The Doctor Says my Son has Phimosis!

By Katie Ward, Director, Your Whole Baby of NY
Endorsed by Dr. Alex Rotta, Professor of Pediatrics, Case Western Reserve University; Dr. Ryan McAllister, PhD, Georgetown University; and Dr. Jórunn Valgarðsdóttir, Family Medicine, Selfossi Health Center, Iceland

Perhaps you’ve taken your intact son to a well-checkup and heard the doctor use the term “phimosis” in regards to your son's foreskin. Before you entertain all the alarm bells in your head, we are here to help you parse out the conflicting information on phimosis, since it’s likely your son doesn’t have a problem at all!

Several studies* (here, here, here, here, here, and here) discuss how common it is for pediatric practitioners to make phimosis misdiagnoses. [1,2,3,4,5,6] Having the right information about your loved one’s particular situation can be crucial, so let’s start by breaking the issue down.

First, some definitions (from Merriam-Webster MedlinePlus)…

  • Phimosis: Tightness or constriction of the orifice of the foreskin arising either congenitally or postnatally and preventing retraction of the foreskin over the glans

On first pass, phimosis can sound like a terrible thing. “Constriction that prevents retraction of the foreskin? Is it dangerous? What can we do?”

You can stop and breathe, and keep reading. As it turns out, there are TWO KINDS of phimosis in medical literature: physiologic phimosis and pathologic phimosis. Since healthcare professionals aren’t always clear on the (really important) distinction between the two, it is essential for you to understand the difference.

  • Physiologic: Characteristic of or appropriate to an organism's healthy or normal functioning

  • Pathologic: Altered or caused by disease

In layperson’s terms, the words physiologic and pathologic are opposites.


Physiologic Phimosis

The foreskin, or prepuce, of an infant or young boy is typically fused to the head of the penis by a shared membrane. Additionally, the sphincter-like muscle within a child's foreskin protects against entry of pathogens and irritants, while allowing urine to pass. [7] This is what current science refers to as “physiologic phimosis” — the healthy, normal, nothing-to-worry-about kind.

The average age at which this membrane has finished separating, and the foreskin tissue has become more elastic to allow for retraction, is 10 years of age, with a wide range of normal. [8,9,10] Sometimes a toddler can have retractable foreskin, and sometimes a boy nearing completion of puberty can have non-retractable foreskin — both occurrences are normal. Unfortunately, the older a boy gets with what’s termed “physiologic phimosis,” the more likely he is to be on the receiving end of a “diagnosis.”

Which brings us to one last definition…

  • Diagnose: to recognize (as a disease) by signs and symptoms

Is it appropriate to “diagnose” a boy with physiologic phimosis, if this is a natural state rather than a disease? We might argue that it is not appropriate to do so, particularly since doctors often refer children to specialists for this developmentally normal state of non-retractability, or suggest treatments ranging from steroid creams and stretching exercises to cutting off the foreskin.

But since the phrase “physiologic phimosis” isn’t disappearing from medical literature anytime soon, parents and providers alike need to be aware that it just means normal kid penis. We encourage you to bring this issue of definitions up if you do hear the word “phimosis” during a doctor’s appointment — the resultant discussion may plant a seed of understanding, or you may determine that this doctor is not a good fit for your family.

Again, the average age of complete foreskin retractability is around 10 years old, and it can be normal when a pubescent boy’s foreskin is not yet retractable. This raises another question: should a doctor be examining your son’s normal penis for retractability in the first place? It would be ideal if all doctors offered an accurate discussion of the normal timeline for retractability and left it at that, unless the boy was experiencing discomfort or functional issues that needed to be addressed. Unfortunately, such a conservative approach appears to be the exception rather than the norm.

