Phimosis: symptoms and treatment
Phimosis is a «male» disease characterized by the inability to expose the glans penis. Phimosis, the symptoms of which can be considered as a normal physiological manifestation, and as a manifestation of the pathological, can be congenital, depending on the nature of the occurrence, or acquired.
Physiological phimosis is diagnosed in practically all healthy children (boys) under the age of 3 years, here it is not considered as a pathological condition. The causes of phimosis in this case are the epithelial gluing of the glans penis and the inner side of the foreskin. From the age of 3 to 6 years, there is a stretching of the prepuce sac, which is normally narrow, which, in turn, causes the formation of conditions for further opening of the head. In other words, within the indicated interval, with the accompanying physiological changes, the phimosis simply disappears.
As for the pathological manifestation of the disease, this phimosis occurs against the background of the narrowing of the foreskin, it, in turn, can be congenital or acquired. Congenital phimosis is characterized by the fact that the foreskin is reminiscent of the external «proboscis». When a disease such as balanoposthitis occurs before the moment of spontaneous opening in the child of the prepuce cavity, the inflammation that is relevant to it becomes the cause of tissue scarring in the foreskin area, against which they lose their inherent extensibility. Because of this, pathological phimosis also develops.
Meanwhile, the acquired phimosis can be not only the result of the transfer of diseases that affect the penis, but also manifest itself as a temporary condition. For example, the development of acquired phimosis may predispose infiltration of the foreskin or glans penis against the background of trauma or inflammation, edema, etc. Phimosis can also be manifested in a permanent form, that is, again, with the development of irreversible pathological processes, for example, When the scar tissue in the region of the glans penis, etc.
Phimosis, diagnosed in males aged 7 years and older, is considered a pathological condition of narrowing of the foreskin. It is important to take into account the fact that the inability to expose the glans penis may cause complications, not only if the pathological variant of the disease is manifested, but also under the condition of the variant of the physiological one. In general, the division of phimosis into physiological and pathological variants regarding the consideration of concomitant complications can be considered conditional, although practical importance is also present in it, it explains the further definition of suitable treatment tactics for the uncomplicated form of one of the actual variants of this disease.
The physiological form of phimosis is due to the gluing of the glans penis and the inner sheet of the prepuce. Phimosis pathological, in turn, develops, as we have shown above, against the background of certain diseases of the penis, against the background of balanoposthitis with concomitant narrowing of the foreskin as a result of scarring of this area, and also because of the trauma of the penis.
As for the causes of phimosis, which arose on the background of the previous normal state of the patient’s health, and therefore without previous inflammatory diseases or trauma, it is not always possible to find them here reliably. There is also a factor of genetic predisposition to the development of this disease, this predisposition is conditioned by the general insufficiency of the elastic component included in the structure of the connective tissue. As diseases often associated with the genetic form of phimosis, flat feet, varicocele, heart defects (in particular — heart valves) and a different type of disease can be designated.
Phimosis can also develop during puberty due to uneven development of the penis and foreskin. Already in the future, as one of the main reasons provoking the progression of narrowing of the foreskin area, this disease itself, that is, the phimosis itself, is considered. Because of constriction, the inner leaf of the foreskin is permanently injured, this is accompanied by scarring of the tissues, accompanied by a further narrowing in this background. As a supplement to this condition, there is an increased risk of micro-injury due to the appearance of erections in adolescents, due to masturbation, and also because of the onset and subsequent sexual behavior.
Depending on the peculiarities of the manifestation of phimosis, the corresponding degrees determining the classification of this disease are distinguished.
So, I degree phimosis is characterized by the ability to open the glans penis solely in resting conditions. An attempt to expose the head in its erect condition will invariably be accompanied by painfulness, and in general this will be accompanied by difficulties. II degree of phimosis is characterized by difficulties in removing the head in conditions of rest, the erect condition of the penis is accompanied by the impossibility of opening the head. grade III phimosis is characterized by the impossibility of opening the head, or perhaps its partial opening at rest with considerable effort to do so. Expression with erection is impossible, difficulties with urination at this stage of the disease there. The most severe form of the disease is IV degree of phimosis, when the penis head does not open even partially, due to which there are difficulties with urination. Urination in this case either occurs either by a thin stream, or by drip. Urination, like ejaculation, is accompanied in this case by the swelling of the foreskin like a sac.
