Conservative Contemporary Treatment of Phimosis

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Conservative Treatment of Phimosis: Alternatives to Radical Circumcision

This page provides information on conservative treatments of foreskin problems such as phimosis and preputial stenosis. In accordance with standard medical ethics, these treatments avoid unnecessarily radical surgery, and preserve normal physiologic function of the patient's body. Note: Reports suggest that external irritants and other environmental factors may cause the foreskin to tighten. One such irritant that is suspected are the chemicals contained in bubble bath. Intact boys are urged to avoid the use of bubble bath. When tightness of a previously loose foreskin occurs (acquired phimosis), environmental factors and general state of health should be investigated before circumcision or conservative treatment is considered. For example, circulatory problems may cause edema of the prepuce and result in non-retractable foreskin.

What is "phimosis?"
This section was written by pediatrician Robert Van Howe, MD, FAAP.
"Phimosis" is a vague term. In common usage, it usually means any condition in which the foreskin of the penis cannot be retracted. Most infants are born with a foreskin that does not retract. This is normal! "True" phimosisbetter termed "preputial stenosis," because "phimosis" has so many different definitions it now is devoid of any useful meaningoccurs in less than 2% of intact males. The incidence of preputial stenosis in circumcised men is actually similar. Of these 2%, 8595% will respond to topical steroids. Of those who fail this, at least 75% will respond to stretching under local anesthesia, either manually or with a balloon. The arithmetic is simple: At the very most 7 boys in 10,000 may need surgery for preputial stenosis. No wonder the Canadian Paediatric Society calls circumcision an

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"obsolete" procedure! There are several alternatives to radical circumcision which preserve the function of the prepuce and result in less morbidity (pain, bleeding, complications). The best article to check out is the 1994 piece by Cuckow et al. After all, why would you want to lose all of those Meissner corpuscles, the same nerve complexes which provide fine touch to the fingertips?

The ``Phony Phimosis Diagnosis''

The prepuce of boys may be tight until after puberty.1,7,8 This is an entirely normal condition and it is not phimosis. According to the experience in cultures where circumcision is uncommon, this tightness rarely requires treatment. Spontaneous loosening usually occurs with increasing maturity.1,7,8 One may expect 50 percent of ten-year-old boys; 90 percent of 16-year-old boys; and 98-99 percent of 18 year-old males to have full retractable foreskin. Treatment is seldom necessary. If treatment should be necessary, it should not be done until after puberty and the male can weigh the therapeutic options and give informed consent.8 It is important to note that the immature foreskin of a child must not be forced back for "cleaning" or for any other reason, because this will cause damage to the developing tissues. The child should be instructed that his foreskin will eventually retract. The first person to retract the foreskin should be the child himself. Rickwood and colleagues provide a specific medical definition of phimosis: True phimosis is tight non-retractable foreskin caused by Balanitis Xerotica Obliterans (BXO) and is distingished by a whitish ring of hardened sclerotic skin at the tip of the prepuce.2,10 Histologic examination by a pathologist is necessary to confirm the diagnosis.2 If BXO is not present, then true phimosis is not present.2,10 A number of reports in the medical literature of the United Kingdom indicate that medical doctors are not trained to distinguish between normal developmental tight prepuce in boys and pathological phimosis.3,4,5,6,11 This results in cases of misdiagnosis of normal developmental preputial tightness as pathological phimosis in the UK.3,4,5,6,11 CIRP has received numerous reports to indicate that normal preputial narrowness in boys in the United States is frequently being misdiagnosed as pathological phimosis. CIRP believes that the situation in the United States is certainly not better, and probably much worse, than the situation in the United Kingdom. Parents of intact boys are also frequently improperly instructed to force the immature foreskin back for cleaning, contrary to the recommendations of the American Academy of Pediatrics. As a consequence of misdiagnosis and confusion of normal developmental narrowessness and non-retractablity with pathological phimosis, many unnecessary circumcisions are performed. Shankar and Rickwood found that the number of circumcisions being performed in the United Kingdom is 8 times greater than the

