Review

Special Issue: Penile Anomalies in Children

TheScientificWorldJOURNAL (2011) 11, 289301
TSW Urology
ISSN 1537-744X; DOI 10.1100/tsw.2011.31

Prepuce: Phimosis, Paraphimosis, and

Circumcision
Yutaro Hayashi*, Yoshiyuki Kojima, Kentaro Mizuno, and Kenjiro Kohri
Department of Nephro-urology, Nagoya City University Graduate School of Medical
Sciences, Japan
E-mail: [email protected]
Received July 7, 2010; Revised October 28, 2010; Accepted December22, 2010; Published February 3, 2011

Phimosis is a condition in which the prepuce cannot be retracted over the glans penis.
Actually, physiologic phimosis is common in male patients up to 3 years of age, but
often extends into older age groups. Balanoposthitisis a common inflammation
occurring in 411% of uncircumcised boys.Circumcision is generally undertaken for
three reasons: first, as an item of religious practice, typically neonatally although
occasionally transpubertally, as a rite of passage; second, as a prophylactic measure
against future ailments for the reduction in the risk of penile cancer, urinary tract
infection, and sexually transmitted infection; and third, for immediate medical indication.
Balanitisxeroticaobliterans is an infiltrative skin condition that causes a pathological
phimosis and has been considered to be the only absolute indication for
circumcision.Various kinds of effective alternatives to circumcision have been described,
including manual retraction therapy, topical steroid therapy, and several variations of
preputioplasty. All of these treatments have the ability to retract the foreskin as their goal
and do not involve the removal of the entire foreskin.Paraphimosis is a condition in
which the foreskin is left retracted. When manipulation is not effective, a dorsal slit
should be done, which is usually followed by circumcision.
KEYWORDS: prepuce, phimosis, paraphimosis, circumcision, preputioplasty

PREPUCE
Natural History of Prepuce
At birth, there is normally a physiologic phimosis or inability to retract the foreskin because natural
adhesions exist between the prepuce and the glans. During the first 34 years of life, as the penis grows,
epithelial debris (smegma) accumulates under the prepuce, gradually separating the foreskin from the
glans. Intermittent penile erections cause the foreskin to become completely retractable.
Gardiner reported that at birth, <5% of boys have a fully retractable prepuce and this figure increases
to 15% at 6 months, 50% at 1 year, 80% at 2 years, and approximately 90% at 3 years in the U.K.[1].
Oster recorded more than 9,000 observations in Danish boys and demonstrated that 90% of foreskins can
be retracted by 3 years of age and <1% of males have phimosis by 17 years of age[2]. In 1996, Kayaba et
al. evaluated preputialretractability in 603 Japanese boys 015 years of age and reported that the
*Corresponding author.
2011 with author.
Published by TheScientificWorld; www.thescientificworld.com

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incidence of completely retractable prepuce increased 0% at age 6 months to 62.9% by 1115 years of
age, while the incidence of completely unretractable prepuce decreased 47.1% at age 6 months to 0% by
1115 years of age[3]. In 1997, Imamura investigated the condition of Japanese prepuce in 3,238 infants
and in 1,283 children aged 3 years[4]. The incidence of completely retractable prepuce increased from
3.0% in infants aged 13 months to 38.4% in children aged 3 years, while the incidence of completely
unretractable prepuce decreased from 88.5% in infants aged 13 months to 35.0% in children aged 3
years. In 2006, Hsieh et al. examined the foreskin and external genitalia of 2,149 Taiwanese schoolboys
and showed that 50% of 7-year-old boys had phimosis, which decreased to 8% at age 13 years[5]. In
2009, Yang et al. investigated preputialretractability in 10,421 Chinese boys aged 018 years and reported
that the rate of phimosis decreased with age from 99.7% at birth to 6.81% in adolescence[6].

Problems of Prepuce
Phimosis
Phimosis is a condition in which the prepuce cannot be retracted over the glans penis. It could be further
defined as physiologic, as in infancy and childhood, or pathologic. Pathologic phimosis would result from
inflammatory or traumatic injury to the prepuce resulting in an acquired inelastic scar that prevents
retraction. Forceful disruption of physiologic adhesions in infants no doubt encourages pathologic
phimosis. Physiologic phimosis is common in male patients up to 3 years of age, but often extends into
older age groups[1,2,3].

