Understanding Phimosis: Causes, Treatments, and Alternatives to Circumcision

Introduction:

Male circumcision is a topic that often does not receive the attention it deserves, leading to a lack of information about conditions related to the foreskin. Among these conditions, phimosis is a common yet often misunderstood issue. This blog aims to shed light on phimosis, its causes, available treatments, and alternatives to the traditional solution of circumcision.

What is Phimosis in adults and men?

Phimosis refers to a condition where the foreskin is too tight to be pulled back, making it difficult or impossible to expose the tip of the penis. While some cases may resolve naturally as children grow, others can lead to complications when left untreated. Let's delve into this condition's details and explore its contributing factors.

Causes of Phimosis:

1. Skin Conditions: Skin disorders like Balanitis xerotica obliterans (BXO), Lichen planus, or Eczema can result in scarring that leads to phimosis.

2. Infections: Studies show that circumcised men have a lower risk of sexually transmitted infections such as syphilis, chancroid, and genital herpes (HSV-2).

3. Scarring: Severe scarring, often caused by BXO, can tighten the foreskin.

4. Potential Cancer: Uncircumcised men have an increased risk of penile cancer. Phimosis, especially chronic, is linked to a higher incidence of penile cancer.

Differentiating Between Types of Phimosis in children and adults:

It's essential to distinguish between physiological phimosis (natural tight foreskin) and pathological phimosis (diseased or scarred foreskin). Treatment options vary depending on the type and severity of phimosis.

Nonsurgical Treatment Options:

For mild cases, nonsurgical treatments may be effective:

1. Steroid Cream/Ointment: Applying these can help reduce inflammation and loosen the foreskin.

2. Stretching Exercises: Gentle stretching exercises can gradually increase the flexibility of the foreskin.

3. Anti-Fungal or Antibiotics: These can be used to address infections contributing to phimosis.

However, it's crucial to note that scarred foreskin in children and adults might not respond well to stretching and could lead to further complications.

Surgical Treatments for tight foreskin:

When nonsurgical methods fall short, surgical interventions are considered:

• Frenuloplasty: A procedure to release the frenulum, allowing the foreskin to detach from the head of the penis.

• Preputioplasty: This procedure involves an incision to expand the foreskin's diameter, facilitating retraction.

• Partial Circumcision: Removing part of the foreskin, leaving some coverage over the glans.

• Full Circumcision: The complete removal of the foreskin, often considered for severe cases like BXO phimosis or penile cancer.

Considering Alternatives to circumcision

If full circumcision isn't preferred, alternatives include various treatments and procedures. These can be discussed with specialists or urologists based on individual preferences and needs.

Conclusion:

Phimosis in men and children is a condition that requires attention and proper treatment. Whether it's physiological or pathological, understanding the causes and available treatments is essential for maintaining penile health. While surgical options like circumcision exist, nonsurgical methods and alternative treatments offer viable choices. If you or someone you know is experiencing phimosis, consulting with a top London Urologist will provide insights into the best course of action for the best sexual health.

Please book at the London Circumcision Centre for further consultation and circumcision.

Adult Circumcision, London UK

When will circumcision be needed for tight foreskin (phimosis) in adults or older men?

Male circumcision is rarely discussed, leading to insufficient information about foreskin conditions. This causes many conditions to go unnoticed, worsening one's health. One such condition is phimosis, where the foreskin is too tight to retract. Sometimes, it can fold back when the penis is relaxed but not when erect. This tightness causes minor damage during erections and sexual activity, leading to scarring. In adults, phimosis can be associated with infections like balanitis or sexually transmitted diseases.

Facts:

- Physiological phimosis in children often improves with age. The foreskin attachment breaks down, releasing a white material called smegma pearls. Most boys have a fully retractable foreskin by ages 10-12.

- Pathological phimosis is a medical condition caused by disease or scarring (BXO). It's important to distinguish it from a natural tight foreskin (physiological phimosis) as treatments differ.

Paraphimosis occurs when the foreskin gets stuck behind the penis head due to a tight ring. It requires immediate treatment, such as pulling the foreskin forward or preputioplasty to preserve it.