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number required.10 The number of unnecessary circumcisions performed in the United States is unknown. Circumcision is now recommended only in confirmed cases of phimosis caused by balanitis xerotica obliterans (BXO), however newer treatments may eliminate the need for circumcision. BXO is recognized by a hardened area of whitish skin near the tip of the foreskin which prevents retraction.2,9,10,11 Shankar and Rickwood found a low incidence of only 0.4 of 1000 boys per year, and only 6 in 1000 by age 15.10 See Balanitis Xerotica Obliterans for more information. Other cases of non-retractile foreskin respond to conservative, non-destructive, non-traumatic, less costly treatment. Library holdings
1. Jakob ster. Further fate of the foreskin: Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys.. Arch Dis Child (published by the British Medical Association), April 1968. p. 200-202. 2. Rickwood AMK, Hemalatha V, Batcup G, Spitz L. Phimosis in boys. Brit J Urol 1980;52:147-150. 3. Rickwood AMK, Walker J. Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence? Ann R Coll Surg Engl 1989;71(5):275-7. 4. Griffiths D, Frank JD. Inappropriate circumcision referrals by GPs. J R Soc Med 1992; 85: 324-325. 5. Andrew Gordon and Jack Collin. Save the normal foreskin. Br Med J 1993;306:1-2. 6. Nigel Williams, Julian Chell, Leela Kapila. Why are children referred for circumcision? Brit Med J 1993; 306:28. 7. Kayaba H, Tamura H, Kitajima S, et al. Analysis of shape and retractability of the prepuce in 603 Japanese boys. Journal of Urology, 1996 Nov, V156 N5:1813-1815. 8. Warren JP: NORM UK and the Medical Case against Circumcision. In: Sexual Mutilations: A Human Tragedy; Proceedings of the 4th Intl Symposium on Sexual Mutilations , Denniston GC and Milos MF, Eds. New York, Plenum, 1997) (ISBN 0-306-45589-7) 9. Van Howe RS. Cost-effective treatment of phimosis. Pediatrics 1998; 102(4)/e43. (Link to www.pediatrics.org) 10. Rickwood AMK. Medical indications for circumcision. BJU Int 1999: 83 Suppl 1, 45-51. 11. Shankar KR, Rickwood AM. The incidence of phimosis in boys. BJU Int 1999 Jul;84(1):101-2. 12. Donnell SC. Diagnosis and treatment of phimosis. In: George C. Denniston, Frederick Mansfield Hodges, Marilyn Faye Milos (eds). Male and Female Circumcision: Medical, Legal, and Ethical Considerations in Pediatric Practice. Kluwer Academic/Plenum Publishers New York, Boston, London, 1999.(ISBN 0-306-46131-5) 13. Rickwood AMK, Kenny SE, Donnell SC. Towards evidence based circumcision of English boys: survey of trends in practice. BMJ 2000;321:792-793. (Link to www.bmj.com) 14. Spilsbury K, Semmens JB, Wisniewski ZS. et al. Circumcision for phimosis and other medical indications in Western Australian boys. Med J Aust 2003 178 (4): 155-158.

Treatment of Phimosis
Contemporary Medical and Surgical Treatment
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Medical science has developed three classes of treatments other than radical circumcision for a narrow foreskin. The first treatment is medical by topical application of an ointment to the prepuce; the second is gradual stretching of the opening of the prepuce to make it wider; and the third is surgical reshaping of the prepuce opening to make it wider. The three treatments are discussed below.