In addition to the listed variants of phimosis classification, it is also customary to designate relative phimosis. This pathology is accompanied by a narrowing of the foreskin, which becomes noticeable and significant only under the condition of the erect condition of the penis. Relative phimosis appears as a tight type of constriction that forms below the opening head of the penis at its trunk. This condition is generally regarded as a norm, but only if there is no pain and other related problems (this condition, in general, is fair for attaching to the norm of any type of phimosis).
It should be noted that the shift in one side or another of the prepuce is difficult for many men during an erection, which can be accompanied even by the impossibility of the reverse closure of the head swelling in a state of excitement after a tight exposure. Occurs so often because the narrowed foreskin, as a result of pulling, begins to fold into the tightly covering trunk of a member of a tight roller behind a strained head, in particular a similar «scenario» is typical in the manifestation for Asians. In some cases, such a roller is difficult to pick up for further extraction due to the head. The penis shrinks so much that it strengthens the state of excitement, as a result of which the head becomes firmer than the trunk. For this reason, it is impossible to squeeze it, because of this, before weakening the erection, it is also impossible to push it back, which excludes a hole of the foreskin that is too narrow for this. The very weakening of erection in the short term is seen as an unlikely possibility. The condition that we have has a corresponding medical definition — paraphimosis.
We will supplement the above-mentioned features of the degrees of phimosis in that I and II of its degree may be accompanied by painful sensations arising at the time of erection due to the tightness of the narrow prepuce on the head. III and IV degrees, in turn, are characterized by the absence of pain during erection, which is already associated with very small sizes, which reached the preputial ring by this period, and also with the fact that the head opening became impossible.
Phimosis in children is manifested as such basic symptoms as impossibility of exposure of the head and inability to remove it. In some cases, phimosis is not accompanied by the appearance of any complaints, although more often children with phimosis face problems associated with urination. In particular, the process of urination can be accompanied by the need for a certain physical stress, in anxiety. The urine later becomes in the preputial cavity, which, in turn, swells, which causes the urine to flow through a narrow aperture either by a thin stream or by drops.
In some cases, the symptoms of phimosis may be supplemented by the symptoms accompanying the inflammatory process, thus manifesting themselves in the form of pains concentrated in the foreskin and head area, and also in the form of purulent discharge appearing directly from the foramen in the foreskin. As additional manifestations there is an increase in temperature, an increase in lymph nodes. When the paraphimosis is urgent for the patient, acute soreness arises due to pinching of the glans penis, which, moreover, increases in size, which is accompanied by cyanosis of the skin. With the development of this picture of the general condition against phimosis, it is necessary to apply urgently for the provision of qualified medical care.
Phimosis in men may be accompanied by some additional features. So, I-II degrees of manifestation of the disease are accompanied by the appearance of soreness during an erection against the background of a corresponding pull on the head of the prepuce. Because of the appearance of such symptoms, the problems with potency may subsequently develop, due to the fact that the patient during sexual intercourse is in a state of tension from waiting for the future appearance of soreness. To achieve III-IV degree of phimosis, soreness during erection disappears, which is explained by a significant narrowing of the preputial ring, which makes it impossible to expose the head.
Phimosis is accompanied by certain difficulties associated with hygiene measures in the area affected by the disease, because of this, stagnation of smegma develops. Smegma is a fat-like secret, produced by the glands of the foreskin. Accordingly, when it stagnates, sufficiently good conditions are created for bacteria, because of which the inflammatory process, which determines such a disease as balanoposthitis, can eventually develop. Because of the accumulation of a significant amount of stagnant smegma, in turn, it is possible to form smegmolites (preputial stones). The inflammation formed in phimosis can be treated with great difficulty, it is accompanied by scarring of the tissues of the foreskin, which leads to an even greater aggravation of the phimosis, and also the transition to the next stage of its manifestation (i.e., transition to the next degree)
Because of difficulty urinating against the background of phimosis, problems associated with bladder emptying and disorders in the upper urinary tract due to their decreased tone may develop. To top it off, a problem may arise, such as the formation of residual urine, which acts as a favorable factor for the development of urinary infections in the future.
Phimosis in children, combined with inflammation with balanoposthitis, can provoke enuresis — the problem of urinary incontinence at night. In addition, this picture of the disease can be accompanied by the development of spontaneous erections, which causes the child to have a corresponding situation of psychological trauma.
III and IV degree of phimosis is often accompanied by a partial increase in the head of the penis of the foreskin, also not uncommon and their full increment. Attempts to open the head are accompanied by soreness and bleeding. With such a course of the disease, there is a need for surgical intervention.