Causes:

- Skin conditions like BXO, Lichen planus, or Eczema.

- Infections: Circumcised men have lower rates of sexually transmitted infections, including syphilis, chancroid, and genital herpes (HSV-2).

- Scarring: BXO can cause severe scarring and phimosis.

- Potential cancer: There's a long-known link between un-circumcised men and penile cancer, especially in cases of phimosis history.

Non-surgical treatment:

Treatment for phimosis depends on age and severity. Options include:

- Steroid creams or ointments.

- Stretching exercises in early stages.

- Antifungal or antibiotic medications.

However, stretching scarred foreskin may cause more tearing and scarring. Scientific evidence is lacking for its effectiveness. Phimosis creams have had limited success in recent reports. Mild phimosis symptoms in adults can be managed by using condoms and lubricants during sexual activity.

Mild tight foreskin caused by fungal infection can be treated with antifungal medications and steroid cream. Adults with high blood glucose levels (diabetes mellitus) and phimosis may require circumcision due to recurring fungal infection or possible BXO. Tight foreskin (phimosis) in diabetic patients often requires circumcision and biopsy of the foreskin.

Surgical treatments:

- Frenuloplasty: A procedure that releases the frenulum, a small fold of tissue. It allows the foreskin to detach from the penis head.

- Preputioplasty: A procedure that expands the foreskin by an incision in front, enabling full retraction.

- Partial circumcision: Leaving part of the foreskin covering the penis head. It has long-term complications.

- Full circumcision: The standard surgical option with glue or stitches for tight foreskin, particularly for BXO phimosis, traumatic injury, or penile cancer.

If sexual activity is painful or uncomfortable due to phimosis, urgent treatment is needed. Home treatment includes daily cleansing, controlled stretching exercises, and clearing smegma. Infections with tight foreskin (balanitis) require antibiotic or antifungal treatment. It's essential to get examined for sexually transmitted diseases by a GUM clinic or a doctor.

In summary, there are various alternatives to full circumcision, such as medications, creams, frenuloplasty, preputioplasty, or a combination. These options should be discussed with a specialist or urologist. Full circumcision without any medical problems should be seriously considered as it is irreversible surgery.

PS: This information is for guidance only. This is not a replacement for professional medical advice. Please call Dr Khan for video consultation £150 advice at +447527314081 without any obligation.

Diabetes and Tight Foreskin

A comprehensive study conducted in the United Kingdom focused on a group of 100 men ranging in age from 17 to 82 years, with an average age of 38 years. The study aimed to investigate the prevalence and characteristics of phimosis, a condition characterized by the tight foreskin, in this population.

The researchers found that among the participants, 31% had a lifelong history of phimosis, meaning they had experienced this condition since birth or early childhood, while the remaining 69% had acquired phimosis, meaning it developed later in life. It is worth noting that the prevalence of acquired phimosis was significantly higher than that of lifelong phimosis.

Additionally, the study revealed that among the men with acquired phimosis, 32% had a medical history of diabetes. This finding indicated a notable association between acquired phimosis and diabetes. In fact, the data showed that men with a history of diabetes were 6.7 times more likely to develop phimosis compared to those without diabetes.

Moreover, the researchers observed that phimosis could potentially serve as a warning sign for diabetes. Surprisingly, among the men who had acquired phimosis but had no previous history of glucose metabolism disorders or diabetes, 12% were found to have diabetes (8%) or impaired fasting glycemia (4%). This prevalence of diabetes was higher than the national average in the UK, which stood at 3.6% during the study period. These findings suggest that the presence of phimosis in some individuals may indicate an increased likelihood of diabetes or related metabolic disorders.

It is important to note that balanitis, a condition characterized by inflammation of the glans penis, is commonly associated with diabetes. The recurrent infections and scarring resulting from balanitis are likely contributing factors to the development of phimosis in individuals with diabetes.