Topical Medication
The 1990s have seen the advent of the use of topical steroidal and nonsteroidal medication for the treatment of narrow foreskins (phimosis) in boys. Topical steroid ointment is now the treatment of choice for phimosis, due to low morbidity, lack of pain or trauma, and low cost. Reports in the medical literature from Sweden, Norway, Denmark, Italy, France, Australia, Serbia, and the United States have demonstrated the efficacy of topical steroid ointment in the relief of preputial stenosis in boys. The application of steroid ointment to the foreskin has the effect of accelerating the normal growth and expansion of the foreskin that occurs over several years and which usually results in the spontaneous relief of the non-retractile condition. Narrow foreskins usually eventually widen without treatment. The treatment is non-surgical. There is no trauma and no surgical risk. The treatment is inexpensive. The foreskin and all of its protective, erogenous, sensory, and sexual physiologic functions are preserved. A success rate in the range of 85-95 per cent is reported. Treatment of narrow non-retractile prepuce with topical steroid ointment is now recommended by the American Academy of Pediatrics in its 1999 Circumcision Policy Statement. CIRP presents a bibliography of the medical articles on the use of topical steroid ointment in the treatment of phimosis. Scientists in have conducted research in the use of topical steroid ointment in the medical (not-surgical) treatment of non-retractile foreskin. All have found that the medical treatment is safe, and has about an 85% success rate. Yilmaz et al. recommend the use of topical steroid ointment to avoid the anxiety, stress, and trauma caused by circumcision. Articles are listed in the approximate order of publication. Library holdings
Lang K. Eine konservative Therapie der Phimose [A conservative therapy for phimosis]. Monatsschrift der Kinderheilkunde 1986; 134: 824-5. Meyrick Thomas RH. Ridley CM. Black MM. Clinical features and therapy of lichen sclerosus et atrophicus affecting males. Clin Exp Dermatol 1987; 12: 126-128. Fortier-Beaulieu M, Thomine E, Mitrofanof P. Laurent P. Heinet J. Lichen scleroatrophique preputial de l'enfant. [Lichen sclerosus et atrophicus in children.] Ann Pediatr (Paris) 1990; 37: 673-676. Jorgensen ET, Svensson A. The treatment of phimosis in boys with a potent topical steroid (clobetasol propionate 0.05%) cream. Acta Derm Venereol 1993; 73: 55-6. Kikiros CS, Beasley SW, Woodward AA. The response of phimosis to local steroid application. Pediatr Surg Int 1993; 8: 329-32. Wright JE. Further to "the further fate of the foreskin". Med J Aust 1994; 160: 134-5. Wright JE. The treatment of phimosis with topical steroid. Aust N Z J Surg 1994; 64: 327-8.

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Jorgensen ET, Svensson A. Phimosis hos pojkar kan behandlas med steroid salva [Phimosis in boys can be treated with a steroid ointment.] (letter) Lakartidningen 1994; 91: 1291. Golubovic Z, Milanovic D et al. The conservative treatment of phimosis in boys. British Journal of Urology 1996; Vol 78: pages 786-788. Atilla M et al. A Nonsurgical Approach to the Treatment of Phimosis: Local nonsteroidal, Anti-inflammatory ointment Application. J Urol, July 1997, Vol. 158, 196-197. Dewan PA, Tieu HC, Chieng BS. Phimosis: Is circumcision necessary? J Paediatr and Child Health 1996;32:285-289. Marzaro M, Carmignola G, Zoppellaro F, et al. [Phimosis: when does it require surgical intervention?]. Minerva Pediatr 1997;49(6):245-8. Ruud E, Holt J. [Phimosis can be treated with local steroids]. Tidsskr Nor Laegeforen 1997;117(4):513-4. Van Howe RS. Cost-effective treatment of phimosis. Pediatrics 1998; 102(4)/e43. (Link to www.pediatrics.org) Chu CC, Chen KC, Diau GY. Topical steroid treatment of phimosis in boys. J Urol 1999;162(3 Pt 1):861-3. Monsour MA, Rabinovitch HH, Dean GE. Medical management of phimosis in children: our experience with topical steroids. J Urol 1999;162(3 Pt 2):1162-4. Pless TK, Spjeldnaes N, Jorgensen TM. [Topical steroids in the treatment of phimosis in children]. Ugeskr Laeger 1999;161(47):6493-5. Orsola A, Caffaratti J, Garat JM. Conservative treatment of phimosis in children using a topical steroid. Urology 2000;56(2):307-10. Berdeu D, Sauze L, Ha-Vinh P. Blum-Boisgard C. Cost-effectiveness analysis of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect. BJU Int 2001;87(3):239-244. Klyver H, Mortensen SO, Klarskov OP, Christiansen P. [Treatment of phimosis with a steroid creme in boys]. Ugeskr Laeger 2001;163(7):922-4. Dewan PA. Treating Phimosis. Med J Aust 2003 178 (4): 148-150. Ashfield JE, Nickel KR, Siemens DR, et al. Treatment of phimosis with topical steroids in 194 children. J Urol 2003;169(3):1106-8. Yilmaz E. Batislam E, Basar MM, Basar H. Psychological trauma of circumcision in the phallic period could be avoided by using topical steroids. Int J Urol 2003;10(12):651-6.

