INFANT PHIMOSIS


Infant phimosis is usually not a cause for concern, even if the foreskin cannot be retracted and the amount of skin ahead of the penis seems too large. Understand what physiological phimosis is, and how it differs from the kind of tight foreskin you should be really worried about: the pathological one.
You may already know that phimosis is nothing more than the impossibility of exposing the glans ("head" of the penis) due to the non-retractability of that portion of skin called the foreskin.
What you may not yet know is that almost all (over 95%) boys are born with phimosis, that is, with a non-retractile foreskin. It becomes retractable (able to expose the glans when pulled back) naturally over a period of time that can range from birth to 18 years of age or even longer (approximately 2% of men continue to have non-retractability throughout adult life)[1]. Usually, however, total retractability is achieved somewhat before puberty[2]. What is important is that, throughout this development period, phimosis (non-retractability of the foreskin) is physiological rather than pathological. Keep reading to understand what this means.

MECHANICAL CONDITIONS

But what exactly can prevent the retraction of the foreskin? There are two main mechanical conditions responsible for phimosis before puberty:
  • ADHESIONS: The inner side of the skin is "glued" to one or more regions of the glans. It is a very normal condition during the first years of life, with surfaces tending to peel over time.

  • PHIMOTIC RING: the narrower part of the foreskin (preputial ring, also called frenar band) is too narrow to pass around the glans penis. When this happens, the preputial ring is then called a phimotic ring, and the technical name of this condition is preputial stenosis ("narrowing" in Greek).​ It is also a normal condition in children, with the ring tending to widen over the years.​​

PHYSIOLOGICAL PHIMOSIS

When the mechanical conditions that cause phimosis are congenital, that is, present from birth, it is called physiological. This is a normal condition[3], tending to be gradually resolved throughout childhood and even adolescence[4].

In physiological phimosis, the skin of the phimotic ring is healthy, and makes a kind of "pout" when a slight pull in the direction of retraction is exerted.
infant physiological phimosis example
Physiological phimosis

PATHOLOGICAL PHIMOSIS

When the preputial opening of the boy becomes stiff or even narrower due to some skin disease or injury, phimosis is called pathological or acquired. Its causes are mainly of an inflammatory nature:
  • Posthides due to ammoniacal dermatitis: when the baby's or child's diapers remain unchanged for a long time, urine (which after a time becomes ammonia) can inflame the foreskin and cause it to narrow. Inflammation of the foreskin is called postitis (its plural form is phostides); when, besides the foreskin, the glans also becomes inflamed, is given the name balanopostitis.​
  • Posthides due to the action of microorganisms: when dirty diapers are not changed frequently, the doors are also opened for the proliferation of bacteria and fungi; these microorganisms can cause inflammation in the foreskin, which in turn causes its narrowing.​
  • LS (BXO): lichen sclerosus (also known as balanitis xerotica obliterans) is one of them. This chronic inflammation of the skin is extremely rare in children, but may also be a possible cause of pathological phimosis during childhood. It is associated with the appearance of lesions that cause a stiffening of the preputial opening, and make the skin look fibrous, lacerated and whitish.​​
  • ​​​Repetitive injuries: chronic inflammations caused by recurrent injuries, such as frequent forced retraction of the foreskin, can also cause phimosis as they generate lacerated and scar tissue, which is stiffer than uninjured skin. For this reason, it is important not to try to accelerate the process of releasing the foreskin by forcing it to retract. Even "massaging" the prepuce is advised against, as it can generate micro-traumatisms that, when eventually healed, end up leaving the foreskin opening stiffer or even more narrow. There must be no rush in the resolution of physiological phimosis: it is perfectly normal for it to completely resolve itself only during adolescence.​
The good news is that the vast majority of cases of pathological phimosis are reversible. In the case of ammoniacal dermatitis, the simple adoption of a more frequent routine of diapering and rinsing of the genital region is usually sufficient for the regression of inflammation. In addition, micro-organism posthides are usually treatable with antibiotics or fungicides[1], and LS can in some cases be reversed with the application of ultra-potent steroids[1,5].
But beware: not all inflammation or infection in the foreskin is synonymous with pathological phimosis: there are cases of physiological phimosis (which is the rule, not the exception, during childhood[2]) in which the manifestation of some dermatitis or skin disease does not contribute to an additional narrowing or stiffening of the foreskin, and therefore does not characterize pathological phimosis. This is just one example of the various types of misinformation regarding phimosis that circulate not only in lay environments, but even in a significant number of clinics and hospitals. Would you like to know more about it, to prevent your child from being the victim of some medical error?

REFERENCES

  1. Shahid SK (2012). Phimosis in Children. ISRN Urology, 2012:707329.
  2. Thorvaldsen MA, Meyhoff H (2005). Phimosis: pathological or physiological? Ugeskr Læger, 167(17):1858-62.
  3. Wright JE (1994). Further to "the further fate of the foreskin". Medical J of Australia, 160:134-5.
  4. Beaugé M (1990-1991). Conservative Treatment of Primary Phimosis in Adolescents. Saint-Antoine University, Paris VI.
  5. Neill SM, Tatnall FM, Cox NH (2002). Guidelines for the management of lichen sclerosus. British J. of Dermatology, 147:640-9.