In summary, this UK-based study shed light on the prevalence and implications of phimosis in a diverse group of men. The findings indicate that acquired phimosis is more common than lifelong phimosis and that there is a significant association between phimosis and diabetes. Furthermore, the study suggests that phimosis could potentially serve as an indicator of diabetes, as a higher proportion of men with phimosis were found to have diabetes or impaired fasting glycemia compared to the general population. The study also emphasized the relationship between balanitis and phimosis in individuals with diabetes, highlighting the role of recurrent infections and scarring in the development of this condition.

We provide is comprehensive treatment of tight foreskin (Phimosis) and also we treat with tight foreskin with diabetics. In some patients , BXO or lichen sclerosis is also present which required treatment in the form of topical steroids, antibiotics, anti fugal and circumcision in most of the advanced BXO.

Reference:

SJ Bromage, A Crump, I Pearce

Phimosis as a presenting feature of diabetes

BJU Int, 101 (2007), pp. 338-340

Jet injection without needle local anaesthesia in adults’ and children's circumcision - recent study

Circumcision: Exploring Different Approaches for Adults and Boys for local anaesthesia

Circumcision is a practice that is often carried out for religious, traditional, and medical reasons. In our country, most men undergo circumcision, and most of these procedures are performed using local anaesthesia. Since circumcision is primarily performed for religious purposes, families typically want their children to know the procedure. Therefore, the preschool period is often chosen as the ideal age for circumcision in Turkey. However, circumcisions performed during this stage, when a child discovers their sexual identity, can negatively affect psychosexual development.

Additionally, using a needle for local anaesthetic injections can significantly increase anxiety in children. Despite the use of topical anaesthetic creams to reduce stress, needle phobia remains unresolved. Research indicates that 63% of children in the USA are afraid of needles.

Needle phobia is a concern for children and adult patients in circumcision procedures. To address this issue, some studies have explored using needle-free jet injectors. For example, Peng et al. found that a no-needle jet injector technique was safe, effective, and well-tolerated for adult circumcision. Similarly, jet injectors have been used in urology practice, such as vasectomy procedures, with high patient acceptance rates. However, the literature has conflicting opinions regarding the pain associated with jet injector injections compared to conventional needle injections.

In urology, jet injectors have been used for intracavernosal alprostadil injections in patients with erectile dysfunction. However, studies have shown that the procedure is more painful and less effective than the conventional needle method, leading patients to prefer the latter. This study aimed to evaluate the effectiveness of jet injector anaesthesia in children who reject needle injections during circumcisions performed under local anaesthesia. However, we observed that local anaesthetic injection with a jet injector did not provide sufficient pain relief for a comfortable circumcision.

The epidermis, the outer layer of the skin, varies in thickness across different parts of the body. For instance, the thickness of the epidermis on the eyelid is 0.04 mm, while it can reach up to 1.6 mm on the palm. The dorsal part of the penis has a thicker epidermis than the ventral surface, which can affect the penetration of the anaesthetic agent when using jet injectors. Injections on the ventral surface may pose a risk of urethral injuries due to the thinner epidermis in that area.

Several parameters are crucial for jet injectors, including thrust pressure, contact pressure, drug volume per shot, nozzle opening, and the distance from the nozzle tip to the skin surface. For small operations, the recommended anaesthetic dose delivered with a jet injector is 0.07-0.1 ml per spurt, with a nozzle diameter of 0.1 mm and an application pressure of 130-160 psi. However, studies have shown that increasing the nozzle diameter may result in deeper penetration and increased pain. Using newer-generation jet injectors with lower pressure has been demonstrated to achieve the same penetration depth with less pain.

In this recent study, consistent with findings in the literature, injection with a jet injector without a needle was better tolerated than the conventional needle method. However, the time for local numbness was long, and the amount of anaesthetic agent used was lower in the jet injector group. However, the FLACC scores (a pain assessment tool) measured during circumcision were higher in the jet injector group, and additional anaesthetic medication was needed for circumcision in children and adults. 

We provide a service for needless anaesthesia with some additional fees for needle-phobic adults and children. 

Please get in touch with us for further details. 

“We provide without needle local anaesthesia in our clinic ”

— https://doi.org/10.1080/08941939.2020.1817635