Dilation and Stretching

Skin that is under tension expands by growing additional cells. A permanent increase in size occurs by gentle stretching over a period of time. The treatment is non-traumatic and non-destructive. Manual stretching may be carried out without the aid of a medical doctor. The treatment is inexpensive. Relief of phimosis by a stretching technique has the advantage of preserving all foreskin tissue and the sexual pleasure nerves. The Beaug method has proved successful for many. Library holdings
Cooper GG, Thomson GJ, Raine PA. Therapeutic retraction of the foreskin in childhood. Br Med J Clin Res Ed 1983; 286: 186-7. Griffiths DM, Freeman NV. Non-surgical separation of preputial adhesions. The Lancet, Vol 8398 (August 11, 1984) No. 2: Page 344. MacKinlay GA. Save the prepuce: Painless separation of preputial adhesions in the outpatient clinic. BMJ 1988; 297: 590-1. Dunn HP. Non-surgical management of phimosis. Aust N Z J Surg 1989;59(12):963.

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Beaug M. Conservative Treatment of Primary Phimosis in Adolescents [Traitement Medical du Phimosis Congenital de L'Adolescent]. Saint-Antoine University. Paris VI. 1990-1991. He Y, Zhou XH. Balloon dilation treatment of phimosis in boys: report of 512 cases. Chinese Med J 1991; 104: 491-3. Lim A, Saw Y, Wake PN, Croton RS. Use of a eutectic mixture of local anaesthetics in the release of preputial adhesions: is it a worthwhile alternative? Br J Urol 1994; 73: 428-30. Beaug M. The causes of adolescent phimosis. Br J Sex Med 1997; Sept/Oct: 26.

Addendum: Turumaki Corporation in Japan claims to have invented a device for stretching the foreskin. They claim that success can be achieved in a number of weeks. (Note: CIRP does not endorse or promote any product or commercial site.) [CIRP Note: There now is an online bulletin board where men exchange notes regarding conservative treatment, especially stretching, of non-retractile foreskin. For more information, visit How to Fix Phimosis and Tight Foreskins, Solutions That Work.]

Combination treatment
There is one report from Italy regarding the use of topical steroid ointment and stretching in combination to effect relief of non-retractile foreskin. Library holdings
Zampieri N, Corroppolo M, Giacomello L, et al. Phimosis: Stretching methods with or without application of topical steroids? J Pediatr 2005;147(5):705-6.

