Phimosis in adults, is surgery necessary?

• There are several types of phimosis in adults and various complications depending on the type of compression of the patient's penis.
• The symptoms of phimosis in adults are mainly pain during sexual intercourse and infectious problems in the area.
• The only definitive solution for adult phimosis problems is the phimosis operation, circumcision.

Phimosis is the anatomical problem of the foreskin, the part of the skin of the penis that normally covers the glans penis, which consists of a narrowing of the foreskin caused by a ring of fibrous tissue that prevents it from sliding smoothly and easily uncovering the penis. 

Thus, we can say that a healthy foreskin should be able to retract completely, leaving the glans fully uncovered during an erection, without discomfort or pain. If this is not possible, the most common procedure is phimosis (circumcision).

Within the term phimosis there are a series of concepts that encompass other pathologies in the foreskin of the penis that accompany or worsen the pathology described above. 

Thus, we call paraphimosis the aggravated condition of phimosis in which the base of the glans penis is squeezed and strangled by the foreskin when it is retracted, preventing its movement and causing congestion of the glans penis due to compression.

This state of paraphimosis must be reduced as quickly as possible as there is a risk of causing penile necrosis by impeding the free flow of blood to the glans penis. If manual reduction is impossible, emergency surgery is necessary to release the compression of the foreskin.

Other complications intrinsically linked to the concept of phimosis in adults are balanitis or inflammation and infection of the glans penis, postitis or inflammation and infection of the foreskin and balanoposthitis or union of the aforementioned pathologies. 

These conditions are closely related to phimosis, since the presence of phimosis causes an increase in the incidence of the former and predisposes to the accumulation of secreted substances and the colonisation of bacteria, fungi and viruses inside the foreskin.

As mentioned above, phimosis is defined as the inability to retract the foreskin behind the balano posterior sulcus of the glans penis, passively or actively during erection. 

This condition is characterised by minor discomfort during sexual intercourse or masturbation, local or urinary tract infections, and even acute urinary retention (AUR) in its maximum degree (sclerosis of the foreskin).

Phimosis in adults can present in three stages:

• Punctate phimosis: one in which the preputial orifice is of minimal diameter, barely noticeable, with the surrounding skin of normal appearance and thickness.
• Non-retractable cicatricial or annular phimosis: where the skin surrounding the preputial orifice is indurated or thickened, usually due to previous balanoposthitis.
• Annular phimosis: those cases that cannot be included in either of the two previous groups, where the foreskin is narrowed to a greater or lesser extent and for some reason there are complications or failure to retract.

Another way of classifying phimosis in adults and at any age is according to its origin or aetiology, so that we can find phimosis of congenital origin and phimosis acquired during development, so that we can define acquired phimosis as that which occurs in a patient who did not previously suffer from this problem. 

Newborns with congenital phimosis represent 8% and the development of the same allows a cure of 50% of them in the first 2 years and about 90% at 5 years. 

This healing process is due to the normal development of the male genitalia and the physiological growth of boys allowing the foreskin to slide over the normal glans without medical intervention in most of them.

Phimosis acquired during normal male development usually follows inflammation of the foreskin or glans penis and infections of the penis over the years. These inflammatory processes transform the preputial tissue into fibrous tissue, losing the normal elasticity of the skin and leading to acquired phimosis in adults. 

Diabetic males are the most affected aetiological group due to their predisposition to suffer from balanitis and xerositis of the glans due to their own underlying pathology. 

The percentage of balanitis in diabetic males is estimated at 16% compared to 6% in non-diabetic males, of which 20% end up forming phimosis or paraphimosis in adults.

There is another way of classifying preputial status according to the Kayaba classification depending on the degree of retractability of the foreskin with respect to the glans penis. This classification tends to be used mainly in children with phimosis problems, although it is perfectly extrapolable to the general and more adult population. 

According to these characteristics we can find:

• Adult phimosis type I: Slight retraction with no glans visible.
• Adult phimosis type II: Exposure of the urethral meatus with slightly greater retraction of the foreskin than before.
• Adult phimosis type III: Exposure of the glans penis up to the middle part of the glans penis.
• Adult phimosis type IV: Exposure of the glans penis to the crown.

The main and most obvious symptom of phimosis in adults is the inability to retract the foreskin over the glans penis, especially during erection. This inability causes intense pain during sexual intercourse and even prevents sexual intercourse, causing sexual dissatisfaction in most cases. 

