appendix to Research in Medical Studies
PHIMOSIS: RESEARCH
A compilation of definitions from the medical studies.

DEFINITIONS

H.L. Tan (FRACS)
Foreskin fallacies and phimosis.
Ann Acad Med Singapore 14(4), 626-630 (1985)
"True phimosis is caused by a thick white fibrous ring around the prepuce, which makes retraction impossible."

J. Chandler Williams MD. MS., et al
Paraphimosis in Elderly Men
American Journal of Emergency Medicine Volume 13 Number 3, May 1995, p. 351-353
"A contracture of the preputial opening (phimosis), usually as a result of chronic inflammation in the area, leads to the formation of a tight ring of skin."

"In adult men, paraphimosis typically occurs in the elderly. The condition is associated with poor hygiene and chronic balanoposthitis. The chronic infection is postulated to cause a contracture of the opening of the prepuce (phimosis). This contracture forms a fibrotic ring of tissue, which leads to constriction when the foreskin is retracted over the pliable glans."

AM Rickwood et al
Phimosis in boys. 1980 ibid
"Phimosis, defined as scarring of the tip of the prepuce, .... the tip of the prepuce loses its normal suppleness and becomes scarred, .... The appearances are unmistakable... the presence of phimosis, which was confined to the tip of the prepuce and did not extend for more than 0.25 cm proximally... "

Satya Parkash, F.R.C.S. (Eng), M.A.M.S., and B Raghurma Rao, M.S.
Preputial Stenosis - Its Site and Correction
Plastic and Reconstructive Surgery, August 1980; 66 (2) : 281-2
Phimosis ... has been pictured as a long defect, shaped like the stem of an inverted champagne glass (my note: imagine a champagne glass inverted over your glans, the stem of the glass represents the overhang). Further observations revealed that the "stem of the champagne glass" was actually normal and disappeared on attempted retraction, revealing a lesion of the prepuce. This lesion forms a narrow ring, which can become wider if scarring occurs as a result of posthitis. ...

PA. Dewan et al
Phimosis: is circumcision necessary?1996 ibid
" ... true phimosis produces a cone-shaped foreskin during .. gentle retraction manoeuvre, with a fibrotic, circular band that forms the most distal and narrowest part of the prepuce."

Meuli M, Briner J, Hanimann B, Sacher P
"Lichen sclerosus et atrophicus causing phimosis in boys: a prospective study with 5-year followup after complete circumcision."
Department of Surgery, University Children's Hospital Zurich, Switzerland.
J Urol 1994 Sep;152(3):987-9
"... severe phimosis due to a sclerotic, whitish ring at the tip of the prepuce, ..."

Note, the first authoritative references in 1994 to a "phimotic ring" confirmed by
Campbell's Urology -7th Edition (1998) Part IX Pediatric Urology
Chapter 69: J. S. Elder, M.D., Congenital Anomalies Of The Genitalia. - pages 2120-44
Male Genital Anomalies: Penile Anomalies: Phimosis
"Early forceful retraction of the foreskin ... a cicatricial (my note: scar left by a wound) preputial ring may form, causing secondary phimosis." - "An alternative to circumcision for phimosis is "preputial plasty" which is essentially a minimal dorsal slit through the phimotic ring (Cuckow et al, 1994)"

Campbell's Urology -7th Edition (1998) - Part XIV Urologic Surgery
Chapter 107: G.H. Jordan, et al., Surgery of the Penis and Urethra - Pages 3316-94
Paraphimosis, Balanitis, and Phimosis: "Paraphimosis, or painful swelling of the foreskin distal to a phimotic ring, "

J. Fairgrieve and R.A. Parker
Acquired phimosis in the elderly caused by LSA
Br. J. of Urology (London) 31(1) Mar 1959 p.74-7
"On clinical examination all these patients were found to have a severe degree of acquired phimosis with a non-retractile prepuce.The large majority had a thickened ring of firm indurated tissue about 1 cm. wide immediately surrounding a very contracted preputial orifice. In some cases this orifice was narrowed down to only 1 to 2 mm. in diameter, giving an almost pin-hole appearance." ...

"... the fibrous ring around the preputial orifice." "Thirty cases of acquired phimosis have been described each presenting the same clinical picture of a hard indurated band surrounding the preputial orifice and mainly involving the "mucosal" surface of the prepuce."

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HISTOLOGY

Contrary to the reports in modern journals there are at least three older studies on histology. It seems probable that these studies were overlooked because they were written in German, French and Italian. (These studies can be made available to any medical researcher who understands the lingo: round cells; plasma deposits; etc. and could help our research further).

X Soubigou (C.R.)
Le Phimosis: Considérations Histo-Pathologiques
Phimosis: an Histopathologic Study
Rev med. nav. 9:103-107, 1954
"Here is a fact to which attention has not been drawn. In effect, from the external observation of a phimosis it is possible to believe that it is the existence of a simple ring which hinders the movement of retraction of the prepuce; the histological examination reveals that the lesions are more complex."

H. Hermann and G. Stüttgen
Über die Histogenese atrophischer Vorgänge am phimotischen Praeputium des Menschen.
Concerning the Histology of Atrophic Procedures in the Phimotic Prepuce of the Human Male
Archiv für Dermatologie und Syphilis, Band 198, S.601-618 (1954)
"The prepuce of the human male .... strong bundles of connective tissue are obvious, and some of these are structured in a ring form. ... In the majority of cases, the tendency for a phimosis to form is potential simultaneously with a strong development of the ring fibre system.

