Phimosis is used to describe a condition where the foreskin of the penis cannot be retracted to expose the head of the penis – the Glans penis. This inability to pull back the foreskin results from inflammation and scarring in the older boys and in adults.
True phimosis is extremely rare in boys below 5. The inner surface of the foreskin in this age group is almost universally, attached to the glans. The process of separation of the foreskin from the glans happens gradually and it involves a process of shedding dead skin cells and a slow retraction to expose the glans. Most boys have a completely retractile foreskin by the age of 3 to 5 years but may take as long as 10 to 15 years in some boys. The shed dead skin collects inside the gradually forming foreskin space and appears white, sticky and putty like. This is called “Physiological prepucial adhesions”
This is very different from true phimosis where the skin is scarred and even forceful attempts are unable to achieve a complete pulling back of the foreskin. The children with true phimosis may also have difficulty in passing urine associated with pain and straining. In contrast, children with prepucial adhesions rarely have urinary symptoms. An occasional child may have ballooning of the prepucial sac when they pass urine which rapidly resolves with age. Frequently, the appearance of the normal white dead skin deposits or “epithelial pearls” is mistaken for pus and infection and with the initiation of unnecessary antibiotic therapy.
A large majority of Prepucial adhesions require no active treatment as they resolve with time. Uncommonly, some of these children may be referred for ballooning of the prepucial sac during passing urine, an occasional secondary infection of the prepuce or urinary infection. These complications are easily treated with medicines and rarely require a Circumcision. The process of separation of the foreskin in these patients can be accelerated with short course of locally applied steroid creams which are extremely safe and have very few side effects.
Circumcision is reserved for the rare boy with True Phimosis, recurrent infections with a physiological phimosis and parental preference for circumcision to facilitate local hygiene. It is unnecessary in most boys who present with Physiological phimosis.