Revoir les différences entre les phimosis normal et pathologique, rappeler les soins appropriés du prépuce et discuter des cas de prépuces phimotiques qui requièrent une consultation.

Cet article est fondé sur les résultats d’une recherche dans MEDLINE concernant les demandes de consultation pour phimosis et circoncision, et sur l’expérience des auteurs à la Clinique d’urologie du Centre hospitalier pour enfants de l’est de l’Ontario. Les rubriques MeSH utilisées pour la recherche dans MEDLINE incluaient «phimosis», «referral and consultation» et «circumcision». La plupart des articles sur les demandes de consultation pour phimosis et prépuce étaient des revues rétrospectives et des études de cohorte (preuves de niveaux II et III).

Le phimosis se définit comme l’incapacité de rétracter le prépuce. Il importe de différencier le phimosis physiologique du phimosis pathologique, puisque le premier se traite aisément tandis que le second exige une intervention chirurgicale. Un prépuce non rétractile suscite beaucoup d’anxiété chez les patients comme chez les parents. La plupart des patients qui sont envoyés aux cliniques d’urologie pédiatrique pour phimosis ont des prépuces phimotiques physiologiquement normaux. Le fait d’envoyer des cas de phimosis physiologiques aux cliniques d’urologie peut inquiéter patients et parents sur l’éventualité d’une chirurgie, tout en allongeant indûment la liste d’attente des évaluations en spécialité. Les pénis non circoncis ne requièrent aucun traitement particulier. La plupart des prépuces finissent par devenir rétractiles si on les lave normalement avec de l’eau et du savon, et si on les rétracte délicatement pendant la miction ou le bain.

Le médecin de famille est souvent consulté pour des phimosis physiologiques. Il doit alors rassurer patients et parents sur la normalité de cette condition et leur rappeler les mesures d’hygiène adéquates du prépuce. En présence d’un phimosis pathologique, il doit demander une consultation, puisque cette condition requiert un traitement chirurgical.

This article is based on selected findings from a MEDLINE search for literature on phimosis and circumcision referrals and on our experience at the Urology Clinic at the Children’s Hospital of Eastern Ontario. The literature on this topic consists mainly of level II (cohort studies) and level III (retrospective reviews) evidence. The cohort studies performed in Europe are the studies most often cited in the urologic community when discussing phimosis.^1,2 These cohort studies pioneered the way we approach phimosis, as they helped elucidate the natural history of the foreskin.

The prepuce (foreskin) is the retractile covering of the glans penis. It serves many functions, including protective, erogenous, and immunologic.^3,4 During neonatal development the prepuce is normally non-retractile, as the inner epithelial lining of the foreskin and the glans adhere to one another.^1,3 Non-retractile foreskins are common among young boys and are a normal part of preputial development. More than half a century ago, it was shown that the prepuces of newborns are non-retractile, while at 3 years of age, up to 10% of foreskins remain non-retractile.² It should be noted that, in these small children, even retractable foreskins might not be fully retractable, as inner preputial adhesions are still seen in most boys at age 6.² What of the 10% of 3-year-old boys with non-retractile foreskins? Oster¹ answered this question in an elegant cohort study published in 1968. Oster extended the study and found that 8% of boys at the age of 6 years, and 1% at the age of 16 years, still had non-retractile foreskins.¹ The foreskin gradually becomes retractable secondary to intermittent erections and keratinization of the inner epithelium.^1,5 The moral of the story told by these 2 seminal studies is that, if one is patient and does not rush Mother Nature, most foreskins will become retractile by adulthood.

Phimosis is a condition in which the prepuce cannot be retracted over the glans penis. True pathologic phimosis exists when failure to retract is secondary to distal scarring of the prepuce. This scarring often appears as a contracted white fibrous ring around the preputial orifice. In contrast, physiologic phimosis consists of a pliant, unscarred preputial orifice. Physiologic phimosis is common in male patients up to 3 years of age, but often extends into older age groups.^1,2,6,7 These 2 separate conditions are, by and large, clearly distinguishable on physical examination (Figure 1B).

Several factors might prevent full retraction of a foreskin. Most of the time retraction is prevented by persistence of preputial adhesions. These adhesions are remnants of the fused layer between the glans and prepuce. Although these can initially prevent full retraction, adhesions usually spontaneously resolve with gentle retraction of the foreskin during bathing and during intermittent erections throughout childhood.

Boys who have recurrent episodes of balanitis or balanoposthitis are at risk of developing scarred preputial orifices, contributing to pathologic phimosis. Application of a corticosteroid cream to the non-scarred preputial outlet loosens the tissues in approximately 80% of cases, allowing for improved foreskin retraction. Balanitis xerotica obliterans is a form of penile lichen sclerosis et atrophicus. Scarring secondary to balanitis xerotica obliterans is a common cause of pathologic phimosis. Balanitis xerotica obliterans is usually resistant to topical corticosteroid therapy.

A variety of conditions can affect the foreskin of a child. Many are benign, but might require medical attention.

Proper care for an uncircumcised penis is simple and helps prevent pathologic foreskin conditions. The foreskin should be left alone until the prepuce demonstrates an ability to retract. If the foreskin does not yet retract, there is nothing to “clean under.” Once the prepuce can be retracted, foreskin hygiene may commence, with children learning to gently retract their own foreskins during voiding or bathing. Children normally stop retracting their foreskins if they have any discomfort. It is important to prevent forceful retraction. Forcefully retracting the foreskin creates microtears at the preputial orifice, leading to scarring that might eventually cause formation of a phimotic ring. Hence, the foreskin should be retracted gently to its maximum extent and no farther.

The foreskin can be cleansed during routine bathing. The foreskin should be pulled back gently and rinsed with soap and water. Once dried with a towel, the foreskin must always be brought back down to its original position to cover the glans.

Most patients who present with tight foreskins have physiologic phimosis.⁸ The best treatment for these patients is “tincture of time.” These patients require no more than reassurance of normalcy and reinforcement of proper preputial hygiene. A 6- to 8-week course of topical corticosteroids (eg, 0.1% triamcinolone topical cream), applied directly to the preputial outlet twice daily, can be tried to help speed up the process,^9,10 but this is not needed in all cases. As discussed above, most foreskins will become retractable with time; only 1% of phimotic foreskins remain non-retractile once children enter their teenage years.¹ Teenagers might experience painful erections secondary to phimotic foreskins. Although this is a rare presentation, it can cause considerable grief for patients; hence urologic consultation should be sought for residual phimosis among teenagers.

The one absolute indication for performing a circumcision remains pathologic phimosis. If the preputial orifice is scarred, consult a pediatric urologist for advice. While waiting for the referral appointment, a course of topical corticosteroids can be prescribed for children. Although this course is usually fruitless, some studies show that topical corticosteroids might help with mild scarring.^8,9 Indications for urologic referral are listed in Table 1.

Table 1 Indications for urologic consultation regarding the foreskin