Editing CUA: Circumcision (2018) (section)

== Phimosis ==

* Physiological phimosis
** Naturally occurring adhesions between prepuce and glans
** '''Mechanisms that lead to resolution of physiological phimosis''' (separation of physiological adhesions) '''over time (2):'''
**# '''The collection of smegma''' (a white exudate of skin cells and keratin) '''separating the prepuce from the glans'''
**# '''Repeated reflex erections'''
*** '''This process is complete by age 3 in 90% of boys; <1% by 17 years of age have phimosis'''
* Pathological phimosis
** Uncommon pediatric diagnosis (0.6‒1.5% of boys)
** Diagnosed by the presence of a whitish, fibrotic preputial ring.
* Diagnosis and Evaluation
** Neonatal examination of the foreskin and urethral meatus should be part of routine clinical assessment of all newborn boys.
** Continued examination of the foreskin without forcible retraction is recommended during yearly physical examinations to rule out pathological phimosis and document natural preputial retraction.
* '''Management'''
** '''Normal foreskin care in early childhood only starts once the foreskin is retractable and this will happen at varying ages.'''
*** Once retractable, the child can be taught normal foreskin care: gently retract and clean during bathing with normal soap and water.
** '''Active retraction should be avoided'''
*** '''Has the potential to cause microtears and lead to scarring and subsequently a true phimosis.'''
** '''Persistent physiological phimosis in an asymptomatic child should not be an indication for circumcision'''
** '''Indication for urological consultation in children with phimosis (4):'''
**# '''Recurrent episodes of balanitis'''
**# '''UTI'''
**# '''Genital lichen sclerosis'''
**# '''Suspicion of true (pathological) phimosis with evident scarring of the preputial ring'''
*** '''Ballooning of the foreskin during voiding is not associated with obstructed voiding and is not an indication for circumcision.'''
** '''If the foreskin is not open by 8–10 years of age, there may be an indication for steroid therapy and gentle retraction'''
*** '''Topical steroids are the first-line treatment for persistent physiological phimosis requiring treatment''' with good success rates and low risk of complications
**** Topical steroids aid by thinning the preputial skin and obliterating the stratum corneum, which then allows gentle retraction over time
**** '''Moderately low-potency steroid (triamcinolone, clobetasone, hydrocortisone, mometasone) may have similar success compared to a highly potent steroid (betamethasone)'''
***** '''Rx: hydrocortisone 2.5% to affected area TID x 6-8 weeks'''
*** Patient selection to ensure compliance, demonstrating the technique of gentle retraction of the foreskin and continued retraction after initial success is important to achieve continued success to topical steroid therapy
** '''Recurrence of physiological phimosis is common and normally responds to another course of topical steroids'''