosis will occur in less than 1 percent of teenagers between 16 and 18.(1)

It is most likely to occur in older boys with:

• repeated urinary tract infections

• foreskin infection (Balanoposthitis) (Fig 2)

• repeated rough handling of the foreskin

• Lichen sclerosus et atrophicus or Balanitis Xerotica Obliterans (BXO). This condition causes scarring on the foreskin that can lead to phimosis. It may be caused by a urinary irritation, and can lead to meatal scarring. It is also a premalignant condition. (Fig 3)

• foreskin trauma many occasions due to zip of trousers. (Fig 4)

• prepucial skin could be secondarily involved : 1.Eczema A long-term condition that causes the skin to become itchy, red, dry, and cracked. 2.Psoriasis: This skin condition leads to patches of skin becoming red, flaky, and crusty. 3.Lichen planus: An itchy rash that can affect different areas of the body. It is not contagious.

Management

Conservative Management

1. Reassuarance and follow-up recommended for those boys with Phimosis with open meatus and no associated morbid conditions as majority of them will have natural separation of prepuce.

2. Asyptomatic: majority of boys will do good with topical application of Mometasone furoate 1% twice daily for 4 weeks followed by gradual retraction of prepuce and cleaning during bath till such time as the child learns to do it himself.( Khope) (2)

Indications for surgery

· BXO

· Recurrent balanoposthitis

· Paraphimosis

· UTI due to VUR, UVJO, PUV

· Ritual circumcision

· Skin of prepuce is also a ready source of grafting especially facial areas in facial trauma,facial burns with scarring in boys with skin loss, reconstruction urethroplasty for stricture urethra.This is a hairless skin and suitable for grafting in such conditions.

Paraphimosis

Retraction of a narrow prepucial skin ring beyond the corona glandis constricting the glans and subsequent oedema is called as paraphimosis.( Fig 5 ) This can also lead to necrosis of glans and terminal urethra at the site of the prepucial stricture ring. Surgical intervention is urgent and consists of manual reduction whenever feasible ( Fig 6) or dorsal slit of the prepucial ring. Circumcision is simultaneously done when glans oedema is not massive in which case it is deferred for later date.

Circumcision Methods

Day care procedure, I always counsel the parents to give sitz bath to all boys one week prior to surgery at least once a day before regular bath to develop the habit so that post-operative care is simple and easy.

Caudal anestheia is prefered in younger boys for surgery and immediate post operative pain releif. Where as penile block is recommended in older boys.

Bipolar diathermy is always used for haemostasis. No dressings are used.

It is preferable to use 4 or 5 ‘0’ catgut four to five sutures for approximation.

Sitz bath is recommended three or four times a day for painless and contactless wound care; local antibiotic ointment to prevent infection and forms an oily layer to prevent the adherence of dress to the exposed glans thus makes the child comfortable.

After prepuciolysis it is always safer to inspect the glans for epispadias, MIP variant of hypospadias which are hidden before prepuce is separated from glans. Even for ritual circumcision a stenotic glandular urethral opening at the caudal end of glans pit can sometimes be missed. Hence circumcision is contraindicated in such cases. Penile skin is also required for reconstruction in Buried penis.

When BXO is suspected, histopathology of the excised prepucial skin is recommended to confirm the pathology. Such patients need to be followed to rule out meatal stenosis as the terminal urethra is ectodermal in origin and could be also involved by the diseases affecting the prepuce . A metal dilator should be passed through the meatus to rule out meatal stenosis due to involvement by the lichen sclerosus process. I also recommend local steroid ointment for six weeks post operatively to prevent stenosis.

References

1. Gairdner D. The fate of the foreskin. Br Med J 1949; 2: 1433-1437.

2. Khope S. Topical Mometasone furoate for Phimosis in boys.

INDIAN PEDIATRICS 2010 ; 47: 282.