Phimosis is a common referral to any Pediatric Surgeon’s chamber.
What is phimosis?
Phimosis is a disorder in males when the prepuce cannot be retracted beyond the coronal margin.
Is Phimosis always pathological and require treatment?
The glans and the prepuce are intimately adherent to each other at birth. The layer gradually separates over the first couple of months after birth. The complete separation may take 3-4 years. So it is not advisable to retract the prepuce forcibly till the natural separation occurs. If one does so, usually advised by the Pediatrician or the local caregiver, minor or major tears develop in the prepucial skin which later on fibroses to create a scar. Then true phimosis develops which usually require surgery.
Whom should one consult for phimosis if the patient is an infant or a child?
Phimosis in children should be dealt with by a Pediatric surgeon as a General Surgeon usually does not have a proper understanding of the disease process as such. We have seen circumcised kids with hypospadias operated in Government Hospitals by senior General Surgeons whereas we all know that circumcision is contraindicated in kids with hypospadias, as the prepucial skin is used to cover the newly formed neourethra.
What are the signs and symptoms when the parents should think that their child may have phimosis?
The following signs and symptoms should prompt the parents to consult a Pediatric Surgeon.
- Straining during passing urine
- Poor flow (rarely occurs with phimosis, usually due to some intrinsic urethral obstruction)
- Pus in the external urinary meatus
- Redness or swelling of the prepuce (balanoposthitis)
- Hardening / scarring of the prepuce (balanitis xerotica obliterans – usually a late sign).
- Non reractibility of prepuce even beyond 3-4 years.
Usually (70% of our patients) phimosis does not warrant surgery. There are some ointments which if properly applied locally, can improve the condition and may even cure the condition.
What are the surgical options? Is it painful? Does the child require admission?
The traditional operation for phimosis is circumcision. Circumcision is usually done as a day case unless required by the Insurance company or the child stays far. Then overnight admission is recommended. The child is operated under general anesthesia and is given a local anesthesia so that he does not have pain after surgery. The oral analgesics take over once the child can tolerate feeds. We usually do not use post-operative dressings as the children have severe pain during removal of the dressings. So the area looks ugly immediately afterwards for swelling, some natural secretion and scab formation but at the end of 2 weeks everything looks normal. The child can wear pants and go to school at the end of 1 week.
Nowadays there is another minimal invasive surgical option called Preputialplasty. In this procedure the prepucial ring that causes phimosis is widened. The pain is much lesser. The post-operative swelling is more than circumcision but the child is pain free, can wear pants from the next day and can go out from the third day. The only flip side is that the parents need to retract the skin and dilate once a day and apply some medicines as advised from the 10th or 11th day onwards for a period of around 2-3 months. At the end of 2-3 weeks the child will appear to be like a normal child who does not have phimosis, without any evidence of surgery. He needs to know that like any other child he needs to clean the prepuce daily during bath.
Does the surgery involves any complication?
Circumcision / Preputialplasty is an extremely safe and low-risk surgery. But like any other surgery the parents have to give an informed consent knowing fully well the possible complications. These are anesthetic complications, post operative bleeding, and wound infection. There are anecdotal cases of rephimosis which need to be fixed again. We have done a couple of them, primary surgery done by other surgeons. Sometimes the urinary opening can become pinhole (meatal stenosis). We have not faced any such problems but have done meatoplasty on kids operated elsewhere.
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