What is Phimosis? personal research

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DISCUSSION

Before we can discuss how phimosis may be treated, we must first establish what phimosis is.

I have often read that phimosis comes from the Greek "to muzzle" or that phimosis means non retractability, but what actually is phimosis, (not merely its effects), what is the reason for this non retractable state? The following studies were not selected. All available descriptive sections from the studies have been included, (vague references like "the inability to retract the foreskin," have been omitted).

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DEFINITIONS

A (rather boring long) List of The Definitions, necessary references and original French and German texts are included in the appendix file.

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SUMMARY

Apart from Clemmensen's "usually" and Fairgrieve's "mainly" all these studies indicate without any qualification that phimosis is physically observable as: a ring, or a fibrotic circular band, or a thick white fibrous ring, a sclerotic (meaning scarred) whitish ring, a tight ring, a narrow ring (which can become wider if scarring occurs), a fibrotic ring of tissue, a cicatricial (scar left by a wound) preputial ring, a hard indurated band. Since 1994 the word "phimotic ring" has been used in recognised medical journals. However there seems to be little information or consensus of opinion on the nature of this ring.

Private mail and interviews confirm the observations and implications that phimosis (usually) effects the inner blade of the prepuce (Clemmensen, Fairgrieve, Parkash, Dewan), in the form of a white coloured ring of skin (Tan, Meuli) This whitish ring of skin lies around 10 to 15 mms. away from the join between inner and outer foreskin on the dorsal side (the top side), the ring then follows the contours of the skin, joining approximately midway with the frenulum ventrally (underneath). The ring usually has a width less than 25 mms. (Rickwood), though in severe cases (e.g. older subjects) this may be wider (Fairgrieve, Hermann). (Private mail indicates the ring is usually around 2 to 4 mms).

What are the exceptions which Clemmensen and Fairgrieve may have noticed?
a) The tubular form of an infant phimosis (which may under specific circumstances remain unstretched).
b) Post circumcision phimosis, (due to the circumcision scar).
c) An injury which could leave a scarring on the outer skin or lengthwise across the ring formed skin structure of the inner prepuce.
d) In special extremely abnormal circumstances (frostbite or famine?) one could imagine that the foreskin may shrivel, or a phimosis could possibly develop exactly on the join between inner and outer foreskin.
Any other form of phimosis must be so extremely rare that I have never heard of or seen any reported anywhere.

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CONCLUSION and APPROPRIATE TREATMENT

It would appear that the most conservative method of surgical removal of this white narrow ring is:
Satya Parkash, F.R.C.S. (Eng), M.A.M.S., and B Raghurma Rao, M.S.
Preputial Stenosis - Its Site and Correction 1980; ibid
Technique: "An attempt is made to withdraw the thin outer skin of the prepuce to reveal the narrow lesion. The lesion is excised quite simply with a pair of fine tipped scissors. The edges need to be staggered sufficiently to avoid an annular scar. Then the two ends are brought together; ..."

Clemmensen's findings may be summarised in the following
Table of the Histologic patterns of phimotic prepuces

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 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 and additional inflammations the described pathological process leads in the end to Balanitis xerotica obliterans"

(Modern texts generally use the name Lichen Sclerosus et atrophicus or LSA, Hermann uses the word Balanitis xerotica obliterans or BXO arguing that "To put Balanitis xerotica obliterans, as a subsidiary of Lichen Sclerosus et atrophicus can hardly be agreed to without reservation ...")

M. Meuli, et al
"Lichen sclerosus et atrophicus causing phimosis in boys: a prospective study with 5-year followup after complete circumcision." (ibid 1994)
"Our prospective study demonstrates that lichen sclerosus et atrophicus is a relatively common cause of phimosis. The 10% incidence is comparable to the 15% found by Kristiansen et al and the 14% reported by Chalmers et al. Therefore this condition is not as rare as was previously reported. Lichen sclerosus et atrophicus has been insufficiently recognised and reported because it is not commonly known."

Meuli gives a way of diagnosing LSA: "The glans demonstrated sclerogenous ivory colored patches located perimeatally, which is the classic manifestation that determines diagnosis." (This is a helpful point because it means that LSA can usually be diagnosed without taking a histological probe (a histological probe involves taking a small sample of skin),).