A reality worth keeping in mind is that many U.S. doctors, urologists included, do not have extensive experience with the normal healthy foreskin of the penis throughout the lifespan. This includes a lack of personal experience for male doctors, who themselves were likely circumcised at birth. Adequate education about development and functions of the complete penis is lacking in many American medical schools. Perhaps you’ve heard of someone who was circumcised for phimosis after infancy. It’s possible that the person’s provider did not opt to try conservative treatments first; or worse, they circumcised a boy for having a normal penis.


Pathologic Phimosis

This brings us to the topic of pathologic phimosis. Is it possible for a non-retractable foreskin to have issues? Yes. Are these issues frequently the result of unnecessary “treatments” [11] for physiologic phimosis (A.K.A. normal kid penis)? Yes.

A small percentage of adults naturally never become retractable and do not experience any difficulties as a result of having a non-retractable foreskin. If an adult is unable to retract his foreskin and he experiences discomfort during sexual activity or urination as a result, this is considered pathologic phimosis. [12]

While you may have heard that it is impossible for a child to experience pathologic phimosis, occasionally it is a true diagnosis resulting from mistreatment of the foreskin. A person whose foreskin has been forcibly retracted before the membrane has naturally separated can develop scar tissue that causes functional issues both in childhood and adulthood — particularly if the forced retraction was a repetitive occurrence. Medical literature refers to these harmful results of forced retraction as a form of pathologic phimosis. [11,13] The condition can warrant treatment prior to puberty if the child experiences problems such as painful erections or difficulty urinating. The most conservative (least invasive) treatment should be sought first, to resolve the issue with as little pain and disruption as possible and to preserve the functionality of the foreskin.

In addition, pathologic phimosis can result from balanitis xerotica obliterans (BXO), a visually identifiable [14] disease that causes whitening of penile tissue and makes the foreskin hardened and inelastic. It can occur in adults and children. While circumcision was once recommended as the first-line corrective option for any intact person with BXO, current professional opinions as to best treatment options differ. Again, conservative therapies can be pursued first.

Though neonatal circumcision is sometimes falsely touted as a way to prevent phimosis, pathologic phimosis of the foreskin remnants can occur in circumcised children [15], as a result of circumcision. [16]


Common Misdiagnoses Related to the Foreskin

  • It is often assumed that non-retractile foreskin automatically requires intervention, but as you’ve learned, physiologic phimosis simply means a normal, healthy penis.

  • Frenulum breve [17] (a short frenulum) sometimes is mistaken for pathologic phimosis in adults. Effective conservative treatments exist for this condition.

  • Some providers are concerned when they are unable to see an intact child’s glans or urethral opening (what some refer to as a “pinhole” opening in the foreskin), and they may incorrectly refer to this normal tight opening as meatal stenosis. A pinhole opening is normal in infancy and childhood, and in the absence of pain or inability to pass urine, is nothing to be concerned about.

  • Ballooning is a normal occurrence and is not considered a symptom of pathologic phimosis, but some providers may mistakenly believe it is abnormal and suggest treatments including circumcision.

To recap: what some medical professionals call “physiologic phimosis” is the normal non-retractable state of a child’s healthy foreskin. Pathologic phimosis for adults is non-retractability accompanied by discomfort, scarring, or disease. Pathologic phimosis for children is scarred or otherwise altered tissue that affects the elasticity of the foreskin, either as a result of forced retraction or disease.

* YWB editors’ note: While these linked articles demonstrate widespread medical misunderstanding of phimosis, they nonetheless contain some outdated information about foreskin development and care. Some of the articles underestimate the average age of retractability, and one incorrectly encourages “gentle” retraction of a child’s non-retractile foreskin and cleaning with soap. In addition, some of the authors consider circumcision a first-line treatment for pathological issues, though less invasive options are available.


Katie Ward

Katie Ward lives in New York state with her husband, daughter, and son. She has worked as a journalist and an English teacher, and provides breastfeeding support in her community. When she first began exploring the issue of circumcision, she assumed there had to be a good reason so many people were choosing it for their boys. What she learned (and continues to learn) compelled her to start speaking out in defense of children and their normal, healthy bodies. She has written for YWB on the subject of balance bias in the circumcision debate.

