Phimosis
Disorders of the penis and foreskin
Treatment
Antibiotic treatment, although often started, is not indicated in most cases unless urinalysis and urine culture show a bacterial infection. Epididymitis is usually self-limiting and with supportive therapy (i.e. minimal physical activity and analgesics) heals without any sequelae (Level of evidence: 3; Grade of recommendation: C). However, bacterial epididymitis can be complicated by abscess or necrotic testis and surgical exploration is required.
Note! Treatment is directed toward the etiologic cause:
· If the epididymo-orchitis is idiopathic, then treatment is similar to treatment for torsion of the appendix testis e.g., NSAIDs, scrotal support and limited activity for 7 days.
· If the etiology is infectious then treatment includes empiric antibiotics until definitive cultures with sensitivity results are available that confirm the empiric treatment or direct new and different antibiotics.
· If there is suspicion that the patient has a sexually transmitted disease, the adolescent is treated with Ceftriaxone 125 mg or 250 mg intramuscular in a single dose plus Doxycycline 100 mg orally twice a day for 10 days.
· For acute epididymitis most likely caused by enteric organisms or with negative gonococcal culture or nucleic acid amplification test, treatment is Ofloxacin 300 mg orally twice a day for 10 days or Levofloxacin 500 mg orally once daily for 10 days.
Phimosis is defined as the inability to retract the foreskin. Phimosis derives from an ancient Greek word meaning “muzzled” and refers to a condition in which the foreskin cannot be drawn back to expose the glans.
At birth, physiologic phimosis is present as adhesions between the prepuce and glans preclude retracting the foreskin. As the child grows, the two layers begin to separate as sloughed epithelial debris, or smegma, accumulates between them, defining this plane. This smegma is commonly referred to as "foreskin pearls" and can be mistaken for infection or purulence by the uneducated parent. With spontaneous erections and natural manipulation, more than 90% of foreskin becomes retractable by age 3 to 4 years.
At the end of the first year of life, retraction of the foreskin behind the glandular sulcus is possible in only about 50% of boys.
Note! Most uncircumcised infants have normal, physiologic phimosis. Acquired cases of phimosis may be secondary to recurrent balanoposthitis, poor hygiene, or forcible retraction of the foreskin.
The incidence of phimosis is 8% in 6 to 7-year-olds and just 1% in males aged 16-18 years.
The phimosis is either primary (physiological) with no sign of scarring, or secondary (pathological) to a scarring such as balanitis xerotica obliterans.
Phimosis has to be distinguished from normal agglutination of the foreskin to the glans, which is a physiological phenomenon.
The diagnosis of phimosis is made by physical examination. There may be a history of ballooning of the foreskin during urination, with dribbling of entrapped urine after voiding is complete.
Forceful retraction is not required for this to occur and may initiate the vicious cycle of tearing and scarring, which can lead to pathologic phimosis.
u In children older than 4 years who are unable to retract the foreskin and are symptomatic with episodes of posthitis or balanoposthitis or ballooning of the foreskin with voiding, a trial of betamethasone cream (0.05%) two times per day for 1 to 2 months allows the foreskin to retract in up to 90% of boys. This treatment has no side effects and the mean blood spot cortisol levels are not significantly different from an untreated group of patients (level of evidence: 1).
For those refractory to corticosteroid treatment, a temporizing dorsal slit (dorsal incision), preputioplasty (surgical enlargement of the phimotic ring), or circumcision is indicated.
According to the current guidelines of the ESPU the childhood circumcision has an appreciable morbidity and should not be recommended without a medical reason (level of evidence: 2, grade B recommendation).