Except as produced in consequence of disease, i. e., by edema or inflammation with swelling, phimosis indicates a congenital condition, either of elongation or constriction of the prepuce, usually with adhesions to the glans. A considerable proportion of male children are born with more or less complete conditions of this kind. These are not so abnormal anatomically, but they lead to serious complications later in life. An extremely tight prepuce is often complicated with stenosis of the meatus, the combined result being a practical stricture at the end of the urethra, through which the infant has to strain with each act of urination. This is a common predisposing cause of hernia. Whether the prepuce be adherent, or so constricted as to make it a retentive sac, there will accumulate between it and the sensitive mucous surface of the glans more or less smegma which, as it decomposes in the course of time, becomes excessively irritating, and a fertile source of reflex disorders, involving even distant parts of the body. Thus in young boys especially, convulsions, chorea, epilepsy, and various other neuroses are produced, while, in addition, its perpetuation produces a condition of unnatural excitability which leads again to habits of masturbation or to sexual irritability and unnatural excitability.
Every newborn male infant should be carefully examined in order that the above condition, if present, may be remedied. This remedy will consist, in mild cases, of forcible retraction of the elongated prepuce, with separation of any adhesions uniting it to the glans. Preputial stenosis may be overcome in some cases by simply slitting up the dorsum, which, if not too long, may be thus released and not require circumcision. On the other hand a much elongated and contracted prepuce should be sufficient justification for prompt circumcision. At the same time any unnatural contraction of the meatus may be overcome by trifling incision. If every boy baby were thus carefully inspected and relieved, if necessary, there would be fewer reflex disorders in young children.
Incidentally it may be said that, in lesser degree, the same thing may apply to girl infants, in whom the clitoris, although small, should nevertheless be freely uncovered by retraction of its miniature hood or prepuce. When this is not easily possible it should be made so. Disorders of the same general character as easily arise in girls, from this same general cause, as in boys, nocturnal incontinence being a frequent expression thereof. In my opinion the teaching of obstetrics should not be considered complete without unmistakable reference to these matters.
Phimosis in the adult may be brought about by disease, especially in connection with a prepuce already retentive, or elongated and difficult of retraction. Retained secretion beneath such a prepuce is a fertile source of danger of all kinds, as well of venereal infection as of cancerous growth. Surgeons in the Orient have described calculi, even of considerable size, found in this location as the result of retention of matter which should not have been at all retained, this condition being noted most often among the Chinese.
Infection, usually gonorrheal, of the concealed surface of the prepuce, which has a distinctly mucous character, is known as posthitis; that of the covering of the glans as balanitis; while, in effect, whatever appears in this location will essentially be a balanoposthitis. If such a condition do not easily subside by irrigation, with a small nozzle introduced beneath the margin of the prepuce, it will then be necessary to slit up the dorsum, or make a complete circumcision, in order that the affected surfaces may be made accessible. The same is true in cases of chancroid and even in cases of chancre; incision or circumcision being justifiable whenever indicated.
PARAPHIMOSIS.
Paraphimosis implies an opposite condition, where the prepuce, having been retracted, is caught behind the margin of the glans and cannot be released nor brought forward. This may be the result of undue effort to retract a very tight but otherwise normal prepuce, or is frequently the result of an acute inflammation, where edema and solid exudate so solidify the tissues as to make them inflexible and almost immovable. In mild cases of paraphimosis cold applications, or pressure with patient manipulation, may be sufficient to restore the proper condition. An extreme degree of such constriction would threaten the nutrition of the glans, to the extent even of possible gangrene, and sloughing of some portion of the end of the penis is not an infrequent result of a neglected condition of this kind. Under these circumstances constriction must be released, it being usually sufficient to apply or inject cocaine, and then with scissors or blunt bistoury nick or incise the constricting ring, to a degree sufficient to release it and permit the desired result; in one way or another this must be attained, else more or less sloughing is sure to follow.
Other rare malformations of the urethra include its more or less complete obliteration, in some portion at least, or, more often, its sacculation or dilatation in certain areas, the result being the formation of pockets or pouches. Such abnormality may persist to adult life, and finally contain a considerable amount of retained urine.
EPISPADIAS AND HYPOSPADIAS.
Epispadias and hypospadias constitute defects in the urethral construction, so that urine escapes at some point much nearer the body than normally intended. A complete degree of epispadias nearly always accompanies extroversion of the bladder, already described. Milder conditions may be met in any degree. In these cases the urethra becomes a canal open above, and the glans is more or less defective. Cases of epispadias may be divided into the balanic, where the urethra terminates on the upper portion of the glans, and the penile, where it terminates between the glans and the pubis; while cases of hypospadias may be divided into balanic and penile, similar to the above, the penoscrotal, where the urethra opens at the junction, and the perineoscrotal, where both the perineum and scrotum are involved. While all of these defects are more or less mutilating and unphysiological, none of them menace life. The physiological requirements of either case demand conditions permitting normal urination, and coitus to a degree permitting fecundation. (See [Fig. 667].)