Balanoposthitis
Balanitis is the term for inflammation of the glans penis. Posthitis is defined as inflammation of the
prepuce. Balanoposthitisis inflammation of both (Fig. 1). It is fairly common, occurring in 411% of
uncircumcised boys[7,8,9]. The etiology is unclear and no cause can be identified in many cases, although
infection, mechanical trauma, contact irritation, and contact allergy are cited[10].

FIGURE 1.Balanoposthitis.

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Management of balanoposthitis includes improved hygiene with gentle foreskin retraction, sitz baths,
and cleaning of the foreskin[11]. Topical ointment and oral antibiotics are indicated for suspected acute
bacterial balanoposthitis. Because Group A beta hemolytic streptococcus is a common bacterial cause of
balanoposthitis, first-generation cephalosporins or penicillins have been typically recommended[12,13].

Paraphimosis
Paraphimosis is a condition in which the foreskin is left retracted because of entrapment of the tight
prepuce proximal to the corona (Fig.2). The glans engorges and the prepuce becomes edematous because
of lymphatic and venous congestion. This could happen because boys have been encouraged to retract the
foreskin for physiological phimosis by parents or medical staff. In most instances, manual compression
can reduce the preputial edema within the first few hours. In difficult cases, various techniques are
described, including applying granulated sugar to the penis[14], adding multiple punctures to the
edematous foreskin before compression[15], injecting hyaluronidase beneath the narrow band to release
it, and wrapping the distal penis in a saline solutionsoaked gauze swab and squeezing gently but firmly
for 510 min[16]. Thereafter, physicians are supposed to push forcefully on the glans with the thumbs,
while pulling the foreskin with the fingers. However, an emergency dorsal slit may be necessary in late
cases. Some authors advise circumcision for paraphimosis because of its tendency to recur, whereas
others insist that circumcision is not mandatory because the foreskin will continue to develop normally.

FIGURE 2.Paraphimosis.

BalanitisXeroticaObliterans
Balanitisxeroticaobliterans (BXO), known as lichen sclerosus, is an infiltrative skin condition that causes
a true phimosis and a clinically recognizable lesion at the tip of the prepuce[17]. It is usually
distinguished by a ring of hardened tissue with extensive scarring, a whitish color at the tip of the
foreskin, and edema (Fig. 3). It has been said to be a common underlying cause of persistent
nonretractability of the foreskin at puberty[2], while the overt lesion is rarely seen in children under 5
years of age[18]. However, Meuli et al. found BXO in 15% of children undergoing circumcision for
phimosis[19]. Presentation is with inability to retract the prepuce, discomfort after micturition, and
occasional minor obstructive signs[20].

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FIGURE 3.Balanitisxeroticaobliterans.

Definitive diagnosis was reached with biopsy, which showed hyperkeratosis with follicular plugging,
atrophy of the stratum spinosumMalpighii with hydropic degeneration of basal cells, lymphedema,
hyalinosis and homogenization of collagen in the upper dermis,and inflammatory infiltration in the mid
dermis.
Whether or not the BXO lesion will respond to the topical steroid is still unclear, although
administration of topical steroid has been proven to be effective in approximately 80% of physiological
phimosis. Vincent and Mackinnon evaluated 56 boys with clinical features of BXO and reportedthat
17.9% of patients showed complete resolution after treatment with topical steroid after 3 months, which
increased to 30.4% after an average of 14 months of the treatment[21]. Kiss et al.performed histological
evaluation of topical steroid application for BXO, and concluded that steroid treatment tends to be
effective when the inflammatory mechanism is active and irreversible tissue damage has not occurred,
including cases of the early and intermediate histological forms of the disease, whereas in the late disease
type in which irreversible changes are exemplified by severe degeneration and atrophy of the genital skin,
treatment is ineffective or at best only slows further worsening[22].
The preferred treatment for BXO has been circumcision, which will remove all the affected tissue.
Preputioplasty is not an option because the continuing inflammatory process results in recurrent stenosis
of the preputial orifice. Remaining lesions on the glans nearly always regress or resolve following
circumcision. Meatotomy or meatoplasty is needed in cases of severe meatal involvement, and
postoperative application of topical steroid may lessen the risk of subsequent restenosis.

