Introduction

Many medical authorities, especially in the United States have claimed that every newborn male suffers from phimosis, a disease that many experts, along the medical history, presume that it is the cause of a wide range of incurable diseases; from club foot to insanity. Since its emergence in the nineteenth century, the modem concept of phimosis has been the focus of a carefully orchestrated campaign of legitimisation. Traditionally, doctors in the United States, who favour involuntary circumcision of the newborn, have claimed that phimosis is ubiquitous in that it apparently occurs as a congenital deformity in nearly all newborn males. In Britain, the ubiquity is reduced to some 30,000 cases a year, but this nonetheless represents an equal or higher rate of disease than the annual rate of breast cancer or lung cancer in Britain¹. It has been demonstrated that the squamous mucosa of the glans, coronal sulcus, and prepuce are fused during the embryologic development of the penis, and they can be considered as one tissue compartment. The fused mucosa of the glans and inner lining of the foreskin separate gradually over years, as a spontaneous biologic process, this separation is variable between individuals and usually complete by the age of 17 years².

Along the recorded medical history ambiguity over the term phimosis continues, so that many children are thought to have a pathological condition when often there is none. Greater understanding among paediatric surgeons and general practitioners of the definition, diagnoses and proper management of phimosis should lead to a decreased rate of referral and reduce the anxiety of parents and patients. The word phimosis is from the Greek phimos (φῑμός) which means a muzzle, and phimosis means muzzling (closure or stenosing the mouth of a tube or a hose).

Phimosis is the inability or difficulty to retract prepuce secondary to tight preputial hiatus; this tightness may be physiological or pathological, and it is completely different from the adhesion between inner prepuce and glans penis, which is called “Synechia”. Phimosis is not a synonym of preputial non retractability or preputial synechiae³. Subsequently, preputial non retractability may be physiologically either due to preputo-glandular adhesion or a stenotic preputial hiatus or a short frenulum (Frenulum breve). The first recorded use of the word phimosis was in Roman times. Various medical writers used the term simply to indicate a condition of being muzzled, irrespective of the part afflicted, ancient Greek physicians, such as Galen,” and others, used the term to refer to inflammatory strictures of the anus, vagina or the eyelid, but not the prepuce. The first known author to use the word phimosis in reference to the prepuce was the Roman author Aulus Celsus in the first century CE, he used the term to indicate an abnormal induration of the foreskin. The second known use of the word is found in the extant writings of the 2nd century CE Greek physician Antyllus, who defines phimosis as a condition where the foreskin cannot be retracted because of inelastic scar tissue on the foreskin or because of a “fleshy growth.” ⁴

Pierre E. Dionis (died in 1718), a French surgeon, hypothesised that there were two types of phimosis: natural and accidental, Dionis defined phimosis as a condition in which “the extremity of the prepuce is so tight that it will not permit the glans to be uncovered. John Hunter (1728-1793) even refined the definition of phimosis to refer only to a symptom of the venereal disease chancre, which presented itself as an abnormal inflammation and thickening of the cellular membrane of the foreskin.

British medicine has been the driving force behind the narrowing European definition of phimosis. The European thinking on phimosis has taken a radical departure from its nineteenth-century roots and from current American ideology. Phimosis is no longer a disease or a cause of disease. Instead, it is a symptom of a single dermatological conditions; mainly the balanitis xerotica obliterans (BXO). In Britain, the argument that the definition of phimosis should be divested of any notions of retractability, balanopreputial attachment, or length, has been most successfully made by Rickwood of Alder Hey Children’s Hospital in Liverpool, who refined the definition of “true phimosis” to designate a condition where the tip of the prepuce is scarred and indurated and has the histological features of balanitis xerotica obliterans. But I think this another hyperbole of the phimosis terminology, if we limit the term for use only in cases of BXO.

Conclusion

Phimosis is a pathologically tight preputial hiatus hindering preputial gliding to expose the glans penis, this tightness may be a congenital anomaly or an acquired disease.

References

1. Hodges F M: The HISTORY OF PHIMOSIS FROM ANTIQUITY TO THE PRESENT. In Male and female circumcision: medical, legal and ethical considerations in pediatric practice/ edited by George C. Oenniston. Frederick Mansfield Hodges. anMdarilyn Fayre Milos. 1999 Kluwer Academic/plenum Publishers.
2. Hsu CC. The development of the prepuce. Taiwan Yi Xue Hui Za Zhi. 1983;82:314–20.
3. Williams N, Chell J, Kapila L. Why are children referred for circumcision? BMJ 1993; 30628.
4. Celsus.De Medicina.7.25.2.In: Spencer WG, ed and trans. Celsus. DeMedicina. vol.3.Cambridge: Harvard University Press, 1938, 422.