To conclude we return to: OJ Clemmensen et al
The histologic spectrum of prepuces from patients with phimosis. 1988 ibid
"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."

In practical terms this means that if a phimosis is primary or congenital (from birth) then there is every reason to believe that gentle stretching will mobilise the elastic capacity of the skin tissue. On the other hand, when a secondary phimosis develops during childhood adolescence or adulthood, then this will be of the lichenoid or fibrous ring type, and this will require surgery. Most probably it will be LSA or of a lichenoid type and such types are atrophic (degenerative), this confirms the usual indication of surgery for LSA on the basis that to stop infections they require anaerobic conditions. Alternatively the fibrous ring type may occur typically in old age as one of the manifestations of the skin losing elasticity; regardless centuries of medical research the process of aging remains irreversible and one may expect that the ring will progressively tighten, thus surgery is required sooner rather than later.

Therefore the consequent question facing medical research in the field of prevention of phimosis is: how does one prevent the "fibrosing" and "lichenoid" processes which lead to the development of an atrophic phimotic ring? ... This is possibly a question of rejuvenation of skin tissue in general: one may speculate that cleanliness, sunshine, oil and exercise hint at an answer.

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An Ironically accurate description
J.R. Taylor, et al
The prepuce: Specialized mucosa of the penis and its loss to circumcision
British Journal of Urology (1996), 77, 291-295
http://www.cirp.org/CIRP/library/anatomy/taylor/

Taboos within taboos (each one more appetising than the last!) In 1996 the British Journal of Urology published a study by a man called Taylor who wished to show the nature and value of the "normal" foreskin. It is as unbelievable as it is true that in order to do this he examined the foreskins of 21 (or 22) corpses.

This study describes a ridged band which appears identical to the band I recognise as a phimosis. The question this study opens up for me is: When rigor mortis sets in do all males develop phimosis? (The tendency for a fibrous phimotic ring to develop in old age as the skin shrinks and dries would tend to confirm this).

Ironically Taylor describes the phimotic ring with more accuracy than any other medical study :"a transversely-ridged band of mucosa 10-15 mm wide, lies against the true skin edge, forming the outer surface of the tip of the prepuce. In the dorsal midline. the `ridged band' lies above the level of the adjacent `smooth' mucosa and merges smoothly, on either side, with the frenulum of the prepuce. When magnified, the ridged mucosa has a pebbled or coral-like appearance. ... The remainder of the preputial lining between the `ridged band' and the glans is smooth and lax."

Please see The Anti-Circ Mythology which discusses Taylor's "ridged band" in more detail

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Appendix: RELATIVE PHIMOSIS

There are degrees of phimosis where nothing is visible on the flaccid member. However, the phimotic ring expands relatively less than the rest of the foreskin, the resultant problems fall under the heading of relative phimosis.

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)
"..."relative" phimosis, this means when on the flaccid organ there is a large quasi normal sized preputial orifice, however during erection this forms a ring shaped bridle. During erection, this bridle may be the cause of an impossibility in retraction, or result in a paraphimosis; pain due to the constricted passage (rapports par etranglement?) over the base of the glans, and tiny rips which can be easily seen on the sheath."

How should one interpret: "large quasi normal"?: as if it were normal; of an almost normal appearance; not easy to see. From the personal reports which are available to me, when the bridle is almost invisible or not easy to see then paraphimosis or an impossibility to retract would not occur.

Alan J. Wabrek, M.D., and Carolyn J. Wabrek, M.Ed.
Dyspareunia Journal of Sex and Marital Therapy Spring 1975: Vol.1, No.3, Pages: 234-41
"During the physical examination, most males don't get an erection, so it is difficult to find out if the foreskin will retract over the erect glans; therefore, this must be elicitated by history."

This is an important point in any study on statistics. Only occasionally have the men in such studies been consulted about their condition, they are generally checked objectively in the flaccid state. In such a medical check relative phimosis would be overlooked. This indicates that a significant extra percentage should be added to most estimations of the statistics for these cases of relative phimosis.

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Appendix: EMBRYOS and CORPSES

Why does the phimotic ring form at this point just behind the tip, on the inner blade of the foreskin?: The tubular nose shape of the infant prepuce bears no relationship to the position of the phimotic ring. Therefore I am led to believe that it is a phase in the embryonic development which leads to the vulnerability of this particular contour or strata of skin.

appendix with references for this file