Phimosis surgery in children, is surgery necessary?

• All boys are usually born with congenital phimosis, which usually disappears before the age of three.
• Phimosis is not a disease in itself, although it can cause other problems, such as urinary tract infections.
• Treatment of phimosis in children does not always require surgery, but treatment without surgery is not always effective.

Phimosis occurs when the foreskin (the skin covering the penis) is attached to the glans penis and is unable to be fully or partially retracted manually over the glans penis, preventing it from being fully uncovered.

Phimosis in children (also called physiological phimosis) is also the inability to retract the foreskin over the glans, as it is attached to it. It is very common for boys to be born with this problem, although it usually separates on its own before the child is three years old.

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Phimosis in boys usually resolves spontaneously due to the accumulation of smegma (a substance that comes from cells in the area of the glans penis and foreskin), spontaneous erections and normal growth of the boy's penis.

We can differentiate between two types of phimosis, depending on when they occur in the patient:

• Congenital or primary phimosis in children: This is acquired at birth, as mentioned above. It will be necessary to treat it if it causes other problems for the child, such as infections or urination difficulties.
• Acquired or secondary phimosis in boys: This is phimosis that occurs over the years. It usually arises due to a series of repeated infections or because the foreskin has been subjected to tearing due to sudden retractions.

Another way of classifying phimosis is according to its anatomical nature:

• Complete or filiform phimosis: This occurs when it is impossible to retract the foreskin due to a narrowing of the foreskin.
• Partial annular phimosis: This occurs when it is possible to remove the foreskin only partially.
• Annular phimosis: This occurs when it is difficult to retract the foreskin due to the ring-shaped narrowing of the foreskin.

The main cause of phimosis in boys is the retraction of the foreskin by parents from their sons when they are babies.

When babies are born, the foreskin is responsible for protecting the glans penis, so much so that it is sometimes attached to the glans penis. It is rarely possible to retract it because of this adhesion.

Sometimes paediatricians recommend that parents lower their child's foreskin a little further each time so that it becomes more elastic. Some parents, in order to avoid phimosis surgery later on, even do it by force, causing the child to feel pain and even causing some wounds that, after healing, prevent the correct retraction of the foreskin of the child.

In order to avoid later problems, it is recommended that parents do not carry out this type of practice, but simply lower the foreskin a little from time to time to let in a little soap and water, i.e. for hygiene. The adhesions will gradually disappear on their own.

These forced retractions of the foreskin in boys can create fibrous rings and balanopreputial adhesions, causing pathological primary phimosis in boys from the age of three years and older.

Another cause of phimosis in children occurs when the foreskin or glans becomes inflamed and scarring occurs. This scar tissue can contract and harden, resulting in phimosis.

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Although each child may experience them differently, the most common symptoms are:

• Inability to retract the foreskin completely.
• Pain when trying to retract the foreskin
• Pain and swelling when urinating due to accumulated urine.
• Infections: because it is not possible to remove the skin to clean the area properly, the dirt can cause inflammation and pain when urinating and even discharge.
• Balanitis: infection caused by the accumulation of smegma (remember that it is a substance that comes from the cells in the area of the glans and foreskin).

It is important to differentiate between phimosis and paraphimosis.

Paraphimosis occurs when the foreskin retracts beyond the glans, trapping it and causing it to become inflamed. This problem must be treated immediately by a specialist, because if it is not treated properly, it can even lead to necrosis.

As we have already mentioned, congenital phimosis cannot be prevented, although scarring phimosis can be avoided by not retracting the foreskin abruptly.

Avoiding inflammation of the glans and foreskin is also essential to prevent phimosis in boys, and this can be achieved by proper hygiene of the area.

From the age of three, if the foreskin still cannot be fully retracted, it is necessary to see a specialist who will recommend to parents what is best for their child.

Sometimes it is not necessary to operate for phimosis, but when there is mild phimosis, the specialist will recommend the application of a corticosteroid ointment. However, this treatment without intervention does not always work.

When narrowing of the foreskin in boys aged three years and older persists and symptoms are present, it is best to operate on the phimosis surgically. This operation is called circumcision.

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Most urological specialists recommend not operating on a boy for phimosis until he is five or six years old, although if there are no symptoms, you can wait longer, as the problem may resolve itself.

It is best to wait until approximately eight years of age, although in some cases the intervention can be brought forward if it is due to:

• Swelling of the foreskin during urination.
• Inability to retract the foreskin.
• When retracting the foreskin produces a ring around the penis.
• If there is a history of balanitis
• Continuous urinary tract infections
• Paraphimosis (remember that this occurs when the foreskin retracts and cannot return to its initial position, as it forms a very narrow ring around the glans penis, which becomes trapped). In this case, the intervention must be an emergency.

Circumcision (phimosis operation) in boys is a simple procedure, usually performed under local anaesthesia and lasts approximately 30 minutes.

In some cases the specialist may also cut the frenulum to prevent tightness and free the glans.

The patient is usually discharged immediately on the same day as the operation. The postoperative period after phimosis surgery does not usually last more than 15 days.

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