By term phimosis we understand such narrowing of the prepuce, which makes it’s retraction impossible or causes pain or discomfot during erection.In children this definition must be corrected. Thay often have narrow, unretractable, fragile prepuce. This state is absolutely normal and should not be forcibly corrected more of less till fourth birthday. Thereafter some inagressive treatment is acceptable – usually strong steroid oinment – Dermovate.
Another feature of infantile penis is strong adhesion of the prepuce to the glans. As a result dead epithelial cells collect under the adhesion forming white or yellow deposits. There is nothing wrong in them, but sometimes they get infected. They transform to pus, reddening and oedema of the prepuce follows. In most of this episodes there are no serious complaints. Most children play and function normally, only occasionaly turning attention to the penis. It takes about 3 days for the pus to evacuate sponataneously, then the oedema and reddening vanish.
In about 10% of cases of balanitis and in children after prior traumatic intervention (which are more prone to express discomfort) symptoms force parents to consult pediatric surgeon. Surgical intervention should be modest, aimed at letting the pus out, not at widening oedematus prepuce and “cleaning” the glans.
Tendency for praeputial adhesion sometimes persists till adolescency, until male hormones influence the tissues. Probably is it justified to correct it at age 10 or 11, before young boy starts to interest in his sexuality. In this age almost all boys can be motivated and the procedure is not so emotionally devastating.
Another condition encountered in infantile glans is short frenulum. Usually there is no hurry in correcting this. For a few men this is very sensitive place essential for sexual pleasure. So it seems resonable to wait till adolescense to let the young man decide. From the other hand short frenulum sometimes is a cause or a part of real phimosis configuration. When we operate on phimosis we should release it.
A “true” phimosis is “balanitis xerotica obliterans”. It is a condition of unknown etiology, characterized by scarring of the preputial tip, whitish apperance of this with tendency for epithelial cracking. First choice of treatment is strong steroidal oinment for 3 weeks – Dermovate. If it doesn’t help surgical treatment is indicated. It can be complete or partial circumcision. Partial cirumcision, though desirable from cultural point of view, sometimes turns out to be insuffitient. The scarring process, of dermatological origin in fact, continues to proceed. treatment can be really challenging if one wants to save the prepuce. Other treatment modalities include local immunosupression (Protopic) or big doses of vitamin E.
Surgical treatment of phimosis is performed in shallow general anesthesia. Requires 3 hours admission. Analgetics (paracetamol) are desirable during first 24 hours. Final effect is visible after 3 months.