Phim Canada05

8/10/2019 Phim Canada05

1/5

RESIDENTS CORNER

The Canadian Journal of Urology; 12(2); April 2005

Accepted for publication March 2005

Address correspondence to Dr. Michael P. Leonard, Divisionof Pediatric Urology, Childrens Hospital of Eastern Ontario,401 Smyth Road, Ottawa, Ontario K1H 8L1 Canada

protective, erogenous, and immunological.1,2Duringneonatal development the prepuce is normally non-retractable as the inner epithelial lining of the foreskinand the glans are co-adherent.1,3 The foreskingradually becomes retractable secondary tokeratinization of the inner epithelium and intermittenterections.3,4 By the age of 3 years, approximately 90%of uncircumcised males have retractable foreskins.5

In the remaining 10%, non-retraction is usually dueto persistence of developmental adhesions between

Phimosis a diagnostic dilemma?Thomas B. McGregor, MD,1John G. Pike, MD,2Michael P. Leonard, MD21Department of Urology, Queens University, Kingston, Ontario, Canada2Division of Pediatric Urology, Department of Surgery, Childrens Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario,Canada

MCGREGOR TB, PIKE JG, LEONARD MP.Phimosis a diagnostic dilemma? The CanadianJournal of Urology. 2005;12(2):2598-2602.

Introduction: Phimosis is defined as the inability toretract the foreskin. Differentiating between physiologicalphimosis and pathological phimosis is important, as theformer is managed conservatively and the latter requiressurgical intervention. Referrals of patients withphysiological phimosis to urology clinics may createanxiety regarding the need for surgery amongst patientsand parents, while unnecessarily expanding the waitinglist for specialty assessment.Objectives: To determine the ability of referringphysicians to differentiate physiological from pathologicalphimosis, and to see whether there is any difference in

this ability between generalists versus specialists.Materials and methods: A retrospective chart reviewof 284 consecutive referrals for phimosis to theChildrens Hospital of Eastern Ontario (CHEO) UrologyClinic during November 2000 - April 2003 wasconducted. Referral sources included family physicians(FP), pediatricians (PD), emergency physicians (ER), andother subspecialists (SS). Data for this study wereobtained from the original referral letters and cross-referenced with the impressions of the pediatric urologistfollowing the initial patient encounter. The accuracy indiagnosing phimosis was evaluated among the various

types of referring physicians.Results: A total of 284 phimosis referrals were reviewedof patients ranging from 2 months to 16 years of age(mean = 6.6 years). The referral sources consisted of 222-

GP, 33-PD, 23-ER, and 6-SS. The majority of referredcases were diagnosed by the attending pediatric urologistas physiological phimosis across all referral sources, withthe exception of subspecialists (FP = 75.2%, PD = 81.8%,ER = 56.5%, SS = 33.3%). Second to this was thediagnosis of pathological phimosis across all referralsources except SS (FP = 14.9%, PD = 12%, ER = 34.8%,SS = 50%). Overall, the circumcision rate for the284 phimosis referrals reviewed was 14.4%.Conclusions: Our findings reveal that many physicianscontinue to face difficulties in distinguishingphysiological phimosis from the pathological. As a result,

many unnecessary referrals are made for phimosis. Wesuggest the implementation of improved educationalmeasures regarding preputial pathophysiology in themedical curriculum. Such measures would serve twopurposes: first, to reduce the number of unnecessaryspecialty referrals and secondly, to aid primary carephysicians in recognizing the presence of physiologicalphimosis so that patients and families may be reassuredof normalcy.

Key Words:phimosis, physiological, pathological,primary care, diagnosis

Introduction

The prepuce (foreskin) is the retractable covering ofthe glans penis. It serves many functions, including

2598


2/5


MCGREGOR ET AL.

the glans and prepuce. This usually resolves by 17years of age with only 1% remaining non-retractable.3

Phimosis is a condition in which the prepuce cannotbe retracted over the glans penis. True pathologicalphimosis exists when non-retraction is secondary to adistal scarring of the prepuce. This scarring oftenappears as a contracted white fibrous ring around thepreputial orifice. On the contrary, physiological phimosislacks this scarring process and is a normal developmentalphase of the prepuce. Physiological phimosis is acommon finding in males up to 3 years of age, but canextend into older age groups.3,5-7Despite the distinctionbetween these two entities, many physicians continueto have difficulty distinguishing one form over theother.8-12 This often results in unnecessary phimosisreferrals to pediatric urology clinics,8,9 as well asunnecessary surgical procedures for which potentialrisks become a concern.9,13 Figure 1 illustrates thedifference between the two entities.