With the long existence of the disease, the possibility of its complication by tumors affecting the penis is allowed, which is caused by the persistence of the carcinogenic effect exerted by the smigma.
Attempts to self-open the head can lead to the development of paraphimosis, which, as we have already noted, is the infringement of the foreskin of the penis head. The exclusion of a doctor’s visit in such a case can lead to such a serious consequence of negligence in relation to the disease, like head necrosis. Closure of the head with extreme flesh is impossible, it becomes cyanotic, swells. The first aid in this case consists in calling the doctor, as well as in applying the cold. After 5 minutes after cooling, attempts are made to direct the head, the absence of the result necessitates further dissection of the pinched ring, which, of course, is performed by the doctor in a hospital.
Diagnosis and treatment
Diagnosis of phimosis does not require special measures, it is enough for it to make a general visual inspection, on the basis of which the diagnosis is made. In addition, a smear is taken for analysis — based on the results, the causes that triggered the inflammation are determined, unless, of course, it occurs in a specific case.
As for the treatment of phimosis, it can be medicamentous, non-medicamentous and surgical.
Non-pharmacological treatment of phimosis
As a basis for this type of therapy, the option of gradual manual extension of the prepuce is considered. The proposed method of treatment consists in the transition to masturbation with full stretching of the prepuce before the head is exposed. Stretching of the foreskin with tension on the head (without excessive activity) is carried out in a gradual manner, until the onset of pain. This action is performed every day, in time — from 5 to 10 minutes. In accordance with the gradual expansion of the opening, masturbation should take a somewhat more limited effect.
Treatment of phimosis is also allowed in the form of the following option: every day, ideally — during shower / bath (which is accompanied by an increase in the elastic qualities of the skin), pull the foreskin as much as possible without pain. Similarly, when urinating attempts are made to open the head with clean hands, the action is performed with weak efforts, without inflicting pain. In a period of 1.5-2 months to open the head so it will be possible even with the condition of pronounced phimosis.
The application of the gentle and gradual stretching technique determines the possibility of achieving effective results in opening the head in the physiological form of phimosis in the period of 1-2 months, with the hypertrophic form of phimosis in children such a result is achieved within 2-4 months.
Provided that there is no scarring, and if the elasticity is not lost by the flesh, the method of stretching can be successfully applied. There is such an impact in a hospital, with local anesthesia. Some surgeons carry plastic of the foreskin area, due to which there is a possibility of correction of the preputial ring (its diameter in particular) without concomitant excision of the foreskin.
We also add that in no case should attempts be made to sharply expose the head in phimosis from grade II and higher!
Medicamentous treatment of phimosis
As the main method of influence with drug therapy, the long-term and regular use of corticosteroid ointments applied to the foreskin and penis head is considered. Due to this, the elasticity of the tissues improves somewhat, which causes the possibility of their stretching, and this, in turn, can help cure the disease. In addition, the use of glucocorticoid drugs contributes to reducing swelling and inflammation, also contributing to the healing of microcracks.
Surgical treatment of phimosis
Surgical methods of exposure in phimosis are very rarely used today, and more often only when it is not possible to achieve efficacy from other measures. As an approved method of surgical treatment, a variant is considered with the implementation of three longitudinal incisions with cross-linking. Treatment of phimosis in children is carried out by the action on the adhesions in the area of the preputial sac by means of their separation, for which a gauze tuffer and a metal probe are used.
The development of cicatricial changes necessitates a complete circular excision of the foreskin, this procedure is better known as circumcision. In certain cases, the Schloffer operation is performed as an effect method replacing the cutoff. It consists in performing a zigzag cut along the foreskin and in the subsequent stitching of the edges. Such an operation under local anesthesia is carried out, this effect allows to completely preserve the foreskin when the desired result is achieved — enlargement of the orifice.
With surgical treatment, the effectiveness of treatment is 99-100%. Carrying out of circumcision in the treatment of phimosis is associated with a risk of subsequent relapse of the disease, as well as the development of a pathology such as a hidden penis. Predominantly, the relapse of phimosis is the result of attempts at treatment aimed at preserving the foreskin (with relapse of 2.4%). Cicatricial phimosis in children requires surgical treatment, measures of conservative therapy are characterized by a lack of proper effectiveness. In this case, the method of circumcision of the foreskin for subsequent excision of scar tissue is considered as the main method.
If symptoms appear that indicate phimosis, it is necessary to contact a urologist, in addition, a surgeon’s consultation may be needed.