Michael A. Poch, MD
Philippe E. Spiess, MD
BASICS
DESCRIPTION
• Phimosis (preputial stenosis) is the inability to retract the foreskin.
• Can be seen in children and adults
– Physiologic (congenital) phimosis: Foreskin (prepuce) is usually not retractile in a newborn. The majority can be retracted by 3–5 yr of age
– Pathologic (acquired) phimosis: The prepuce cannot be retracted when previously possible or it has never been retractile and is associated with symptoms and/or complications
• Paraphimosis
– The prepuce is retracted, left in position causing vascular engorgement of the glans preventing reduction.
EPIDEMIOLOGY
Incidence
• Phimosis
– 10% nonretractile at age 3–5
– <1% nonretractile at puberty
• Paraphimosis
– 0.7% of uncircumcised boys
Prevalence
N/A
RISK FACTORS
• Poor hygiene
• Forced or traumatic retraction of foreskin
• Indwelling catheter
• Chronic balanitis
• Genital piercings
Genetics
N/A
PATHOPHYSIOLOGY
• Physiologic phimosis:
– The foreskin is naturally adherent to the glans in infants.
– Glandular secretions and keratin debris (smegma) and intermittent erections facilitates separation of preputial skin from glans
– This is best simply observed; the newborn foreskin does not require manipulation or retraction.
• Pathologic phimosis:
– Chronic irritation, often due to poor hygiene, leads to sclerosis of the preputial opening
Premature manipulation and trauma leads to scarring of the delicate prepuce.
Inadequate circumcision or postcircumcision care allows constriction of the circumcision line
• Paraphimosis
– Retraction of the prepuce and leaving it in place behind the glans leads to vascular engorgement of the glans and subsequent inability to reduce the prepuce
ASSOCIATED CONDITIONS
• Penile cancer
• Balanitis (inflammation of the glans)
• Posthitis (inflammation of the prepuce)
• Balanoposthitis
• Balanitis xerotica obliterans (BXO)
• Diabetes mellitus
GENERAL PREVENTION
• Good hygiene
• Don’t prematurely manipulate the foreskin
• Circumcision
DIAGNOSIS
HISTORY
• Was foreskin previously retractile?
• Recent urethral manipulation (Foley catheter placement, cystoscopy)
• Circumcision status
• Dysuria and/or other voiding symptoms
• Penile discharge
• Cracking or bleeding from the foreskin
• Ballooning of the foreskin with voiding
• Postvoid dribbling
• Penile pain
PHYSICAL EXAM
• Evaluate for penile abnormalities such as hypospadias, chordee, webbed penis
• Local irritation and redness
• Appearance of foreskin:
– Normal skin color
– Erythema and inguinal adenopathy
– Penile discharge
– Circumferential white discoloration
– Urethral meatus cannot be visualized
– Crack in skin with attempted retraction
– Severe scarring or BXO
– Smegma (normal finding)
• Paraphimosis:
– Marked edema of inner prepuce distal to the constricting band
– Ulcerations if chronic
– Evaluate glans for ischemia/necrosis
– Glans tenderness
– Glans firm with flaccid penile shaft
– Rule out hair or foreign body in a circumcised male
DIAGNOSTIC TESTS & INTERPRETATION
Lab
Usually not necessary unless symptoms of urinary tract infection (UTI) or sexually transmitted infection (STI) are present.
Imaging
Not usually performed
Diagnostic Procedures/Surgery
Physical exam is usually all that is necessary
Pathologic Findings
N/A
DIFFERENTIAL DIAGNOSIS
• Phimosis:
– Physiologic vs. pathologic
– Trapped penis occurs when a dense cicatricial scar traps the penis under the prepubic or scrotal skin after neonatal circumcision.
– BXO
• Paraphimosis:
– Penile edema
– Postcircumcision cicatrix
– Hair/thread tourniquet:
Hair or thread wraps around a child’s penis and causes penile edema or strangulation
• Balanitis
TREATMENT
GENERAL MEASURES
• In the elderly male undergoing bladder catheterization, failure to replace the foreskin to its normal reduced position may result in paraphimosis (1,2).
