Cause: At birth, a physiologic phimosis is present in the majority of infants due to preputial adhesions

Epidem: By age 3 yr, 90% of foreskins are retractable; fewer than 1% of males have phimosis by age 17 (Arch Dis Child 1968;43:200).

Pathophys: Phimosis in infants is physiologic. During the first few years, as penis grows, accumulation of epithelial debris (smegma) occurs under prepuce, which separates preputial adhesions. Rarely, a cicatricial preputial ring may form, preventing spontaneous retraction.

Sx: Usually asx. If irritation present, may develop pain, bleeding, dysuria.

Si: Ballooning of foreskin with voiding, inability to retract foreskin fully; smegma pearls, balanitis, and balanoposthitis can occur.

Crs: Often resolves by 3-5 yr of age

Cmplc: Increased incidence of penile Ca in uncircumcised males with poor personal hygiene. Increased risk of STDs. Cochrane review based on three trials in South Africa concluded there is strong evidence that medical male circumcision reduces the acquisition
of HIV by heterosexual men by 38-66% over 24 mo (Cochrane Database Syst Rev 2009 issue).

Lab: UA; c + s if UTI suspected

Xray: Not routinely indicated

Rx: Rx of congenital phimosis not routinely indicated until age 4-5 yr, at which time spontaneous retraction should occur. Indications for circumcision include h/o UTI and vesicoureteral reflux (VUR), recurrent UTI, persistent phimosis, recurrent balanitis and balanoposthitis, and parental desire (parents should be counseled about indications and risks of circumcision). Complication rate for neonatal circumcision is 0.2-3% (Ross JH. Circumcision: pro and con. In: Elder JS, ed. Pediatric Urology for the General Urologist. New York: Igaku-Shoin; 1996:49). Contraindications to neonatal circumcision include coexisting hypospadias, chordee without hypospadias, webbed penis, small penis, and dorsal hood deformity. Infants with a large hernia or hydrocele are more likely to develop buried penis and secondary phimosis if circumcision is performed prior to rx of hernia/ hydrocele (Campbell’s Urology 1998;7[2]:2120). Topical steroid cream (0.05% betamethasone cream) has up to a 95% success rate in small series (BJU 1996;78:786; J Urol 1999;162:1162).