This distinction is important to recognize

considering the divergent management for these twoconditions. Physiological phimosis is moreappropriately managed by conservative measures,such as tincture of time, or in select cases topicalsteroid therapy.4,14-21 The standard treatment forpathological phimosis, on the other hand iscircumcision,8,9,13although several studies have nowshown topical steroids may be effective in the earlyphases of preputial outlet scarring.4,14-21

Given the importance in distinguishing betweenpathological and physiological phimosis, we haveconducted a 3-year retrospective analysis ofreferrals to Childrens Hospital of Eastern OntarioUrology Clinic made by a variety of practitionersto assess the accuracy of diagnosis between the twoforms. Our analyses were further compared withthose of earlier reports spanning over half-a-centuryto determine whether there have been considerableimprovements in the ability to diagnose betweenthese phimotic conditions.

2599

Figure 1.The left side demonstrates a normal foreskin. The right side shows the typical circumferential cicatrisationof the preputial orifice present in pathological phimosis.


3/5


Materials and methods

Upon approval of the hospitals ethics review board,a retrospective chart review of 284 consecutivereferrals for phimosis to Urology clinic duringNovember 2000 April 2003 was conducted. Referralsources included family physicians, pediatricians,emergency physicians, and other subspecialists(which included one orthopedic surgeon, twodermatologists, and three adult urologists). Onlyreferrals that specifically stated phimosis as thereason for referral were included in this study. Otherreferral diagnoses, such as paraphimosis and preputialadhesions were not included. Data for this study wereobtained from the original referral letters and by theclinical impressions of the pediatric urologistfollowing the initial patient encounter. Findings fromfollow-up visits were not included. The diagnosismade by the pediatric urologist upon the initialencounter was then used to determine the diagnosticaccuracy of the referring physician. During the timeof the review, there were two pediatric urologists atCHEO (JGP, MPL) who concurred on the managementof phimosis referrals. The diagnostic accuracieswere then considered and compared amongst thevarious categories of referring physicians. Descriptivestatistics were used to summarize the actual diagnosesamong the various specialty groups of referringphysicians. Differences in physicians diagnoses were

compared using the chi-square test. All reportedp-values are two-sided, and a p-value < 0.05 wasconsidered statistically significant.

Results

Two hundred and eighty four consecutive phimosisreferrals were reviewed. Patient age ranged from 2months to 16 years, with a mean age of 6.63 years. Alltogether, of the 284 phimosis referrals reviewed, only48 (16.9%) were confirmed as pathological phimosis.

TABLE 1. Breakdown of phimosis referrals

Actual diagnosis Number (%)

Pathological phimosis 48 (16.9)

Physiological phimosis 209 (73.6)

Preputial adhesions 18 (6.3)

Congenital megaprepuce 6 (2.1)

Other 3 (1.1)

However, 209 (73.6%) of the referrals were determinedto be physiological phimosis Table 1. These resultsare further stratified among the various groups ofreferring physicians as shown in Table 2. In terms oftreatment, the overall circumcision rate for the 284phimosis referrals reviewed was 14.4%. The

remaining patients (85.6%) were treated withconservative measures, which included observationor topical steroid cream in select cases.

Overall, there was no significant difference foundbetween family physicians and pediatricians in theirability to diagnose pathological phimosis (p= 0.611).However, both emergency physicians and other sub-specialists were significantly better at recognizingpathological phimosis when compared to familyphysicians (p=0.015 and p=0.012 respectively).

Discussion

Non-retractable foreskins are common in young boysas a normal part of preputial development. Over halfa century ago it was shown that the prepuce of thenewborn is non-retractable, while at 3 years of age upto 10% of foreskins remain non-retractable.5It shouldbe noted that the retractable foreskin in these smallchildren might not be fully retractable, as innerpreputial adhesions are still seen in the majority ofboys at age six years.5 What of the 10% of 3 year oldswith non-retractable foreskins? Oster answered this

2600

TABLE 2. Analysis of phimosis referrals by primary physician type

Referral Number of Actual diagnosessource phimosis Pathological Physiological Preputial Congenital Other

referrals phimosis phimosis adhesions megapepuce

Family physician 222 33 (14.9%) 167 (75.2%) 17 (7.7%) 2 (0.9%) 3 (1.4%)

Emergency physician 23 8 (34.8%) 13 (56.5%) 0 2 (8.7%) 0

Pediatrician 33 4 (12.1%) 27 (81.8%) 0 2 (6.1%) 0

Other subspecialty 6 3 (50%) 2 (33.3%) 1 (16.7%) 0 0

Phimosis a diagnostic dilemma?


