When the orifice of the prepuce is very narrow or the prepuce itself is very long, and when from the accumulation of secretion attacks of balanitis occur, the phimosis must be dealt with by surgical means. The irritation of a long foreskin may lead to the establishment of masturbation. The foreskin should be capable of being drawn back so as to completely un cover the glans in every boy, hut in the great majority of cases where this cannot be easily accomplished it does not follow that a cutting operation should be decided upon. By forcibly pulling back the skin of the penis the glans may be gradually exposed and the narrow preputial orifice becomes dilated in the act, so that after a daily performance of this process, unless the foreskin is at the same time very long, the narrowing soon disappears and the prepuce shortens so as to leave the glans hare. During the retraction for the first time it gill be often necessary to peel back the layer of epithelium lining the interior of the prepuce which has become adherent to the surface of the glans and to remove old accumula tions of smegma around the corona.
In cases which do not readily yield to the above simple procedure surgical measures must be considered. These are (i) mechanical dilatation, (2) slitting of the foreskin on the dorsum of the penis, and (3) circumcision, The writer for many years has advocated a more frequent resort to dilata tion than is usually considered to be orthodox. I'Vhen practising as surgeon to a children's hospital he was surprised to find how seldom a cutting operation was necessary to remedy a congenital phimosis, and often has he been able to effectually deal with the acquired variety of the affection in adults by the same means.
In the case of a child whose narrow preputial orifice scarce admits a stout probe, a few sittings suffice to dilate the contracted opening by inserting the blades of a very fine forceps in the closed state, and gradually and very gently separating the handles till the tissues are thoroughly stretched. The ordinary old-fashioned phimosis forceps, opening by
means of a finely threaded screw, answers all purposes. It is surprising to find to what extent dilatation may be pushed without causing pain, cracking or tearing of the prepuce. Once or twice a week is often enough, and frequently in young children the prepuce may be painlessly slipped over the glans after one or two trials with the forceps. When this has been accomplished with such ease as to render paraphimosis unlikely, the child's parents may be safely entrusted to periodically draw the prepuce back, and in the case of older children they see to this themselves. In a comparatively short period the elongated prepuce shortens, and the writer has seen several cases where a long narrow prepuce after dilatation has been found years subsequently to have almost disappeared, leaving the glans bare as if circumcision had been skilfully performed. In several 45 cases where an extremely narrow opening had existed from the time of birth, and caused no inconvenience till marriage, dilatation was found to effect a permanent cure in a few weeks.
Enuresis and symptoms of bladder irritation and of stone, depending u•on the condition of the prepuce, rapidly disappear after gradual dilatation by the phimosis forceps. These symptoms, however, are rarely caused by the constricted orifice, as generally stated. They arise from the irritation produced by the partial or complete adhesion or growing together of the mucous surfaces of the lining of the prepuce and the covering of the glans with retained secretion, and this cannot be remedied till the orifice of the prepuce is dilated so as to permit of the foreskin being drawn hack and peeled off the glans by forcible scraping with the finger-nail till the head of the penis is completely bared. Occasional drawing back of the foreskin in the act of micturition effectually prevents any further adhesion of the contiguous mucous surfaces, and tends to cause gradual shortening of the foreskin.