Types of Phimosis
Phimosis is classified into two main types: physiological phimosis and pathological phimosis, with the latter having several subtypes including phimosis associated with lichen sclerosus. 1
Physiological vs. Pathological Phimosis
Physiological Phimosis
- Normal developmental condition common in males up to 3 years of age but can extend into older age groups 2, 3
- Characterized by natural adherence of the foreskin to the glans
- Gradually resolves with age as the prepuce naturally separates
- Requires conservative management with proper hygiene and gentle retraction during bathing
- No surgical intervention required
Pathological Phimosis
Pathological phimosis requires medical or surgical intervention and can be further classified into several subtypes:
1. Lichen Sclerosus-Associated Phimosis
- Most common cause of pathological phimosis in adults (30-40% of adult phimosis cases) 4
- Characterized by white, sclerotic, scarred tissue at the preputial ring
- Presents with:
- Tightening of the foreskin
- Painful erections
- Erectile dysfunction due to phimosis
- Changes in urinary stream
- Decreased penile sensitivity
- Can lead to meatal stenosis and urethral involvement 4
- Has potential risk for malignant transformation to squamous cell carcinoma 4
2. Inflammatory Phimosis
- Results from recurrent balanitis or balanoposthitis (inflammation of the glans and/or prepuce)
- Occurs in 4-11% of uncircumcised males 3
- Can be caused by:
- Bacterial infections
- Fungal infections (particularly Candida)
- Poor hygiene
- Irritant dermatitis
- Presents with erythema, swelling, discharge, and painful retraction
3. Traumatic Phimosis
- Develops following injury to the prepuce
- Can result from:
- Forceful retraction
- Zipper injuries
- Sexual trauma
- Iatrogenic causes
- Leads to scarring and subsequent narrowing of the preputial opening
4. Complicated Phimosis
- Features of both lichen sclerosus and lichen planus
- Often associated histologically with squamous cell hyperplasia 4
- Poorer response to topical ultrapotent corticosteroid treatment 4
- Higher risk of developing squamous cell carcinoma 4
Clinical Presentation and Diagnosis
Key Diagnostic Features
- Inability to retract the foreskin over the glans penis
- In pathological phimosis: visible scarring, whitening, or thickening of the preputial ring
- Associated symptoms may include:
- Pain during erection or attempted retraction
- Difficulty urinating with poor stream
- Ballooning of the foreskin during urination
- Recurrent infections
Diagnostic Pitfalls
- Many physicians struggle to differentiate between physiological and pathological phimosis 5
- Studies show that 75-82% of phimosis referrals to urology clinics are actually physiological phimosis that doesn't require surgical intervention 5
- Unnecessary referrals create anxiety for patients and parents while expanding waiting lists for specialty assessment 5, 2
Management Approach
Conservative Management
For physiological phimosis:
- Reassurance and education about normal development
- Proper hygiene with gentle washing using soap and water
- Gentle retraction during urination and bathing
For mild pathological phimosis:
Surgical Management
Indicated when:
- Medical management fails
- Severe scarring is present
- Recurrent infections occur
- Urinary obstruction exists
- Suspected malignancy
Surgical options include:
- Circumcision (complete removal of the prepuce)
- Preputioplasty (plastic repair of the prepuce)
- Dorsal slit (for emergency treatment of paraphimosis) 3
Special Considerations
Phimosis in Children
- Physiological phimosis is normal in boys up to age 3 and often beyond
- Pathological phimosis in children is often due to:
- Forceful retraction attempts causing scarring
- Balanitis xerotica obliterans (pediatric lichen sclerosus)
- Recurrent infections
Phimosis in Adults
- Almost always pathological
- Higher association with lichen sclerosus
- Increased risk of penile cancer, particularly in cases of chronic inflammation 4
- May require more aggressive treatment approaches
Follow-up and Monitoring
- Regular follow-up is essential, especially for cases of lichen sclerosus
- Long-term monitoring for recurrence and malignant transformation
- Emphasis on proper hygiene measures to prevent complications 1
By understanding the different types of phimosis and their appropriate management, clinicians can provide targeted treatment that minimizes unnecessary surgical interventions while effectively addressing pathological conditions.