Makindo Medical Notes

Related Subjects: |Hypospadias |Phimosis |Paraphimosis |Balanitis (Children)

👶 Phimosis = inability to retract the foreskin. ✅ Normal in infants and young boys (physiological). ⚠️ Persistent phimosis in older children/adults may be pathological. Symptoms may include pain, swelling, discolouration, poor hygiene, infections, and interference with sexual activity.

🧾 Patient History

• 🚽 Urinary symptoms: Pain on urination, difficulty voiding, or ballooning of foreskin during micturition (suggests obstruction).
• ❤️ Sexual function: Pain or difficulty with intercourse (dyspareunia, discomfort).
• 🦠 Infection history: Recurrent balanitis or balanoposthitis.

👀 Physical Examination

ℹ️ Normal: non-retractile foreskin until ~4 yrs. By 11 yrs, prevalence of non-retractability <8%. True phimosis = tight, scarred foreskin preventing retraction.

• 🔎 Retraction test: Gently attempt foreskin retraction. Avoid force → risk of scarring/paraphimosis.
• 🎈 Ballooning: Observe during urination for ballooning (suggests obstruction).
• 🩺 Skin assessment: Scarring, thickening, or white plaques → possible lichen sclerosus (BXO).
• 🔥 Infection signs: Redness, swelling, purulent discharge.
• 👶 Age factor: Physiological in children; persistent in adolescents/adults = pathological.

🧪 Investigations

• 🧾 Clinical assessment usually sufficient.
• 🩸 Labs: Swabs or CRP/WBC if infection suspected.
• 🖥️ Ultrasound: If complications suspected.
• 📉 Uroflowmetry: If significant obstructive urinary symptoms.

📌 Causes

• 👶 Physiological: Normal in infants; resolves gradually with age.
• ⚠️ Pathological: Recurrent balanitis, trauma, or scarring (e.g. lichen sclerosus/BXO).
• 🧬 Congenital anomalies: Rare developmental defects affecting foreskin elasticity.

💊 Management

• Conservative:
  • 💊 Topical steroids: Potent steroid cream for several weeks may soften foreskin and allow retraction.
  • 🤲 Gentle stretching: Manual/stretching exercises (never forceful).
• Surgical:
  • ✂️ Preputioplasty: Incisions to relieve constriction, foreskin preserved.
  • 🔪 Circumcision: Full foreskin removal. Indicated if severe, recurrent infections, or failed conservative therapy.
• Post-op care:
  • 🧼 Maintain hygiene; follow wound care advice.
  • 📅 Review for healing and complications.

🌟 Conclusion

Phimosis is common and usually physiological in children 👶. Persistent or pathological phimosis in older patients requires careful evaluation. Management ranges from conservative options (steroids, stretching) to surgical correction (preputioplasty or circumcision). Individualised care, patient education, and follow-up are key for good outcomes.