Conservative Surgical Alternatives

Preputioplasty is the medical term for plastic surgery of the prepuce or foreskin. It is a more conservative alternative to the traditional circumcision or dorsal slit for the treatment of preputial stenosis or phimosis. Many doctors have proposed surgical alternatives to circumcision because of the many problems, risk, complications, and disadvantages inherent in circumcision. Advantages claimed for preputioplasty are more rapid, less painful recovery, significantly less morbidity, and preservation of the foreskin and its various protective, erogenous, and sexual physiologic functions. There are a number of articles is the medical literature describing various preputioplasty techniques. CIRP presents below a bibliography of articles known to us (there may be others.) The articles are listed in the approximate order of their appearance. Some of the procedures such as Y- and V- plasties are complex and require a skilled surgeon to perform properly. Consequently, they have not won favor. Many doctors recommend the "dorsal slit with transverse closure" procedure described by Cuckow, Rix, and Mouriquand. The American Academy of Pediatrics now

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recommends the Cuckow procedure in its 1999 Circumcision Policy Statement. The procedure is relatively simple to perform and gives good results. The newer lateral procedure described by Lane et al., however, may offer a cosmetic improvement over the Cuckow procedure. It moves the "slit with tranverse closure" from the top to the sides. Library holdings
Schloffer, H. Zur Technik der Phimosenoperation. Zentralblatt fr Chirugie 1901; 28:658-660. Marschner, G. Zur Technik der Phimosen-Operation. Methoden und Ergebinisse. Zentralblatt fr Chirurgie 1971; 96: 131-135. Diaz A, Kantor HI. Dorsal slit. A circumcision alternative. Obstet Gynecol 1971; 37: 619-22. Parkash S. Phimosis and its plastic correction. J Indian Med Assoc 1972; 58: 389-90. Kodega, G. and Kus, G. Operative treatment of phimosis by means of spiralo plastic operation of the foreskin. Urologija i Nefrologija (Moscow) 1973;38:56-57. Holmland DE. Dorsal incision of the prepuce and skin closure with Dexon in patients with phimosis. Scand J Urol Nephrol 1973; 7:97-9. Emmett AJ. Four V-flap repair of preputial stenosis (phimosis). Plast Reconstr Surg 1975; 55: 687-9. Gil Barbosa M, Aguilera Gonzalez C, Alipaz A, Garcia Sanchez JL. La balanolisis como sustituto de la circuncision. [Balanolysis as a substitute for circumcision] Salud Publica Mex 1976, 18: 893-9. Parkash S, Rao BR. Preputial stenosis--its site and correction. Plast Reconstr Surg 1980;66(2):281-2. Ohjimi T. Ohjimi H. Special surgical techniques for relief of phimosis. J Dermatol Surg Oncol 1981; 7: 326-30. Emmett AJ. Z-plasty recontruction for preputial stenosis---a surgical alternative to circumcision. Aust Paediatr J 1982; 18: 219-20. Codega G, Guizzardi D, Di Giuseppe P, Fassi P. Helicoid plasty in the treatment of phimosis. Minerva Chir 1983; 38(22):1903-7. Cooper GG, Thompson GJL, Raine PAM. Therapeutic retraction of the foreskin in childhood. Brit Med J 1983 286: 186-187. Hoffman S. Metz P, Ebbehoj J. A new operation for phimosis: prepuce saving technique with multiple Y-V plasties. Br J Urol 1984; 56: 319-21. Moro G, Gesmundo R, Bevilacqua A, Maiullari E, Gandini R. La circoncisione con postoplatica. Nota di tecnica operatoria. [Circumcision with preputioplasty: Notes on operative technique.] Minerva Chir 1988; 43: 893-4. Wahlin N. "Triple incision plasty." A convenient procedure for preputial relief. Scand J Urol Nephrol 1992; 26: 107-10. Cuckow PM, Rix G, Mouriquand PD. Preputial plasty: a good alternative to circumcision. J Pediatr Surg 1994; 29: 561-3. de Castella H. Prepuceplasty: an alternative to circumcision. Ann R Coll Surg Engl 1994; 76: 257-8. Leal MJ, Mendes J. A circuncisao ritual e correccao plastica da fimose. [Ritual circumcision and the plastic repair of phimosis.] Acta Med Port 1994; 7: 475-481. Ohjimi H, Ogata K, Ohjimi T. A new method for the relief of adult phimosis. J Urol 1995; 153: 1607-9. Van Howe RS. Cost-effective treatment of phimosis. Pediatrics 1998; 102(4)/e43. (Link to www.pediatrics.org) Pascotto R, Giancotti E. The treatment of phimosis in childhood without circumcision: plastic repair of the prepuce. Minerva Chir 1998;53:561-565. Lane TM, South LM. Lateral preputioplasty for phimosis. J R Coll Surg Edinb 1999:44(5):310-2.