Hermann makes numerous references to connective tissue, and the homogenising bundles of fibre changing with old age for example "With advancing age the pigment deposit increases."

" ... the histology of atrophic processes in the prepuce show a great deal of different characteristics. The most remarkable are the homogenis of the kollagenen(?) bundles of fibres and disappearance of elasticity, which can occur even in the deeper levels of the Corium (thick skin?)."

"On the basis of the available histological findings we may assume that there is a fluent transition between each of the atrophic forms of phimosis." - "... the observable transition between the different forms of phimosis finds its expression as well in changes of the peripheral nerve system lying in the foreskin."

"The results of histological examinations of other authors and our own findings suggest a transition between the different forms of phimosis, in such a way, that when influenced by the length of time, severity und additional inflammations the described pathological process leads in the end to Balanitis xerotica obliterans.

OJ. Clemmensen et al
The histologic spectrum of prepuces from patients with phimosis.
Am J Dermatopathol 1988 Apr;10(2):104-8
"Since phimosis especially in young boys may regress spontaneously, and since on the other hand LSA may evolve into squamous cell carcinoma, we conclude that treatment of phimosis should be planned according to its histologic pattern and not according to its monotonous clinical appearance."

"The criterion for surgery was phimosis; that is, a taut fibrotic foreskin that could not be retracted .... The lesion usually affects the inner blade of the prepuce, leaving for direct examination only a nonretractable prepuce with a conspicuous distal stenosis. The glans penis may or may not be affected, but it is often inaccessible for inspection due to the preputial stenosis. Therefore, circumcision for phimosis is often performed without primary knowledge of the nature of the underlying pathologic condition."

"Since phimosis especially in young boys may regress spontaneously, and since on the other hand LSA may evolve into squamous cell carcinoma, we conclude that treatment of phimosis should be planned according to its histologic pattern and not according to its monotonous clinical appearance."

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AGE GROUPS

Horst Danner,
"Zirkumzision bei Dermatologischer Indikation"
Hamburg University. (1986) p.59-60
In a study specifically on congenital phimosis, (i.e. excluding LSA or balanitis) the operation was performed on 40 hospitalised men and boys at the following ages.

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Appendix: ORIGINAL TEXTS

X Soubigou (C.R.)
Le Phimosis: Considérations Histo-Pathologiques
Phimosis: an Histopathologic Study
Rev med. nav. 9:103-107, 1954
"Il y a là un fait sur lequel l'attention n'a pas été attirée. En effet l'observation extérieure d'un phimosis peut faire croire à l'existence d'une simple bague qui empêche de ramener le prépuce en arrière; l'examen histologique montre que les lésions sont plus complexes."

H. Hermann and G. Stüttgen
Über die Histogenese atrophischer Vorgänge am phimotischen Praeputium des Menschen.
Concerning the Histology of Atrophic Procedures in the Phimotic Prepuce of the Human Male
Archiv für Dermatologie und Syphilis, Band 198, S.601-618 (1954)
"Das Praeputium des Menschen ... fallen starke Bindegewebsbündel auf, die teilweise einen ringförmigen Verlauf haben." .... "Neigung zur Ausbildung einer Phimose besteht bei einer meist gleichzeitig vorhandenen starken Entwicklung des Ringfasersystems."

"Mit zunehmendem Alter erfährt die Pigmentablagerung eine Verstärkung."

" .... weist die Histogenese atrophischer Vorgänge am Praeputium mehrere Charakteristika auf. Die imponierendsten Veränderungen sind Homogenisierung der kollagenen Faserbundel und Schwund der Elastica, die selbst in den tieferen Schichten des Coriums noch vorkommen können."

"Auf Grund der vorliegenden histologischen Befunde läßt sich ein fließender Übergang zwischen den jeweiligen atrophischen Formen der Phimose vermuten." - "Der ... feststellbare Übergang zwischen den unterschiedlichen Formen der Phimose findet auch in Veränderungen des in der Vorhaut gelegenen peripheren Nervennetzes seinen Ausdruck."

Die histologischen Untersuchungsergebnisse anderer Autoren und die eigenen Befunde deuten auf einen Übergang der unterschiedlichen Formen der Phimose hin, dergestalt, daß der geschilderte pathologische Prozeß von Dauer, Schwere und zusätzlichen Entzündungsvorgängen beeinflußt schließlich zur Balanitis xerotica obliterans führt.

P. Houdelette, et al.
Phimosis relatif en érection - Procédé plastique conservateur par plastie en Z asymétrique
Relative phimosis on erection. - Conservative plastic procedure with an asymmetrical Z plasty
J Urol (Paris) 97(3), 148-149 (1991)
" ... des phimosis "relatifs", c'est-à-dire quand il existe un orifice préputial large, quasi normal sur verge flaccide mais faisant une bride annulaire en érection. Cette bride peut être à l'origine d'une impossibilité de décalottage ou entraîner un paraphimosis en érection, des doleurs lors des rapports par étranglement de la base du gland, des mini-ruptures bien visibles sur le fourreau."