Phimosis

Scope

This guideline covers Phimosis in both adults and children.

Phimosis is the inability to retract the foreskin

True pathological phimosis is rare in those under 18 year old and must be distinguished from physiological adherence of the foreskin to the glans, which is normal.

The proportion of partially or fully retractable foreskin by age is at:

  • Birth 4%
  • 6 months 20%
  • 1 year 50%
  • 11 years 90%
  • 12-13 years 95%
  • 14+ years 99%

A non-retractile foreskin and/or ballooning of the foreskin during micturition in a child under two, do not routinely need to be referred for circumcision.

Pathological phimosis is more common in the adult population. This is due to scarring of the foreskin secondary to a wide list of conditions. The differential diagnosis includes recurrent balanitis, sexually transmitted diseases (STDs) and skin diseases such as eczema, psoriasis, lichen sclerosus, Zoons balanitis, carcinoma in situ, and frank squamous carcinoma.

Phimosis is a risk factor for penile carcinoma.

Cultural circumcision is not NHS funded within Devon – see circumcision commissioning policy

Parents and patients should be made aware of the risks and benefits of circumcision.

Assessment

Phimosis (true or physiological) usually presents with one or more of the following:

  • poor stream
  • ballooning of foreskin on micturition
  • 'spraying' or poor stream on micturition
  • recurrent attacks of balanitis
  • pain on intercourse in adults
  • in severe cases, hydronephrosis

Management

Phimosis

  • Why has the patient presented at this time?
  • What problem is the condition is causing?

Both patient and parental expectations should be explored and the options explained.

  • If the issue is a non-retractile foreskin and/or ballooning during micturition in a child under two, a conservative approach should be taken as physiological phimosis which will usually resolve with time.
  • Avoid forcible retraction of a congenital phimosis, as this can result in scar formation and an acquired phimosis.
  • Personal hygiene is very important. Advise cleaning under a retractable foreskin and always reduce it to cover the glans after cleaning.
  • Topical steroid application to the preputial ring to treat 'phimosis' has reported success rates between 33-95%.A prescription would not normally exceed three months and should have achieved maximal therapeutic benefit within this time. A topical steroid such as Betamethasone (0.025-0.1%) is commonly prescribed

Only a minority of children will have pathology and be subsequently listed for circumcision:

Indications for referral for circumcision (circumcision commissioning policy):

  • Pathological phimosis - The commonest cause is lichen sclerosus, balanitis xerotica obliterans (BXO ) Recurrent episodes of balanitis
  • Relative indications for circumcision or other foreskin surgery: Prevention of urinary tract infection in patients with an abnormal urinary tract

Parents and patients should be made aware of the risks and benefits of circumcision.

Referral

Referral Instructions

For adults

e-Referral Service Selection

  • Specialty: Urology
  • Clinic Type: Not Otherwise Specified
  • Service: DRSS-Northern-Urology- Devon CCG- 15N
For children

e-Referral Service Selection

  • Specialty: Children's & Adolescents Services
  • Clinic Type: Urology/Surgery – not otherwise specified
  • Service: DRSS-Northern-Child & Adolescent Services-Devon CCG - 15N

Referral Forms

DRSS referral form

Supporting Information

Pathway Group

This guideline has been signed off by the Northern Locality on behalf of NHS Devon CCG.

Publication date: June2020

Last updated: 08-06-2020

 

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