CIRCUMCISION
Circumcision as Religion and Rite of Passage
Globaly, most circumcisions are performed for religious reasons and are a fundamental part of the Jewish
and Muslim faiths.
In the Jewish belief, circumcision is a covenant between God and Abraham, as written in the
Bible(Genesis) and should be performed by a mohel when the boy is 8 days old[23].
Muslim society considers it a tradition of the Prophet Mohammed (Sunnah) to introduce the boy into
the religious Islamic community, although it is not mentioned in the Holy Koran[24].

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Male circumcision that is performed for any reason other than physical, clinical need is termed
nontherapeutic (or sometimes ritual) circumcision.

Circumcision as Prophylactic Therapy

Prophylactic Circumcision to Prevent Urinary Tract Infection (UTI)
Incomplete preputial separation has been considered responsible for colonization of the prepuce by
pathogens, which leads to balanoposthitis or UTI.
The incidence of UTIhas been reported to be lower in circumcised than uncircumcised infants[25,26].
An unretractable prepuce has been considered responsible for colonization of the prepuce by pathogens,
which leads to UTI. An association between a decreased incidence of UTIand circumcision during the
first year of life has been reported[27].
Hiraoka et al. analyzed 100 consecutive children (males and females) who developed febrile UTI, and
investigated preputialretractability in 64 boys with febrile UTIand 714 healthy boys who underwent
public health checkups[28]. The external urethral meatus could not be observed by gentle retraction in
85% of the boys under the age of 7 months with their first urinary infection,compared to 42% of
healthyboys. They mentioned that the tightly covered urethral meatus may cause urinary infection
frequently found in uncircumcised young infants, although spontaneous resolution of phimosis could be
expected with maturation of prepuce.

Prophylactic Circumcision to Prevent SexuallyTransmitted Infection(STI)

Whether early childhood circumcision reduces the risk of future STIs other than human
immunodeficiency virus (HIV) has been controversial.
In 1998, Moses et al. analyzed 11 studies and reported a strong association between the lack of
circumcision and chancroid, syphilis, genital herpes, and gonorrhea, but no association with urethritis
other than gonorrhea and genital warts[29].
Cook et al. performed a cross-sectional study of 2,776 heterosexual men attending an STI clinic in
1998 and identified a positive relationship between lack of circumcision and both syphilis and
gonorrhea[30].They recognized a negative relationship with genital warts and no relationship with genital
herpes or nongonococcal urethritis.
Laumann et al. conducted a study of 1,410 American men aged 1859 years, examining the
prevalence of circumcision across various social groups, and the health and sexual outcomes of
circumcision[31]. They did not find a statistically significant difference in the incidence of STIs based on
circumcision status.
Weiss et al. conducted a systematic review and meta-analysis for male circumcision using 26 articles
in 2006[32]. They reported that circumcised men are at low risk of chancroid and syphilis, but there is
less association with herpes simplex type 2.

Prophylactic Circumcision to PreventHuman Immunodeficiency Virus (HIV)

Three randomized controlled trials (RCTs) in Africa confirmed that male circumcision reduces the rate of
female-to-male HIV transmission by 5576%[33,34,35]. These three RCTs were abandoned before their
designed completion because of significant reductions in HIV incidence in the circumcised groups. Lack
of circumcision has long been recognized as a risk factor for HIV acquisition in heterosexual men[29].
This makes biological sense because superficial Langerhans cells, which express HIV-1 receptors, are
more prevalent in the male foreskin than in the remainder of the penis[36]. Additionally, decreased

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keratinization of the foreskin increases susceptibility to minor trauma during intercourse, potentially
aiding the passage of HIV[37].
In 2009, an expert group, consisting of the Joint United Nations Programme on HIV/AIDS
(UNAIDS), the World Health Organization (WHO), and the South African Centre for Epidemiological
Modelling and Analysis (SACEMA), reviewed six mathematical models using the latest data on the effect
of circumcision on HIV prevention[38]. The models predicted that one new HIV infection would be
averted for every 515 men newly circumcised.