• Paraphimosis
– Manual reduction should be attempted 1st prior to medication or surgical procedure
– 1st attempt manual compression for 5 min to reduce edema and reposition foreskin
– Manual reduction technique:
Place thumbs on the glans while stabilizing the foreskin in between the 2nd and 3rd fingers.
Apply pressure on the thumbs while attempting to pull the foreskin over the glans
• Physiologic phimosis:
– Observation and reassurance
MEDICATION
First Line
• Physiologic phimosis:
– Topical steroids (0.05% betamethasone) may allow atraumatic retraction (3)
– Parents should be taught to never force back the foreskin but gradually retract it over time.
• Pathologic phimosis
– Topical steroid
– Aggressive retraction can cause worsening of preputial scarring
• Paraphimosis:
– Immediate manual reduction should be attempted
– Pain medication (eg, morphine, Demerol) or local anesthesia (lidocaine without epinephrine, infiltration, or penile block) may be necessary
Second Line
• Paraphimosis
– Hyaluronidase injection
– If manual reduction fails, a dorsal slit or incision of constricting band is indicated
– Recurrent paraphimosis may need definitive circumcision to prevent recurrence.
SURGERY/OTHER PROCEDURES
• Phimosis:
– Preputioplasty (dorsal slit with transverse closure) for patients wanting to maintain foreskin
– Circumcision is curative; should be generally avoided in children unless for indications such as recurrent UTI, vesicoureteral reflux, or superficial infections
– Circumcision is contraindicated in newborns with penile deformities (hypospadias, chordee, webbed penis, etc.) as foreskin may be needed for possible reconstructive surgery
• Paraphimosis
– Dorsal or ventral slit urgently treats narrowing and preserves the foreskin
– Immediate circumcision is occasionally necessary
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
N/A
Complementary & Alternative Therapies
• Paraphimosis
– Compression wraps
– Topical osmotic agents
ONGOING CARE
PROGNOSIS
• 95% of physiologic phimosis resolves by puberty, with the majority retractile by the age of 5
• Circumcision is curative.
COMPLICATIONS
• Complications of phimosis:
– UTI
– Postvoid dribbling
– Chronic inflammation with recurrent balanitis or balanoposthitis
– Calculi or pearls from smegma
– Penile carcinoma (rarely)
• Complications of paraphimosis
– Glans necrosis
• Complications of circumcision:
– Hemorrhage
– Persistent adhesions
– Skin bridges
– Inadequate skin removal
– Insufficient skin removal
– Inclusion cyst
– Cicatrix/concealed penis
– Meatal stenosis
FOLLOW-UP
Patient Monitoring
• Proper hygiene of uncircumcised males
• Foreskin reduction after procedures
Patient Resources
N/A
REFERENCES
1. Jordan GH, McCammon KA. Surgery of the penis and urethra. In: Wein AJ, ed. Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Elsevier; 2011.
2. Pohlman GH, Phillips JM, Wilcox DT. Simple method of paraphimosis reduction revisited: Point of technique and review of the literature. J Pediatr Urol. 2013;9:104–107.
3. Palmer LS, Palmer JS. Efficacy of topical betamethasone for treating phimosis: A comparison of two treatment regimens. Urology. 2008;72:68–71.
ADDITIONAL READING
• Choe JM. Paraphimosis: Current treatment options. Am Fam Physician. 2000;62:2623–2626.
• Hamdy FC, Hastie KJ. Treatment for paraphimosis: The ‘puncture’ technique. Br J Surg. 1990;77(10):1186.
• Hutcheson JC. Male neonatal circumcision: Indications, controversies and complications. Urol Clin North Am. 2004;31:461–467.
See Also (Topic, Algorithm, Media)
• Circumcision, Adult Considerations
• Circumcision, Pediatric Considerations
• Penis, Cancer, General Considerations
• Phimosis and Paraphimosis Image 
CODES
ICD9
• 605 Redundant prepuce and phimosis
• 607.1 Balanoposthitis
ICD10
• N47.1 Phimosis
• N47.2 Paraphimosis
• N48.1 Balanitis
CLINICAL/SURGICAL PEARLS
• In most cases physiologic phimosis will resolve.
• Aggressive retraction of phimosis can cause preputial scarring.
• Manual reduction of paraphimosis should be attempted 1st prior to surgical intervention.