Practice 10-Minute Consultation

Phimosis in childhood

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f3678 (Published 20 June 2013) Cite this as: BMJ 2013;346:f3678

This article has a correction. Please see:

  1. Tamsin Drake, core trainee year 2 doctor, surgery1,
  2. Jane Rustom, general practitioner2,
  3. Melissa Davies, consultant urologist1
  1. 1Salisbury District Hospital, Urology, Salisbury, UK
  2. 2New Street Surgery, Salisbury
  1. Correspondence to: T Drake tamsindrake{at}hotmail.com
  • Accepted 1 March 2013

A 3 year old boy is brought to your surgery by his parents with the complaint of a “tight” foreskin. They are concerned because his foreskin has never retracted fully, despite daily attempts to pull it back during bath time over the past few months. They are particularly alarmed as his foreskin seems to “balloon” during micturition, and wonder whether he needs circumcising.

What is phimosis?

The prepuce (foreskin) is the retractile covering of the head of the penis (glans). During neonatal development the foreskin is normally non-retractile due to adhesions, which fuse the inner epithelial lining of the foreskin on to the glans. Non-retractile foreskins are therefore common among young boys and form a normal stage in development. At age 3 years, up to 10% of boys will have completely non-retractile foreskins, and a further proportion will have partially retractable foreskins due to persistent adhesions, which are present in almost 75% of 5 year old boys. Over time, the foreskin gradually becomes retractile due to intermittent erections and keratinisation of the inner foreskin.

Phimosis is a condition in which the foreskin cannot be retracted over the glans. This may be physiological, because of the reasons mentioned above, or may be due to pathological scarring of the foreskin. This scarring often appears as a contracted white fibrous ring around the preputial outlet, and in older children (>5 years old) may be due to balanitis xerotica obliterans (see fig 1). This chronic scarring condition (akin to lichen sclerosus) appears as itchy or sore areas of white discolouration in the genital skin. The true incidence of the condition is unknown, but its presence has been reported in up to 40% of foreskins sent for analysis after paediatric circumcisions performed for phimosis, with a peak incidence occurring at around 10 years of age.

Figure1

Fig 1 Typical white fibrotic ring of balanitis xerotica obliterans. Reproduced with permission from Becker K. Lichen sclerosus in boys. Dtsch Arztebl Int 2011;108:53-8.

What you should cover

History

Ask about the presence of the following, which may be complications of a pathological phimosis:

  • Infections of the foreskin or glans

  • Painful foreskin or erections

  • A weak urinary stream or dysuria

  • Episodes of acute urinary retention

  • Urinary tract infections.

Parents are often alarmed about “ballooning” of the foreskin during micturition (fig 2), but this simply represents pooling of urine under the foreskin, which can occur if the inner layer of the foreskin is physiologically separating from the glans before the foreskin has become fully retractable.

Figure2

Fig 2 “Ballooning” of the foreskin during micturition. Reproduced with permission from Springer Images (www.springerimages.com/Images/MedicineAndPublicHealth/2-PEDIA01-18-026D)

Examination

Inspect for

  • Normal, healthy, pink mucosa pouting or “flowering” outwards on attempted retraction of the foreskin (fig 3)

  • Abnormal scarring of the preputial orifice or a white fibrotic ring suggestive of balanitis xerotica obliterans (fig 1)

  • Erythema and oedema of the foreskin and glans (balanoposthitis) or glans in isolation (balanitis).

Figure3

Fig 3 Physiological “flowering” of the foreskin. Reproduced from Malone P, Steinbrecher H. Medical aspects of male circumcision. BMJ 2007;335:1206-9.

Other possible examination findings are:

  • Smegma—A harmless substance consisting of shed skin cells and sebaceous secretions that may become trapped under the foreskin and aggregate to form small lumps or “pearls”

  • Paraphimosis—Occurs when the foreskin is left retracted for an extended period, leading to swelling that causes the foreskin to become painfully stuck behind the glans. It requires prompt manual reduction, but does not necessarily mean that circumcision is inevitable

  • Megaprepuce—A rare congenital condition characterised by excessive inner preputial skin in combination with a phimotic ring. It classically presents as a “ballooning scrotal mass” on voiding (due to urine collecting underneath the baggy foreskin), which is drained by compressing the scrotum.

What you should do

Reassure parents that when the foreskin itself is healthy (not scarred) phimosis is a normal part of development and does not pose any immediate health risks. The condition will generally resolve with time and good foreskin hygiene (see box). Furthermore, there is no evidence to suggest that having a physiological phimosis leads to a pathological one at any stage.

Guide for parents on preputial hygiene

  • Leave the foreskin alone until it shows an ability to retract

  • Once the foreskin is mobile, gently retract it during voiding and bathing; children can be taught to do this themselves and will normally stop if they experience any discomfort

  • If your son has frequent bouts of soreness and redness at the end of his penis encourage him to pull up any slack in his foreskin during voiding and then shake and dab it dry afterwards

  • Do not forcibly retract the foreskin as this can create microtears in the foreskin, which may turn into scar tissue

  • The foreskin can be cleaned during routine bathing, where it can be pulled back and gently rinsed with water. Avoid the use of soaps and bubble bath, which can cause irritation. Once dried with a towel, the foreskin must always be replaced into its original position to prevent it getting stuck behind the head of the penis

A short course (2-8 weeks) of topical corticosteroid (such as 0.05% betamethasone) applied twice daily to the tightest part of the foreskin can speed up the natural development process without systemic side effects.

If there is evidence of balanoposthitis or balanitis, attempt to swab and send any purulent discharge for microscopy and culture. In many cases, inflammation of the glans simply represents chemical irritation caused by urine trapping under the foreskin, rather than true infection. Good foreskin hygiene therefore forms the mainstay of treatment. In refractory cases, however, short courses of an antifungal cream (such as clotrimazole) for a fungal infection or a combined steroid and antibiotic cream (such as Fucidin) or oral flucloxacillin for a bacterial infection may be useful.

Onward referral to a paediatric surgeon or urologist should be made in cases of foreskin scarring, recurrent balanitis or balanoposthitis (>3 episodes), voiding difficulties, and a pinhole meatus in the absence of an obvious prepuce. Under these circumstances, circumcision may be medically indicated.

Useful resources

Notes

Cite this as: BMJ 2013;346:f3678

Footnotes

  • This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.

  • Contributors: TD was the principal author. JR and MD supervised and provided senior input.

  • Competing interests: We have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Not commissioned; externally peer reviewed.