Prophylactic Circumcision to Prevent Penile Cancer

Incidence of carcinoma of the penis varies greatly with the standards of hygiene, and the religious and
cultural practices of different countries. It is usually seen in men who have poor standards of penile
hygiene.
In men who have not been circumcised, tumor development has been attributed to the chronic
irritative effects of smegma, a by-product of bacterial action on desquamated cells within the preputial
sac. Closed preputial sacs promote development of penile carcinoma by a carcinogen[39]. Smegma has
been implicated as the carcinogenic agent and, although definite evidence has not been established, its
association with the development of penile cancer has been widely observed.
Phimosis is present in 2575% of patients with penile carcinoma[40,41,42,43].The true incidence of
phimosis might be even higher, since information about its presence is not available in many patients in
whom the prepuce has been destroyed by the tumor.
Circumcision protects against penile carcinoma and is a well-established prophylactic measure that
almost eliminates the occurrence of penile cancer. Neonatal circumcision is done for all Jewish males and
carcinoma of the penis is almost nonexistent in this population[40]. Neonatal circumcision reduces the
risk of penile cancer by at least ten times[29].In Muslims, who circumcise boys before puberty, penile
carcinoma is rare[44].
Adult circumcision does not offer protection from subsequent development of disease, suggesting that
some period of exposure to smegma might be necessary for carcinogenesis, and accounts for the
decreased effectiveness of pubertal circumcision and the negligible protective effect of adult
circumcision[45].
In developed countries, penile cancer is a relatively rare disease, with an incidence of <1 in
100,000[46]. The absence of RCT evidence, combined with the rarity of penile cancer, suggests that
circumcision is not justified for the sole purpose of protecting against penile cancer.

METHODS OF CIRCUMCISION
Neonatal circumcision is most commonly performed under local anesthesia outside the operating room,
using one of three techniques. Two of these, the Gomco clamp and the Plastibell device, require the use of
a specialized apparatus. The Mogen clamp is a simple instrument used in conjunction with conventional
sharp and blunt dissection. In the beginning of the operation, all three techniques assure inspection of the
glans and mobilization of the foreskin from physiological adhesions. Both the Mogen and the Gomco
clamps protect the glans, while producing crush injury to the prepuce, which is then surgically removed.
Jewish ritual circumcisions are usually conducted with a Mogen clamp[47,48]. The Plastibell device
induces necrotic tissue, which is sloughed off, along with the plastic shield, within 12 weeks. In the
meantime, the infant voids through the open end of the bell. A retrospective cohort study of 5,521
American boys compared neonatal circumcision results using the Gomco clamp and the Plastibell device.
The overall complication rate of 0.2% did not differ between the two groups. However, the
Plastibelldevice was associated with more infections, whereas the Gomcoclamp was associated with more
dehiscence and removal of too much skin[49].

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In older children, circumcision is usually performed in the operating room under general anesthesia,
with the addition of a local anesthetic penile or caudal block to provide good analgesia during and
immediately after the surgery. Because circumcision devices seem to be less adequate for older children,
most circumcisions are conducted by the sleeve or freehand technique.
Any remaining adhesions between the glans and prepuce are bluntly lysed. A circumferential incision
is made overlying the coronal impression of the glans through the skin. On the ventral surface, the skin
incision should be in a Vshape opposite the frenulum. The foreskin is then retracted and a circumferential
incision is made in the inner prepuce approximately 0.5 cm proximal to the coronal sulcus, preserving the
frenular arteries. After both incisions are made, a sleeve of preputial tissue is created. On the dorsal
surface, a pair of scissors is used to create a plane superficial to Bucks fascia between the two
circumferential incisions. The ring of the prepuce is incised along this plane and then removed. The skin
and the inner prepuce are reapproximated with absorbable sutures after hemostasis is achieved.
When the prepuce cannot be retracted easily, a dorsal slit is initially required from the tip of the
prepuce extending to the circumferential outer skin incision and proximal to the coronal sulcus at the
inner side. The edges of the preputial incision are grasped and both layers of the prepuce are divided
circumferentially on the marked line, leaving the frenulum in place. After the removal of the prepuce, the
remaining steps are the same as the sleeve technique.
In circumcision, a carbon dioxide laser beam can be used as a cutting device, which significantly
decreases the incidence of postoperative bleeding and also postoperative edema[50,51,52].
Although an absorbable suture of a fine caliber provides a good cosmetic result, a tissue glue supplied
with a fine nozzle applicator gives a cosmetically pleasing result[53,54,55].