If the degree of phimosis is less severe, satisfaction during sexual intercourse is possible but the prevalence of skin lesions, wounds and cracks in the skin of the foreskin increases and may worsen the symptoms and characteristics of phimosis in adults.

In severe degrees of phimosis we can find difficulty during urination as the degree of retraction and the diameter of the foreskin opening is so small that it prevents the exit of urine in a physiological way and can cause urinary retention, increasing the rate of urinary tract infections and even acute urinary retention, medically known as RAO.

In moderate and/or severe cases where foreskin retraction is very difficult, there is an accumulation of substances excreted during ejaculation, urination and sweating, which leads to an increased rate of inflammation and infections of the foreskin and penis. 

Skin changes secondary to infection and inflammation lead to increased susceptibility to penile cancer in males with adult phimosis. The increased risk is estimated to be around 30% in various studies. 

Squamous cell carcinoma is one of the main types of invasive penile cancer associated with the accumulation of substances in the grooves of the glans penis as a consequence of adult phimosis.

In recent years, a decrease in the rate of cervical cancer in women with a circumcised stable partner has been observed, although the main reasons for this decrease in cervical cancer prevalence cannot be established with certainty at present.

The definitive solution for adult phimosis is surgical intervention. 

The indications for circumcision in adults with phimosis are clear and tend to focus on males with moderate or severe phimosis who have problems during sexual intercourse or have secondary complications such as infections and inflammation of the foreskin or penis. 

Of course, in the case of severe phimosis in adults, circumcision is indicated in all affected males, unless there is a surgical contraindication due to comorbidity of the patient.

Anaesthesia in adult phimosis or circumcision surgery is generally topical by injecting local anaesthetics such as mepivacaine or lidocaine into the dorsum of the penis and around the crown of the glans penis.

The operation for phimosis or circumcision is generally simple, lasting approximately 30 to 40 minutes, with a rapid and complete recovery usually lasting around 15 days until the stitches fall out.

The surgical procedure or circumcision usually consists of 4 clearly differentiated stages:

• 1st circumferential incision: If the foreskin cannot be retracted due to irreducible phimosis, a dorsal incision is first made until the glans can be uncovered. With the foreskin already retracted, the 1st circumferential incision is made parallel to the balanopreputial sulcus at approximately 1 cm.
• 2nd circumferential incision: With the foreskin reduced (covering the glans), a second circumferential incision is made following the relief of the balano-preputial groove.
• Resection of the cuff: The foreskin is retracted again and the cuff of skin and dartos that remains between the two circumferential incisions is resected. Good haemostasis of the site must be ensured to avoid postoperative haematomas.
• Suturing the edges: First, 4 cardinal stitches of 4 zeros are made and left referenced; then 3-4 interrupted stitches of the same material are made in each of the 4 remaining quadrants.

Phimosis repair surgery in adults is a short procedure lasting just 30 minutes and does not usually require hospitalisation afterwards, so the patient usually leaves the clinic after the operation and starts the postoperative period of phimosis surgery at home.

Aftercare of the surgical wound and sutures is simple. The most important thing is to keep the wound and stitches clean and dry. For this purpose, it is advisable that during the first week daily dressings with saline solution and betadine are carried out and the wound is kept covered with gauze and/or a bandage.

The main complications come from the penis rubbing against underwear and involuntary erections while the stitches are being held in place. It is possible that due to these conditions small episodes of pain and small bleedings may occur when the penis stretches the stitches with erections.

To reduce these conditions, tight-fitting underwear and the application of ice (never directly) to the area of the stitches at intermittent intervals of no more than 10 minutes are recommended.

Cleaning of the surgical wound should be carried out with saline solution, avoiding scraping with hard sponges and taking into consideration the drying of the wound as one of the important points of post-surgical care.

The stitches administered usually fall out on their own between the 10th and 14th day, although it is possible that, depending on individual variability, they may have to be removed after 2 weeks.

It is recommended to avoid sexual intercourse for 3 to 4 weeks after the procedure, as erections may be painful. After that time there is no problem to maintain an active sex life.

If during the immediate postoperative period excessive swelling of the penis, the appearance of redness or heat or the discharge of yellowish liquids through the surgical wound occurs, you should consult your doctor immediately. A follow-up visit is usually made 15 days and one month after the operation. 

Full recovery is estimated to take 15 days and you will be able to carry out daily activities from the third day onwards.