 

Reference List

  1. Van Howe, R.S. (1998, October). Cost-effective treatment of phimosis. Pediatrics, 102(4). Retrieved from http://pediatrics.aappublications.org/content/102/4/e43
  2. McGregor, T.B., Pike, J.G., & Leonard, M.P. (2005, April). Phimosis: a diagnostic dilemma? Canadian Journal of Urology, 12(2): 2598-602. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/15877942/
  3. Griffiths, D., & Frank, J.D. (1992, June). Inappropriate circumcision referrals by GPs. Journal of the Royal Society of Medicine, 85(6): 324-5. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/1625262
  4. Kumar, P., Deb, M., & Das, K. (2009, August). Preputial adhesions--a misunderstood entity. Indian Journal of Pediatrics, 76(8): 829-32. DOI: 10.1007/s12098-009-0120-3
  5. Shahid, S. K. (2012). Phimosis in Children. ISRN Urology, 2012. DOI: 10.5402/2012/707329
  6. Huntley, J. S., Bourne, M. C., Munro, F. D., & Wilson-Storey, D. (2003, September). Troubles with the foreskin: one hundred consecutive referrals to paediatric surgeons. Journal of the Royal Society of Medicine, 96(9): 449–451. Retrieved from http://pubmedcentralcanada.ca/pmcc/articles/PMC539600/
  7. The penis and foreskin: Preputial anatomy and sexual function. (2007, March). Circumcision Information Resource Pages. Retrieved from http://www.cirp.org/library/anatomy/
  8. Thorvaldsen, M.A., & Meyhoff, H. (2005). Patologisk eller fysiologisk fimose? Ugeskr Læger, 167(17), 1858-1862. Retrieved from http://www.cirp.org/library/normal/thorvaldsen1/
  9. Ishikawa, E., & Kawakita, M. (2004). Preputial development in Japanese boys. Hinyokika Kiyo, 50(5), 305-308. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/15237481
  10. Kayaba, H., et al. (1996, November). Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol., 156(5), 1813-1815. Retrieved from http://www.cirp.org/library/normal/kayaba/
  11. Doctors Opposing Circumcision. (2017). Care of the intact (not circumcised) penis in the young child. Retrieved from https://www.doctorsopposingcircumcision.org/for-professionals/care-of-the-intact-penis/
  12. Doctors Opposing Circumcision. (2017). Phimosis. Retrieved from https://www.doctorsopposingcircumcision.org/for-professionals/alleged-medical-benefits/phimosis-balantis/
  13. Oettgen, A.B. (2017). Phimosis. In McInerny, T.K., Adam, H.M., Campbell, D.E., DeWitt, T.G., Foy, J.M., & Kamat, D.M. (Eds.), American Academy of Pediatrics Textbook of Pediatric Care (2nd ed., pp. 2502-2505). Elk Grove Village, IL: American Academy of Pediatrics.
  14. The Center for Reconstructive Urology. Lichen Sclerosus – Balanitis Xerotica Obliterans – BXO. Retrieved from https://www.centerforreconstructiveurology.org/urethral-stricture/bxo-lichen-sclerosus/#.WWOdjRMrKV5
  15. Blalock, H.J., Vemulakonda, V., Ritchey, M.L., & Ribbeck, M. (2003, June). Outpatient management of phimosis following newborn circumcision. The Journal of Urology.;169(6):2332-4. DOI: 10.1097/01.ju.0000067602.42875.d8
  16. Kidger, E., Haider, N., & Qazi, A. (2012). Acquired phimosis after plastibell circumcision: a preventable consequence. Annals of The Royal College of Surgeons of England, 94(6), e186–e188. http://doi.org/10.1308/003588412X13373405384774
  17. Tight foreskin. (2017, March 29). The Student Room. Retrieved from https://www.thestudentroom.co.uk/life/health/sexual-health/tight-foreskin