ALTERNATIVE TREATMENTS TO CIRCUMCISION

Manual Retraction Therapy
Cooper et al. performed foreskin retraction on 106 boys under general anesthesia. Of them, 93 had
presented with symptoms (balanoposthitis, dysuria, preputial ballooning, or retained smegma) and 13 had
been referred because of a nonretractable foreskin alone. After the therapeutic retraction under anesthesia,
the parents were asked to retract their childs foreskin constantly. As a result, the symptoms resolved in
85% of the boys and the foreskin became fully retractable in 62%[56].
Tsugaya et al. practiced the manual retraction therapy for 98 boys between the ages of 1 month and
12 years. They reported that exposure of the glans by forceful retraction should not be performed because
readhesion between the glans and prepuce occurred in 68% of those who underwent the
retractiontherapy[57].
Rickwood et al. mentioned that BXO commonly occurs as a result of forceful retraction of the
prepuce[18]. Iatrogenic injury from forcible retraction of the prepuce is a common cause of true phimosis.
Preputial injury leads to cicatrix formation, which narrows the preputial aperture.

Topical Steroid Therapy

Since 1993, various kinds of topical ointment have been successfully used to treat phimosis in boys.
Success rates ranging between 67 and 95% have been reported with topical application
ofbetamethazonecream as a highly potent steroid[58,59,60]. Several studies have noted success with the
application of clobetasol propionate as an ultrahigh potent steroid and described success rates between 70
and 92%[61,62,63]. As a medium potent steroid, monometasonefuroate topical cream has had success
rates of 66[64] and 88%[65], and triamucinoloneacetonide topical cream has had success rates of 76[66]
and 84%[67]. In addition, even with a low potent steroid, hydrocortisone, two studies showed satisfactory
success rates of 86[68] and 90%[69]. The anti-inflammatory and immunosuppressive effects[70], as well

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as the skin thinning effects[71], of the topical steroids may explain their effectiveness. No adverse side
effects were reported in all potent grades of these steroid treatments.
Pileggi et al. evaluated cortisol secretion in 31 boys by the measurement of salivary cortisol before
starting treatment and after 8 weeks of topical treatment for phimosis with 0.05%
clobetasolpropionate[72]. They mentioned that the salivary cortisol level should be considered as a
laboratory marker in long-term treatment or during repeated cycles in order to detect possible
hypothalamus-pituitary-adrenal axis suppression, although clobetasol propionate does not affect the axis
in most patients.
On the other hand, Muller and Muller first applied topical conjugated equine estrogen to treat
phimosis, expecting that it would increase collagen and water content of the skin tissue[73]. According to
additional reports, the topical application of estrogen ointment for phimosis revealed successful results in
76100%[74,75,76]. Although the response rate seemed to be consistent to that of the other topical steroid
therapies, gynecomastia occurred during the treatment as a side effect in several reports. Yanagisawa et
al. commented that prolonged application of estrogen ointment on a poorly responding foreskin may
increase the patients risk to side effects[75].

Dorsal Slit
The dorsal slit, a longitudinal incision of the dorsal preputial skin, is used to release the paraphimosis or
severe balanitis with urinary retention when the prepuce cannot be retracted easily[77]. Emergent
circumcision does not tend to be selected because it is technically difficult due to massive edema or it
would carry a greater risk of postoperative infection.
However, in Japan, many physicians conductedthe dorsal slit for boys with phimosis even in
nonemergent situations. Matsuoka et al. performed the dorsal slit for 43 children with phimosis and
during the follow-up (from 1 to 12 years, mean: 4 years), they interviewed and examined 20 responders
for the questionnaires about postoperative appearance[78].The results showed that 30% of them expressed
some dissatisfaction with the penile appearance, and about half were apparently recognized to have
abnormal appearance (ventral-sided redundant foreskin) compared with usual boys from the view of the
operators.

