Phimosis, or the constriction of the foreskin is a physiological (normal) condition. The foreskin is not retractable in the majority of young males after birth. Later occurrence of phimosis is 8% between the ages of 6 and 7 and 1% between the ages of 16 and 18.
If a boy can freely urinate and does not suffer from repeated urine or preputial sac infections, previous foreskin injury caused by vigorous retracting, or paraphimosis, there is no reason to disturb the natural development of the foreskin. Parents as well as doctors should allow the gradual loosening and enlargement of the foreskin during the first years of life. By no means should the foreskin be retracted by force. It could be injured and scarred.
Phimosis treatment should start (provided there are no complications) at the age of about 3. The first treatment involves the local administration of steroid ointments. Treatment with a corticoid preparation is safe as the ointment only acts locally and the child’s hormone levels are not affected. The ointment is massaged into the foreskin two times a day for a period of 4-6 weeks. After a week of application, a very sensitive, gradual foreskin retraction may be started. This treatment should be done by a pediatrician.
Children with scarred foreskins, or whose corticoid ointment treatments have failed, should be referred by their GP to a children’s urology outpatient clinic. Independent examinations are performed by the children’s urologist. A physical penis examination is sufficient to establish the diagnosis and to make a decision about suitable treatment. The physician particularly concentrates on finding out whether the foreskin constriction is primary, congenital, or secondary, caused by infection or vigorous retraction. A child’s urologist proposes the treatment after the examination. The options are to continue the conservative treatment (ointment) or to perform a circumcision (partial or full).
We must distinguish between phimosis and conglutination, which is an adhesion of foreskin to glans. Such conglutinations are again a normal finding. The majority of such natural conglutinations disappears in 90% of boys during their first 2 or 3 years of life because of glans surface and inner foreskin surface maturation along with penis erections. In the case of conglutination, we recommend regular penis hygiene and sensitive retraction of the foreskin, if possible. Conglutination is only treated where there are complications such as foreskin or urinary tract infections.
Circumcision is performed in indicated cases only, i.e if it is inevitable. We respect parents‘ wishes. The circumcision can be partial or full (total).
In partial – plastic circumcision, only the narrowed part of the foreskin is removed so that the remaining part covers the glans and the outer circumference of the preputial sac is dilated and can be pulled back freely. Any conglutinations are removed, the potentially tight frenulum is extended and the narrowed urethral orifice is dilated. In full circumcision, the whole foreskin is removed and the glans remains exposed permanently. Full circumcision is usually performed when there is a suspicion of balanitis xerotica obliterans, for which circumcision is an effective treatment.
The hospital stay is usually 3 days (1st day admission, 2nd day surgery, 3rd day discharge).
As with any surgery, complications may be associated with circumcision. Their occurrence is between 0.2 – 3 %. The most common complication is bleeding or infection of the wound, while subsequent constriction of the outer urethral orifice is less common. Phimosis may recur after partial circumcision. It is important that parents take care of their child’s penis in the post-operative period. A urologist usually checks the progress of healing and the cosmetic effect two to three weeks after surgery.
25-30 % of men have been circumcised worldwide. Many studies have shown that circumcision has no effect on a man’s sexual life. On the other hand, a reduction in HIV and HPV infection has been reported in circumcised men.