Phimosis

Phimosis is commonly referred to as the inability to freely expose the glans penis. penis due to the narrowing of the skin covering it (foreskin).  The definition itself contains one of the "pitfalls."  The fact is that in the practice of adult surgeons and urologists, the narrowing of the foreskin is always interpreted as a pathological condition requiring the intervention of a doctor. Therefore, it is not uncommon to hear from the parents of our patients that a urologist diagnosed a child with phimosis at an early age and therefore immediately recommended surgery.

Types of phimosis

In pediatric practice, physiological and pathological types should be distinguished фимоза. At an early age, it is the physiological phimosis that prevails, associated with the structural features of the child's genitals. Only 10% of male children have the glans penis fully or partially open in the first year of life. In most newborn boys, the skin of the foreskin, as a rule, is fused to the head of the penis by means of synechiae - peculiar adhesions that prevent or completely exclude the free removal of the head. This is a normal condition for the first 5-6 years of life, which does not require any special treatment. Moreover, the fusion of the glans with the foreskin can be considered as a protective mechanism to reduce the likelihood of infection under the foreskin and the development of inflammation there.

Gradually, during the growth of the penis, the glans pushes the foreskin apart, there is a slow independent separation of the synechiae and the opening of the glans. This process can continue until the beginning of puberty of the boy, when sex hormones are activated, which make the foreskin tissue more elastic and stretchy. This is significantly influenced by the individual structure of the foreskin of each particular child. For example, it may be excessively developed (the so-called proboscis foreskin), forming a hypertrophic variant of phimosis. In this case, spontaneous recovery takes longer and does not always occur.

Treatment of phimosis

In the area of the glans penis there are special glands that produce a protective substance – smegma. Sometimes smegma accumulates under synechiae in the form of a dense formation similar to a white tumor. Such clusters are also called smegmolites. In the case of a large accumulation of smegma, minimal medical attention may be required: using a special probe, similar to a thin rod, synechia are separated, preventing the secretion from escaping.

Note that you should not succumb to the persuasions of some experts who recommend removing synechia just because they exist. Apart from crying a child and developing a fear of white coats, you won't achieve anything, and splices can form over and over again.

Violent manipulation of the foreskin in most cases leads to tearing of its leaves and scarring. As a result, cicatricial phimosis develops, the only way to treat it is through surgery. In this case, either the foreskin is dissected with subsequent suturing, or its complete removal by circular circumcision (circumcision). The second type of intervention is the most widespread, as it guarantees the complete elimination of phimosis without the risk of recurrence.

For parents, three basic rules can be formulated that will allow them to navigate the problem of phimosis in a child of the first years of life.

So, special manipulations on the foreskin are not required if:

1. there are no recurring episodes of purulent inflammation of the glans and foreskin, balanoposthitis;
2. there is no critical narrowing of the foreskin opening, making it difficult to urinate;
3. there are no large accumulations of smegma under the foreskin, which can be detected visually.

Balanoposthite

It should be mentioned separately about acute inflammation of the glans penis and foreskin - balanoposthitis. The chance of developing balanoposthitis increases in children with reduced immunity or other infectious diseases. Many parents make the mistake of mistaking the red color of the external opening of the urethra for the manifestation of inflammation. Normally, the narrow transition zone of the urethral mucosa to the glans skin may have an intense pink-red color. Inflammation of the foreskin is characterized by its pronounced edema, extensive redness (hyperemia), pain, purulent discharge from the prepuce space (the space between the glans penis and the foreskin). The result of inflammation may be scarring of the skin of the foreskin and, as a result, the development of phimosis. In some cases, balanoposthitis causes acute urinary retention (the child cannot urinate due to a strong urge and an overflowing bladder). This is a condition that requires urgent treatment - call an ambulance!

Paraphimosis - pinching of the head

With existing phimosis, as a result of an attempt to remove the glans penis, it may be pinched in the narrowed ring of the foreskin - paraphimosis. Then the blood supply and lymph outflow in the penis are disrupted, which leads to rapid swelling of the foreskin and glans, and later to their necrosis (necrosis) and the development of purulent complications. The development of paraphimosis requires emergency medical care. With a short duration of the disease, manual reduction of the pinched head is possible (sometimes with the use of short-term anesthesia). If this is not possible, then surgical dissection of the infringing ring is performed, and later, after the inflammatory changes subside, circumcision of the foreskin is performed.

Treatment of phimosis in EMC

So, in most cases, physiological phimosis resolves on its own as the child grows up. However, in the case of a complicated course or as a result of improper actions, phimosis can certainly become pathological. In this case, the only correct tactic is surgical treatment. The operation is performed at any age, immediately after diagnosis, as planned. Circumcision of the foreskin is most often performed - circumcision (or circular excision of the foreskin leaves).

In our clinic, this operation lasts 10-15 minutes and is performed under general anesthesia, i.e. under anesthesia. The foreskin is cut off circularly, the remaining inner and outer sheets of the foreskin are sewn with a material that subsequently resolves itself. A few hours after surgery, the child can walk and urinate independently.

Parents who decide to circumcise a child's foreskin should take into account certain circumstances:

1. Often, for promotional purposes, clinics offering this operation emphasize the use of a laser, plasma scalpel, etc. In fact, the use of this equipment does not change the essence of the operation in any way, and the likelihood of postoperative complications and the cosmetic result depend overwhelmingly on the surgeon's experience, and not on the surgical instruments used.

2. Circumcision performed on a child under local anesthesia (without anesthesia) is a dangerous procedure in which the risk of developing both immediate complications (bleeding, damage to adjacent anatomical structures, acute urinary retention) and long-term ones is much higher. In addition, such "procedures" often lead to psychological trauma in children.

3. A child's circumcision cannot be considered a "frivolous" operation. Even in the best surgical clinics, complications after circumcision of the foreskin develop in 0.1-0.2% of patients, and circumcision performed outside a specialized clinic (especially ritual circumcision at home) leads to complications 20 times more often!

4. In some countries, the so-called hygienic circumcision is quite popular - the removal of healthy foreskin in order to avoid, as supporters of the procedure claim, possible long-term problems (for example, penile cancer, sexually transmitted diseases, inflammation of the foreskin, etc.). Parents should be aware that there is not a single evidence-based medical study to support this point of view.

Thus, the correct definition of tactics for managing a child with a narrowing of the foreskin is the key to a successful solution to the issue. An extremely important role in this is played by the qualification of a pediatric urologist–andrologist with experience in both conservative and surgical treatment of children with phimosis.

If your child has been diagnosed with phimosis and is strongly recommended to have surgery faster, take your time. Only a few of the situations described above require urgent intervention. In case of elective surgery, you have time to consult another doctor. Listen to the opinions of several experts who have experience working with children, and then make a decision.