When the foreskin will not pass over the glans comfortably, or will not retract at all, due to tightness, this is referred to as ‘phimosis’. During childhood, the foreskin usually remains attached to the glans, then detaches during normal development, and as a result of this, retraction of the foreskin is often impossible until later in childhood. This is a normal part of a child’s development and any attempts to forcefully retract, or stretch the foreskin should be avoided. Between birth, and 18 years of age, any adhesion to the glans will usually subside, and the foreskin will develop to the stage where it can be retracted fully.
For some men however, the foreskin will remain non-retractile, and when this is due to tightness, the individual is then considered to have phimosis. Historically, medical professionals have favoured circumcision as the most suitable phimosis cure, but in more recent times, we can see that a far less invasive and preferred method to treat phimosis, is by stretching the foreskin. The previous clinical reasoning behind the prescription of circumcision for phimosis, was led by a lack of appreciation for it’s function. Thankfully, we now respect that the foreskin is a very important part of the male anatomy, in protecting the glans from trauma, keeping it lubricated, and maintaining the correct level of neural function for optimal sexual pleasure. When a male is circumcised, sexual pleasure can change as a result of the skin becoming kerratinised as it is exposed to air and clothing, so inevitably we would prefer to maintain natural function if possible.
Although there is usually a desire to avoid circumcision, there are of course, some incidences where it is the only viable option. This may be due to illnesses preventing a successful stretching regime, such as vascular impairment due to diabetes for example, or severe Lichen Schlerosus (although success has still been noted with both illnesses if the condition is well managed).
As we can imagine, there are a broad spectrum of reasons leading to phimosis, but assuming that underlying medical conditions are absent, we can divide individuals into two categories: Physiologic and Pathologic Phimosis.
Physiologic Phimosis relates to ‘present from birth’ and it is now widely accepted that this can be treated at home by stretching.
Pathologic Phimosis refers to a limited retractability of a previously retractable foreskin. This is considered to have an element of scarring, and this had led some within the medical field to still favour circumcision as a more suitable option to stretching.
When the foreskin is injured, either by aggressive stretching or other trauma, the healing process is shown in the following stages:
- Hemostatsis: Constriction of blood vessels at the site of the wound, platelets adhere to seal the injury, then coagulation occurs to prevent blood loss and to form a surface layer.
- Inflammation phase: Cells, pathogens and bacteria removed. The site is warm, painful and red.
- Proliferation phase: The wound begins to contract and is repaired with type 3 collagen.
- Remodeling phase: As the type 3 collagen used in the previous phase is disorganised and excessive, and the scar has low levels of elastin, the region has limited elastic properties. During this final phase, collagen is replaced with type 1, and this forms a healthier scar with improved strength. A significant improvement in the elastin network improves the elasticity in the region, and this then prepares the foreskin for stretching.
We outline the stages above, to indicate the importance of preventing further trauma to a tight foreskin, by modifying any aggressive activity which could cause tears to the skin. Provided that any scars are allowed to completely heal, it is usually relatively easy to treat phimosis by stretching.
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