Preputioplasty
The dorsal slit, as traditionally and still occasionally performed, israrely to be recommended because the
cosmetic result is unsatisfactory and, hence, formal circumcision almost always ensues. However, as
mentioned before, in Japan, routine neonatal circumcision has never been conducted so far. Therefore,
genital appearance with exposed glans after circumcision would look unusual among Japanese boys, even
if surgical repair was eventually chosen as a prophylactic therapy for pediatric phimosis.
Preputioplasty, with preservation of the foreskin, has been proposed as an alternative to circumcision
and may take the form either of a limited dorsal slit, with transverse suture[79], or longitudinal incision of
the constricting ring proximal to the preputial meatus, again with transverse suture[80].
Dean et al. developed a geometric variant of the dorsal slit procedure, which added a ventral slit to
achieve a natural appearance of intact foreskin and to be easily fully retractable[81].
Lane and South described a lateral preputioplasty as a variant of the dorsal slit[82]. In this procedure,
two laterally placed longitudinal incisions were made and the defects were sutured transversely. They
advocated that the lateral placement of the incisions provides cosmetic improvement over the dorsal
approach, and avoids the impairment of frenular area over circumcision or other procedure including
ventral slits.
A triple-incision preputioplasty was described by Welsh in 1936. The technique consisted of three
longitudinal, full-thickness skin incisions across the stenotic ring down to the inner preputial layer and

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transversal suturing of the three defects to enlarge a phimotic ring(Fig. 4). Whlin modified the procedure
and three rhomboid-shape defects made by the longitudinal incisions were closed with interrupted sutures
placed obliquely in the middle of each incision[83].Fischer-Klein and Rauchenwald undertook the
monitoring of the triple-incision preputioplasty modified by Whlin for 197 boys and were able to
reassess 65% of parents and children[84]. They reported that 84% of parents were satisfied with the
function and 80% answered a good cosmetic outcome. They mentioned that a slight rotation and
shortening of the prepuce will be achieved, which is equally distributed around the whole circumference
of the penis, avoiding the so-called dog earspreputialdeformity. They also commented that three
parallel displaced suture lines are more likely to prevent restenosis than an almost continuous ring of
transverse scars.

D
FIGURE 4.Triple-incision preputioplasty.

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After the triple-incision preputioplasty, Pascotto and Giancotti added frenulotomy and two more
incisions between the previous ones, which are left to heal spontaneously, and reported that the devised
technique resulted in no recurrence, normal preputial anatomy, and function in all 22 children[85].
A Y-V plasty procedure(Fig. 5) to relieve phimosis was first described by Hoffman et al. in
1984[86].Multiple Y incisions across the narrow preputial ring were conducted. The tips of the flaps were
advanced proximally and closed as multiple Vs, like a sawtooth.Forty-four patients underwent the
procedure with an excellent result functionally and cosmetically. Nieuwenhuijs et al. carried out a
retrospective study between 47 patients treated with a Y-V plasty and 18 treated by transversely closed
longitudinal incisions of the narrow preputial ring, with recurrence rates of 4.3 and 11%[87].They
concluded that a Y-V plasty could be an alternative to circumcision in the treatment of phimosisresistant
to a topical steroid therapy.

D
FIGURE 5.Y-V plasty.

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Dessanti et al. developed a T-V plasty to enlarge the stenotic ring of prepuce by a transversal
widening on the dorsal side[88]. Consequently, they achieved excellent cosmetic results in all 26 children
at 7 days after operation and at 1-year follow-up.
Additional variations to these preputioplasties include a four V-flap repair[89], Z plasty[90],
andhelicoidsplasty[91], and no complications were reported.

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This article should be cited as follows:

Hayashi, Y., Kojima, Y., Mizuno, K.,and Kohri, K. (2011) Prepuce: phimosis, paraphimosis, and circumcision.
TheScientificWorldJOURNAL: TSW Urology 11, 289301. DOI 10.1100/tsw.2011.31.

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