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Saxena AK, Schaarschmidt K, Reich A, Willital GH. Non-retractile foreskin: a single center 13-year experience. Int Surg 2000;85(2):180-3. Fischer-Klein C, Rauchenwald M. Triple incision to treat phimosis in children: an alternative to circumcision. BJU Int 2003;92(4):459.

Traditional treatment of phimosis and paraphimosis in the classical medical literature

Frederick M. Hodges, D. Phil., an Oxford medical historian, has researched the classical medical literature. He presents his report on the treatment of phimosis and paraphimosis in antiquity.
Hodges FM. Phimosis in antiquity. World Journal of Urology 1999; 17(3):133-136.

Traditional treatment of phimosis in Western medicine

For many years, before modern methods had been developed, radical circumcision was the only treatment offered for tight foreskin. However, radical circumcision is now obsolete. It is more painful and has a more difficult recovery than the newer conservative treatments. Radical circumcision also destroys much functional tissue, results in severe loss of sexual sensation, and destroys normal male sexual-mechanical functioning. According to cost-benefit studies, radical circumcision is also the most expensive method of treating tight foreskin, but is still promoted by many medical doctors. Holman and Steussi provide us with an excellent description of this traditional but outmoded procedure. Choe and Kim provide a description and images of the traditional procedure.
Holman JR, Stuessi KA. Adult circumcision. American Family Physician 1999; March 15: 1514. (Link to www.aafp.org) Choe JM, Kim H. Phimosis, adult circumcision and buried penis. E-medicine 20 September 2001.

See also
Phimosis: Non-Retractile Foreskin

Paraphimosis
Paraphimosis is the term used to describe the condition that occurs when a tight foreskin is forcibly prematurely retracted and becomes trapped behind the head of the penis. Forcible retraction of a tight foreskin should be avoided. According to John P. Warren, MD, "Education concerning proper care of the prepuce is the most effective way of preventing paraphimosis from occurring." Parents, doctors, and other caregivers should be instructed to avoid forcible retraction of a boy's foreskin. Prolonged paraphimosis can become an emergency condition.1,3 If this condition persists the tissue may become oedematous and swell thus further aggravating the problem.3 First aid for this condition is simple. The head of the penis must be squeezed very tightly between thumb and forefinger. This forces blood out of

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the head and reduces the size. The foreskin can then be brought forward to its normal position. Application of ice may also be helpful.3 Hospital treatment with injection of hyaluronidase has been shown to be successful.1,3 Hyaluronidase works by reducing the oedema, after which the foreskin may be returned to its normal position. When the foreskin has been returned to its normal position, no further treatment is necessary. Some doctors recommend circumcision but there is no evidence in the medical literature to support this recommendation. Reynard and Barua recommend the puncture technique.2 Incisions are not necessary. Improved cosmetic outcome is claimed. Again no circumcision is necessary. Library holdings
1. DeVries CR, Miller AK, Packer MG. Reduction of paraphimosis with hyaluronidase. Urology 1996 48(3):464-465. 2. Reynard JM, Barua JM. Reduction of paraphimosis the simple way - the Dundee technique. BJU Int 1999;83(7):859-860. 3. Choe JM. Paraphimosis: current treatment options. Am Fam Physician 2000;62:2623-6,2628.

(File revised 12 July 2006)

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