Phimosis – Guess What, You’re Wrong.

So I see it said all the time that a ‘child under 18 can’t be diagnosed with phimosis’. So at 17 years 364 days, no.  A day later, yes?
No.

What is phimosis?

What is the definition of phimosis?

• Phimosis is the inability to retract the foreskin behind the glans in males.
• Phimosis is usually divided into physiologic and pathologic phimosis.
• Physiologic phimosis is the normal condition in which children are born with a tight foreskin and separation occurs during late childhood and early adolescence.
• Pathological phimosis occurs due to infection, inflammation, or scarring and is usually found in uncircumcised adult men.

However, pathological phimosis can occur in someone of any age.  Typically, once it is explained that children can, in fact, develop pathological phimosis it’s usually waved away with some accusation of premature forcible retraction.  Since we seem to have to start at the basics, what is retraction? It is when you pull the foreskin back toward the body of the child.  You can retract safely to the point of resistance, should you need to wipe poo or some other particulate off of the outside of the child’s penis, but most children cannot be fully retracted, which is when the foreskin can be fully pulled back over the head of the penis.  This was an old standard of care which was advised to parents with uncircumcised children in the past, but the current standard of care now says to simply wipe the outside without retraction.  So why did I just say you can retract to the point of resistance?  Because lets face it, if poo can get in there, it will get in there.  Intactivists make any retraction sound akin to ripping your child’s fingernail off, but just as if they go something under the top of the nail (NOT THE NAIL BED) you could easily clean that out without harming the child.  Same concept.  However, just like you would not force the nail off the nail bed, you should not force the foreskin back.  This is also not something that needs to or should be done routinely, but only in special circumstances.  Forcibly retracting the child can, and does, cause scar tissue to develop, which can also cause…you guessed it, phimosis.  However, many parents who I’ve seen talk about their sons having phimosis never retracted them.

How can that be?  Well, pathological phimosis can be due to anything from an unknown cause (idiopathic) to infection, inflammation to forced retraction or even eczema.  Yes, I keep bringing retraction up because it is actually a cause.  But intactivists blame pretty much any issue with the intact penis on premature forcible retraction.  Regardless of the individual case.

And here’s the thing about phimosis…it doesn’t require circumcision.  Steroid creams and stretching (pulling forward AND back to the point of resistance) work the majority of the time.  The small amount of time it doesn’t work (about 15-20% of the time) then a much less invasive surgery called a preputiaplasty, or modified dorsal slit, works.  Dorsal slit also works but it creates an unappealing ‘flap’.  However, phimosis is what is put on the form when circumcising an infant, which is code word for ‘unnecessary’, I guess.  Because they’re talking about physiological phimosis, and that is the normal inability to retract the foreskin.  This normal inability is not phimosis caused by disease or inflammation.  It generally resolves by puberty, and regardless, as I said above, there is no need for circumcision to resolve it even if it was pathological.

I can’t think of a good ending for this blog, so there you have it.  Enjoy.