4/5


MCGREGOR ET AL.

question in an elegant cohort study published in 1968.He documented that amongst Danish schoolboys,only 1% had non-retractable foreskins at age 17 years.3

The moral of the story told to us by these two seminalstudies is that if one is patient and does not rushMother Nature, the vast majority of foreskins willbe co me retr ac ta ble by adul th ood . To da te ,pathological phimosis remains the predominantindication for performing a circumcision in ourpractice. However, it is our bias that misdiagnosedphimotic conditions occurs too frequently, resultingeither in costly and unnecessary medical consultationswith specialists, or worse, unnecessary circumcisions.

Physiological phimosis, consisting of a pliant non-scarred preputial orifice, is clearly distinguishablefrom the rather uncommon pathological formconsisting of a white cicatrisation of the orifice. Still,the inability to distinguish true pathological phimosisfrom the physiological form remains problematic.According to our data, of the 284 phimosis referralsmade to the CHEO Urology Clinic, only 16.9% wereof the pathological form. The vast majority (73.6%)were confirmed to be physiological phimosis. Theseproportions closely match those previously reportedin two separate, independent studies, where 13% and25% of the referred cases of phimosis for circumcisionwere of the pathological form.8,9 Overall, suchobservations reveal that ambiguity in diagnosis iswidespread and still exists in distinguishing

pathological phimosis from a normal developmentallynon-retractable prepuce.Pathological phimosis is the one absolute

indication for performing a circumcision. In our study,the circumcision rate was found to be 14.4% whichcorrelates closely with the number of referralsdiagnosed as pathological phimosis (16.9%). In fact,other studies quote similar circumcision rates; that ofRickwoods study was 28%, while that of Griffithsstudy was 25%, both of which correlated closely withtheir diagnosis rate of pathological phimosis, 13% and25% respectively.8,9

As reported here, the greatest proportion ofphimosis referrals were made by family physicians,comprising 78.2% of the total. Given that this grouprepresents the front line providers of medical care, thisfigure appears nontrivial, as they are more likely tomake the initial discovery of a phimotic foreskin.Nevertheless, past studies state that most reprimandhas gone towards family physicians for over-diagnosing phimosis, in general.9 Thus, it is essentialthat family physicians be able to distinguish normalversus pathological phimosis. Of the 222 phimosisreferrals made by family physicians, 14.9% were later

determined to be of the pathological variant, and75.2% of the physiological variant, a clear indicationof diagnostic uncertainty.

Significant proportions of phimosis referrals weremade by specialists, comprising 21.8% of the total.These included pediatricians (11.6%), emergencyphysicians (8.1%), and other subspecialists (2.1%). Ofthese three groups, referrals made by emergencyphysicians were more often diagnosed as pathologicalphimosis. This may be attributed to a form of selectionbias, as emergency physicians are more likely to seeurgent (pathological) conditions rather thanasymptomatic (physiological) conditions. However,of the 62 phimosis referrals made by specialists, 24.2%were determined to be pathological. Once again, thegreatest proportion of these referrals was diagnosedas physiological phimosis (67.7%). These findingsdemonstrate that when one considers all referralsmade by the various groups of physicians studiedherein, more than half of these patients were referredfor an otherwise normal finding. These results arerather startling and troublesome, as the assumptionwould be that such a common, normal developmentalprocess would be more easily recognized.

It is clear from the data presented here thatimproved educative measures are essential in orderto accurately differentiate pathological phimosis fromphysiological phimosis across all specialties. By virtueof the fact that family physicians represent the greatest

number of overall referrals, our results, as well asthose previously reported, would suggest directingeducational efforts primarily towards these front linepractitioners. Proportionately, however, the majorityof referrals made to our clinic were later diagnosedas physiological, with the exception of those referralsby other subspecialists. Thus, once the distinctionbetween pathological and physiological phimosisbecomes clearer, then it is obvious that the majorityof referrals reviewed in this study were unnecessary.Being able to make this distinction would greatly assistin reducing unnecessary, costly referrals. Second to

this, it would aid primary care physicians inrecognizing and treating these cases moreappropriately, along with reassuring the patients andtheir families.

