JOURNAL OF THE INDIAN MEDICAL ASSOCIATION, Volume 58: Pages 389-390,
16 May 1972.
Phimosis is a word of Greek origin meaning muzzled and is used for a condition when the prepuce is non-retractile.
The development of the prepuce (separation from the glans is generally not completed at birth. In only 4 percent of infants the prepuce is retractable. The prepuce become retractable between the age of 6 months and 3 years in most children and it is only in 10 percent that non-retractility persists. On the other hand a study made at Pondicherry (Chaudhuri, 1965) revealed that 51 out of 335 male adults had non-retractile and 77 had partially retractable prepuce. Removal of this part of the anatomy, even if normal, has been practised for various reasons for at least 6000 years. Evidence of circumcision has been seen in ancient mural in Egypt, and also noticed in mummies dated to 2300 B.C. One-sixth of the population of the world is, perhaps, circumcised.
The non-retractility of the prepuce in early life has a protective function to perform in view of the child being wet at this stage (Gairdner, 1949; Editorial, 1949). Pain, if any, is usually due to ammoniacal dermatitis in babies, where napkins are used. Circumcision is not without its complications, such as meatal stenosis and urinary fistulae are not unknown. On the other hand, in older males, the prepuce is a useful source of skin cover for various conditions such as hypospadias (removed only as a ritual as no phimosis is possible), acquired fistulae and strictures of the urethra, traumatic loss of skin of the penis, extensive warts of glans, filiarsis involving the penis wher preputial skin is practically never involved.
Sixty-four cases were studied in the last 18 months. This operation was performed on fifteen of those patients who preferred retaining the prepuce. Two of theses cases were infants who had a marked ballooning and difficulty in mictirition. A relatively long prepuce with a champagne glass shape (the narrow portion distal to the glans, forming the stem of the glass) was found in the majority of cases. "Smegma", commonly associated with phimosis, was found in only four out of 64 cases studied. Accretion or minimal dry epithelial debris was present in 6 cases, scarring and meatal stenosis in three. Most of these patients were adults.
Besides a ritual removal, circumcision has been recommended for various other conditions:
(1) In infancy, non-retractility of the prepuce is normal and would correct itself in most cases or dealt with easily by just passing a probe gently under the prepuce after the age of three years.
(2) Posthitis is a result of ammoniacal dermatitis, trauma, insect bites, or a cellulitis. Circumcision is not necessary. Balanitis is rare.
(3) There is no rationale for circumcision in treatment of conditions like enuresis, convulsions and masturbation.
(a) Paraphimosis is a relatively uncommon condition and does not justify a routine circumcision. The operation recommended can be used for subjects with a tight prepuce.
(b) Circumcision has no value in preventing venereal diseases.
(c) Males, circumcised before age 5, are known to be practically immune to carcinoma. On the other hand the disease is associated with phimosis or a poor personal hygiene. A retractile prepuce and a good personal hygiene should be sufficient safeguards against a carcinoma.
(d) There is not enough evidence to incriminate the prepuce in causation of carcinoma of the cervix.
(e) Circumcision leads to a darker, drier and less sensitive glans. A bare corona-glandis in a skin-short penis after a badly performed circumcision leads to discomfort. There is no proof to suggest that these changes are an advantage.
The operation consists of multiple "Z" plasties. The cuts in the outer layer of the prepuce and the inner layer are alternated to give three outer and inner flaps, respectively. The edges are trimmed (a bit more generously in a long champagne glass prepuce). The flaps are interdigitated and stitched with 3 "O" chromium catgut. This procedure results in some of the outer part of the skin being turned inside. The scar is not annular and the opening is, therefore, adequate and not tight. No special postoperative care is indicated. A revision operation had to be done in two cases having a very long prepuce where the trimming was inadvertantly inadequate.
The prepuce is not a useless structure. If proper personal hygiene is observed, the risk of malignancy is not high enough to justify its ritual excision. Besides the prepuce provides valuable spare skin for cover in various conditions. Conservation of the prepuce is fully justified even in cases with phimosis which does not resolve spontaneously or which is not giving rise to symptoms.
Partial circumcision is known to lead to a tight nonretractile prepuce with partial baring of the glans, because of an annular scar. Operations based on a dorsal stitch with trimming of edges given a poor result cosmetically and functionally. This technique of "Z" plasty is based on sound principles and gives an effectively retractile and cosmetically good prepuce. The observation that smegma does not usually collect under the foreskin in phimotic subjects is significant and needs further study.
A plea is made for retaining the prepuce, even in older phimotic subjects, by correction of the tight prepuce by a plastic procedure consisting of multiple "Z" plasties.
My thanks are due to the Principal, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry, for the facilities provided by him, to the Medical Illustration Department and to my colleagues in the Surgical Department for their kind help.
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