Phimosis 

• Due to normal adhesion of the foreskin to the glans. 
  • Common in male children up to 3 years of life.
  • Can be seen even into the teenage years.
• Does not require surgical correction.

• Due to scar tissue formation that prevents retraction of the foreskin.
• Often associated with: 
  • commonly due to repeated attempts to forcibly retract the foreskin before it has become naturally retractable 
  • Recurrent balantitis or balanoposthitis
  • Balanitis Xerotica Obliterans (BXO) from penile lichen sclerosis an aggressive scarring condition (very rare <8 yo)
• Requires correction and, potentially, circumcision.

• Normal tissue adhesions prevent full retraction.
• There is no scar tissue.
• The preputial outlet is always closed and the glans is not visible, unless retractile force is applied to foreskin (and then only a small area of the glans, if any, is visible).
• With gentle retractile force, the inner mucosal surface everts through outlet. [McGregor, 2007] 
  • Said to “Open like a Flower” (the visual image is odd).
• Ballooning can be seen with physiologic phimosis. 
  • Occurs due to a tight orifice, but a distensible preputial sac.
  • Urination leads to ballooning of the prepuce.
  • Not found to be associated with obstructive voiding and not a mandate for circumcision. [Babu, 2004]

• Scar tissue prevents retraction of the foreskin.
• The scar tissue will often hold the preputial outlet open, exposing a portion of the glans without retractile force being applied.
• Inner mucosal will not evert through the outlet when retractile force applied.

Features

• Obvious ring of scar tissue visible at foreskin opening
• Foreskin not retractable at the conclusion of puberty
• Previously retractable foreskin becomes non-retractable
• Persistent ballooning of foreskin on urination in older children, with pinhole foreskin opening, narrow urinary stream and no response to topical steroid creams
•  

• • Education and reassurance!
  • Hygiene 
    • Families and children should be taught to GENTLY retract the foreskin to the point of resistance during bathing and urination.
    • It should not be forcefully retracted (as this may lead to scarring!). [McGregor, 2007]
  • 6-8 week course of topical steroids can help accelerate the normal process if this is desired. 
    • 0.05% betamethasone 
    • 0.1% triamcinolone
  • • applied to preputial outlet BID
• If no / poor response to steroids, pathologic phimosis is likely. Refer to Urology services

• Circumcision is the default answer, but…
• Steroids have been shown to be effective in cases of mild scarring and can help avoid circumcision. 
  • If phimotic ring persists after steroid therapy, then circumcision is necessary. [Esposito, 2008]