ABSTRACT: Phimosis is the inability to retract the preputial skin over the glans. 0.4 per 1000 boys per year 0.6% of boys are affected by their 15th year. Paraphimosis may also occur in some children as a complication of phimosis, when tried to retract it forcefully. Apart from the general management and circumcision of the penis, recent advancement procedures like ‘preputioplasty’ have shown remarkable results in the management of the phimosis. Homoeopathy being a unique medical science also has an answer in phimosis in children. There are remedies such as merc-sol, rhus-tox, nit-ac etc. which can prove to be beneficiary in this condition without any interventions.
KEYWORDS: Phimosis, Preputioplasty, Management, Homoeopathy.
INTRODUCTION: Phimosis is the inability to retract the preputial skin over the glans1. Phimosis may appear as a tight ring or “rubber band” of foreskin around the tip of the penis; preventing full retractions2.
Incidence is about 1% among the 7th grade boys2. 0.4 per 1000 boys per year 0.6% of boys are affected by their 15th year4.
By the time most uncircumcised boys are 10 years old, they can pull the foreskin back from the head of their penis. For some, it may not retract completely until they are about 17 years old. Boys who are born with phimosis, and it can last through puberty3.
Parents are often overly anxious and over concerned about this non-retractability in their infant/toddler. Most of these cases end up in surgical interventions in forms of circumcision.4
ETIOLOGY4: Physiological phimosis is the rule in new-born males. The prepuce is adhered to glans, attempts to retracts it causes microtears, infection and fibrosis. Poor hygiene, recurrent balanitis (infection of glans penis), posthitis (inflammation of foreskin) all leads to difficulty in retraction of foreskin and lead to consequent true phimosis.
Pathological phimosis may also be due to Balanitis Xerosis Obliterans (BXO), a genital form of genital of lichen sclerosis et atrophicans.
The exact aetiology is unknown; infections, inflammatory or hormonal causes have been implicated.
- Physiological phimosis: Seen in infants. It’s due to the inadequate separation of the inner preputial skin from the glands penis and doesn’t warrant any active treatment. Retracting it may result in fibrosis and converts physiological phimosis to pathological phimosis.
- Pathological phimosis: It’s due to fibrotic cicatrix of the preputial aperture and thus requires treatment.
SYMPTOMATOLOGY1,5: Symptoms can be a bit different in each child. Bulging of the foreskin when urinating, not able to fully retract the foreskin by age 3 (in some boys it may take longer), poor stream, straining at micturition, burning micturition, recurrent attacks of balanoposthitis.
When you forcefully retract the phimotic foreskin, paraphimosis may develop, which is an emergency condition.
Swelling of the tip of the penis when the foreskin is pulled back, pain, not able to pull the foreskin back over the tip of the penis, tip of the penis is dark red or blue in colour, pain while urinating, decreased urinary stream.
DIAGNOSIS1,4: Diagnosis of phimosis is primarily clinical and no laboratory tests or imaging studies are required. Treating physician should be able to distinguish development non-retractability from pathological phimosis, grading and severity of phimosis should be done.
MANAGEMENT:1,2,4,5,6When a child is brought with history of inability to retract the foreskin, confirm whether it is physiological or pathological.
- Care of uncircumcised penis:2,4 No special care is required for the foreskin in infancy. The foreskin shouldn’t be forcibly retracted, however gentle retraction is advised.
In the first few years of life, gentle retraction with cleansing underneath the foreskin is sufficient during diaper change or bath.
- Circumcision:4,5,6Male circumcision refers to surgical removal of foreskin, which is not often required for the treatment of phimosis. Circumcision is recommended due to failure of steroid ointment, pathological phimosis, paraphimosis, recurrent urinary tract infection, etc.
- Recent advances1– ‘Preputioplasty’: The earlier form of circumcision has been diluted by the American Association of Paediatricians. In recent years, “preputioplasty”, which ensures easy retractability but preserves the preputial covering, is rapidly becoming popular. This procedure preserves the preputial cover of the glans, it enables the preservation of cutaneous sensitivity.
REPERTORIAL RUBRICS FOR THE SYMPTOMS
- Genetalia, Male organs, Prepuce, phimosis9: Merc., Nit-ac.
- MALE, Phimosis7: MERC., NIT-AC.
Arn., calc., cann-s., canth., cinnab., dig., ham., hep., lyc., rhus-t., sulph.
- CLINICAL, PHIMOSIS7: MERC., NIT-AC.,
Calc., cann-s., canth., cinnab., dig., ham., hep., rhus-tox., sulphur.
- NITRICUM ACIDUM: Soreness and burning in glans and beneath prepuce. Pains, burns and stings. Scanty, dark offensive urine. Special action on body where mucus membrane and skin meet.
- MERCURIUS SOLUBILIS: Prepuce- irritated, itches. Vesicles and ulcers. Greenish discharge from urethra. Burning in urethra on beginning to urinate.
- ARNICA MONTANNA: Ailments from injury, over stretching of prepuce. Vesicle sediment with very painful micturition, phimosis resulting from an injury.
- RHUS TOXICODENDRON: Swelling of the glans and prepuce. Dark-red erysipelatous; scrotum thick. Swollen, oedematous. Itching intense. Scanty urine with white sediment.
- CANNABIS SATIVA: Retained urination, with obstinate constipation. Micturition in split streams. Stitches in urethra. Painful urging. Inflamed sensation; with soreness to touch. Burning while urinating.
- CINNABARIS: Prepuce swollen, warts on it, which bleeds easily. Enlarged testes. Buboes. Acts upon pain with syphilitic base. Sleeplessness associated with complaints.
CONCLUSION: Phimosis is the inability to retract the preputial skin over the glans. Paraphimosis may also occur in some children as a complication of phimosis, when tried to retract it forcefully. Apart from the general management and circumcision of the penis, recent advancement procedures like ‘preputioplasty’ has also showed good results in the management of the phimosis. In Homoeopathy, medicines like Mercurius sol, Nitric acid, Rhus-tox, etc. has shown a wide range of action in the treatment of phimosis.
- Parthasarathy A, Menon P.S.N.IAP Textbook of Paediatrics, 7th ed: MC Graw Hill; 2005. Page No: 1240-1244, Jaypee publishers
- http://www.webmd.com/men/phimosis-paraphimosis. (Accessed on 11.10.2019)
- https://www.chop.edu/conditions-dseases/phimosis (Accessed on 11.10.2019)
- Murphy Robin MD, Homoeopathic Medical Repertory, A Modern Alphabetical and Practical Repertory, Third Revised edition, Indian Edition. Page no: 456, 1481
- Boericke William, Boericke’s New Manual of Homoeopathic Materia Medica with Repertory, Third Revised and Augmented Edition Based ON Ninth Edition
- Boger CM, Boger Boenninghasuen’s Characteristic and Repertory with Corrected Abbreviations, Word Index & Thumb Index. Page no: 651, New Print Edition, B Jain Publications.