Phimosis and Paraphimosis

Background

• Phimosis is a condition of tightness of the tip of the penile prepuce (foreskin) in which the prepuce cannot be retracted partially or completely over the glans penis:
  • Phimosis may be divided into
    • Physiologic (primary or congenital)
      • Common in children ≤ 3 years old and can often extend into older age groups
      • At birth, < 5% of male children have fully retractile foreskin
      • Most will resolve over time
    • Pathologic (secondary)
      • Caused by the development of scarring of the preputial orifice skin
      • Risk factors include
        • Poor hygiene
        • Recurrent infections
        • Forceful disruption of physiologic adhesions in infancy
• Paraphimosis is a condition where foreskin that has been retracted proximal to the glans onto the penile shaft cannot be advanced back over the glans:
  • Can act as a tourniquet or constrictive ring on the proximal penile shaft, causing pain and, in severe cases, distal swelling of the penis
  • Regarded as a medical emergency that requires urgent treatment
  • Risk factors include
    • Failure to reduce foreskin after voiding or bathing
    • Foreskin not properly reduced back into normal position
    • Poor hygiene and balanoposthitis
• The complications of phimosis may include balanitis and adhesions; whereas, those of paraphimosis may include preputial necrosis, penile gangrene, and autoamputation.
• The prognosis for physiologic phimosis is that most resolve over time, but pathologic phimosis may require circumcision; most paraphimotic foreskins can develop normally but the prognosis is poor if complications develop and are left untreated.

Evaluation

• Obtain a complete history, focusing on the foreskin and any urinary or infection symptoms.
• Perform a thorough physical examination focusing on the genital exam to differentiate the 2 types of phimosis or to evaluate for paraphimosis.
• Differentiate physiologic from pathologic phimosis based on the physical exam findings of
  • Physiologic phimosis (normal part of preputial development)
    • Pliant, unscarred preputial orifice with nonretractile foreskin
    • Common in children ≤ 3 years old, but can often extend into older age groups
  • Pathologic phimosis
    • Nonretractile foreskin due to distal scarring of prepuce from inflammatory or traumatic injury
    • Scarring often appears as a contracted white fibrous ring around preputial orifice
• Suspect and confirm the diagnosis of paraphimosis based on the physical exam findings of a retracted foreskin with the constricted ring proximal to the glans that is not able to be reduced over the glans into normal position.
• There are no specific tests required to diagnose phimosis or paraphimosis.

Management

• For the treatment of phimosis,
  • Management is mainly observation since phimosis is congenital in most children and typically resolves spontaneously
  • First-line medical therapy for phimosis is a trial of corticosteroid ointment or cream (0.05%-0.1%) applied topically twice daily to the phimotic ring at the tip of the foreskin for 4-8 weeks (reported success rate > 80%) (Strong recommendation).
  • Corticosteroid options may include:
    • betamethasone 0.05% or 0.1%
    • triamcinolone 0.1%
    • clobetasol propionate 0.05%
    • mometasone furoate 0.1%
    • hydrocortisone 1%
  • Offer surgery (preputioplasty or circumcision) for
    • Symptomatic phimosis refractory to first line treatment or if patient/caregiver prefers surgical treatment (Strong recommendation)
    • Recurrent balanoposthitis or urinary tract infection
    • Asymptomatic phimosis in infants with urinary tract abnormalities that place them at increased risk for recurrent urinary tract infections (such as high grade vesicoureteral reflux or posterior urethral valves) (Strong recommendation)
• For the treatment of balanitis xerotica obliterans (form of pathological phimosis),
  • Consider consultation with dermatologist
  • Offer circumcision (Strong recommendation)
  • Consider extended follow-up to monitor for development of complications such as meatal stenosis or urethral involvement
• For the treatment of paraphimosis,
  • Attempt to manually compress edematous tissue followed by reduction of the foreskin back over the glans penis, which may be augmented with topical agents to reduce distal edema
  • Perform a dorsal slit procedure urgently if manual repositioning is unsuccessful (Strong recommendation)
  • Consider a circumcision immediately following paraphimosis reduction or in a second session after resolution of pathologic distal penile/glans edema