Compounding this problem is the fact that mosttextbooks and medical curricula regarding phimosisare outdated. However, sources do exist that providedistinct guidelines for diagnosing and referring forsuch conditions.22 Information regarding the normaldevelopment of the prepuce and how to distinguishpathological from physiological phimosis will help toreduce the over diagnosis of pathological phimosis,

2601


5/5


or likewise, the under-recognition of physiologicalphimosis.

Conclusion

Since family physicians and pediatricians constitutethe largest referral source for phimosis, effortsdirected at educating them to distinguish betweenpathological and physiological phimosis should beundertaken. This would hopefully allow theindividuals with pathological phimosis to receivemore prompt urological care, while reassuring thefamilies of children with physiological phimosis thatthey need not see a surgeon. Such efforts at educationshould ideally occur in the medical school curriculumand in post-graduate CME courses for thoseindividuals already in practice.

18. Jorgensen ET, Svensson A. The treatment of phimosis in boyswith a potent topical steroid (clobetasol propionate) cream.Acta Dermato-Venereol 1993;73:55.

19. Atilla MK, Dundaroz R, Odabas O, Ostur H, Akin R, GokcayE. A nonsurgical approach to the treatment of phimosis: localnonsteroidal anti-inflammatory ointment application.J Urol1997;158:196-197.

20. Chih-Chun C, Ke-Chi C, Guan-Yeu D. Topical steroidtreatment of phimosis in boys.J Urol 1999;162:861-863.21. Monsour M, Rabinovitch J, Dean G. Medical management of

phimosis in children: our experience with topical steroids.J Urol1999;162:1162-1164.

22. Redman JF, Reddy PP. Common Urologic Problems InChildren: Guides to evaluation and referral, Part II. The Journal2001;98:22-24.

References

1. Cold CJ, Taylor JR. The Prepuce. British Journal of Urology1999;83(Suppl 1):34-44.

2. PM Fleiss, FM Hodges, RS Van Howe. Sexually TransmittedInfections (London), Volume 74 Number 5, Pages 364-367,October 1998. Immunological functions of the human prepuce.

3. Oster J. Further fate of the foreskin.Arch Dis Child1968;43:200-204.4. Orsola A, Caffaratti J, Garat JM. Conservative treatment of

phimosis in children using a topical steroid. Urology2000;56:307-310.

5. Gairdner D. The fate of the foreskin. BMJ1949;2:1433-1437.6. Krolupper M. Care of foreskin constriction in children. Cesk

Pediatr 1992;47:644-645.7. Kayaba H, Tamura H, Kitajima S et al. Analysis of shape and

retractability of the prepuce in 603 Japanese boys. Journal ofUrology1996;Nov V156 N5:1813-1815.

8. Griffiths D, Frank JD. Inappropriate circumcision referrals byGPs. Journal of the Royal Society of Medicine 1992;85:324-325.

9. Rickwood AMK, Walker J. Is phimosis overdiagnosed in boysand are too many circumcisions performed in consequence?Ann R Coll Surg Engl 1989;71(5):275-277.

10.Gordon A, Collin J. Save the Normal Foreskin. Br Med J1993;306:1-2.

11.Williams N, Chell J, Kapila L. Why are children referred forcircumcision? Brit Med J1993;306:28.

12. Shankar KR, Rickwood AM. The incidence of phimosis in boys.BJU Int1999 Jul;84(1):101-102.

13.Spilsbury K, Semmens JB, Wisniewski ZS, Holman CJ.Circumcision for phimosis and other medical indications inWestern Australian boys.MJA2003;178:155-158.

14.Webster TM, Leonard MP. Topical steroid therapy forphimosis. Can J Urol2002 Apr;9(2):1492-1495.

15. Golubovic Z, Milanovic D, Vukadinovic V, Rakic I, Perovic S.The conservative treatment of phimosis in boys. Brit J Urol1996;78:786-788.

16.Wright JE. The treatment of childhood phimosis with topicalsteroid.Aust New Zeal J Surg 1994;64:327.

17. Lindhagen T. Topical clobetasol propionate compared withplacebo in the treatment of unretractable foreskin. Eur J Surg1996;162:969.

Phimosis a diagnostic dilemma?

Documents

Phim Canada05