AUTHOR AND EDITOR INFORMATION

Section 1 of 8  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• References

INTRODUCTION

Section 2 of 8  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• References

Background

The true definition of phimosis has been confused in the literature. Essentially, there are two entities, based on age and pathophysiology: congenital phimosis and acquired phimosis. Both terms imply the inability to retract the distal prepuce over the glans penis. Once the foreskin can be retracted so that the glans penis partially appears, a phimosis is no longer present. Paraphimosis is the entrapment of a retracted foreskin behind the coronal sulcus. These conditions occur in the uncircumcised or incorrectly circumcised penis.

Frequency

United States

The incidence is approximately 1% of males older than 16 years.

Sex

Male only

Age

Phimosis and paraphimosis can occur at any age; however, a higher incidence is seen in infancy and adolescence.

CLINICAL

Section 3 of 8  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• References

History

• Congenital phimosis
• • Congenital phimosis is physiologic in young children.
  • It is entirely normal for young children, even into the teenage years, to have a congenital phimosis, which does not cause problems such as urinary obstruction, hematuria, or preputial pain.
  • Children with congenital phimosis may have a history of recent catheterization or of parents forcibly retracting the foreskin in an attempt to clean the glans.
• Acquired phimosis
• • In acquired phimosis, there likely is a history of poor hygiene, chronic balanoposthitis, or forceful retraction of a congenital phimosis.
  • The physician must always obtain a historical description of the urinary stream. If it decreases, referral to an urologist is necessary for eventual circumcision.
  • In addition, the presence of hematuria or preputial pain is an important historical factor and may be an appropriate reason to refer the patient for circumcision.
  • Children with acquired phimosis have the usual history (as obtained in the adult) of poor hygiene and/or chronic balanoposthitis eventually leading to paraphimosis.
• Paraphimosis
• • Pain and edema of the uncircumcised or improperly circumcised penis are characteristic.
  • Adults, especially the elderly population, may have a history of frequent catheterizations or of poor hygiene and/or chronic balanoposthitis leading to phimosis and eventual paraphimosis.
  • Vigorous sexual activity has been reported to predispose one to paraphimosis.
  • Pain with erection may occur.

Physical

• Congenital and acquired phimosis
• • Foreskin cannot be retracted proximally over the glans penis.
• Paraphimosis
• • Edema, tenderness, and erythema of the glans
  • Edema of the distal foreskin
  • Flaccidity of the penile shaft proximal to the area of paraphimosis (unless there is accompanying balanoposthitis or infection of the penis)
  • Ensure the absence of an encircling foreign body, such as hair, clothing, metallic objects, or rubber bands.

Causes

• Congenital phimosis can be considered physiologic in the young male since the foreskin is always tight, nonretractable, and adherent to the glans at birth.
• • The foreskin continues to be tight until progressive keratinization of the epithelial layers between the glans and the inner prepuce dislodges the foreskin from the glans.
  • In Japan, where no custom of circumcision exists, one study noted that congenital phimosis was present in 88.5% of children aged 1-3 months and in 35% of children aged 3 years. Within the same study, only 39.7% of foreskins were fully retractable over the glans by 3 years of age.
  • Oster noted a congenital phimosis still present in 6% of boys aged 8-11 years and in 3% of boys aged 12-13 years. Gairdner noted fully retractable foreskins in only 20% of 200 boys aged 5-13 years. Thus, congenital phimosis can be present even into late childhood.
• Acquired phimosis is usually the result of poor hygiene or chronic balanoposthitis, which eventually leads to the formation of a fibrotic ring of tissue close to the opening of the prepuce. Repetitive forceful retraction of a congenital phimosis by parents attempting to clean the underlying glans may lead to an acquired phimosis because of scar formation and a resultant fibrotic ring of tissue at the prepuce.
• As long as obstruction of the urinary stream, hematuria, or preputial pain is not present, phimosis is never a urologic emergency; only reassurance and proper hygiene are necessary. However, because of the tight preputial narrowing, retraction of a phimosis over the glans can predispose to paraphimosis, which is a true urologic emergency.
• Paraphimosis is the inability to reduce a retracted foreskin over the glans penis into its naturally occurring position.
• • Constriction by the tight band of retracted foreskin can quickly lead to edema and venous engorgement of the glans and foreskin.
  • As the condition progresses, necrosis of the glans may occur secondary to arterial occlusion.
  • In children with congenital phimosis, the congenitally narrowed preputial opening is the usual cause of paraphimosis, especially after parents forcibly retract the foreskin while attempting to clean the glans or after catheterizations of the bladder are performed by medical personnel who retract the foreskin and fail to reduce it back over the glans.
  • In adults, frequent bladder catheterizations without replacing the foreskin in its reduced position may eventually lead to a paraphimosis.
  • Poor hygiene may predispose one to acquired phimosis, which can eventually result in paraphimosis if the foreskin, with its tight fibrotic ring, is retracted over the glans.
  • With the rising incidence of body piercing, those obtaining penile rings are at increased risk of paraphimosis, especially if the newly placed ring causes enough discomfort to prevent the reduction of a retracted foreskin.

DIFFERENTIALS

Section 4 of 8  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• References

Other Problems to be Considered

Urticaria
Penile hematoma
Penile fracture
Idiopathic penile edema
Hair or thread tourniquet

WORKUP

Section 5 of 8  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• References

Lab Studies

• Phimosis and paraphimosis are clinical diagnoses, thus lab and imaging studies are not indicated.

TREATMENT

Section 6 of 8  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• References

Emergency Department Care

• Paraphimosis reduction: After determining the absence of an encircling foreign body, one may proceed to emergent reduction of the paraphimosis. Many techniques of paraphimosis reduction have been described. The main goal of each method is to reduce the foreskin to its naturally occurring position over the glans penis by manipulating the edematous glans and/or the distal prepuce. When necessary, all of the following procedures can be facilitated by the use of local anesthesia or a penile block using lidocaine hydrochloride without epinephrine. Occasionally, some children require conscious sedation.
• • Manual reduction of the prepuce over the glans can be achieved by placing both index fingers on the dorsal border of the penis behind the retracted prepuce while placing both thumbs on the end of the glans. The glans is pushed back through the prepuce with the help of thumb pressure while the index fingers pull the prepuce over the glans. This technique may be facilitated by the use of ice and/or hand compression on the foreskin, glans, and penis to help decrease the amount of edema prior to manual reduction. This, as with all of the reduction techniques, requires a fair amount of patience and cannot be rushed.
  • The use of noncrushing Babcock clamps on each quadrant of the constricting portion of the foreskin may facilitate reduction if manual reduction fails. After placement of the clamps, apply gentle continuous symmetrical traction until the foreskin is reduced over the glans penis.
  • Placing direct pressure on the glans penis with the fingers or with the help of a 2 x 2-inch Kerlix bandage around the glans has also been described as an effective method for the reduction of a paraphimosis. Wrapping the glans in Kerlix provides equal pressure throughout the whole glans and may speed the process of reduction.
  • Based on the principle of osmotic gradients, a technique that involves the placement and holding of fine granulated sugar onto the edematous glans and foreskin for several hours may help reduce edema and, subsequently, facilitate manual reduction.
• The following methods are considered more invasive and should not be performed unless all noninvasive attempts have been exhausted. These methods are better performed by a urologist unless one is not immediately available and ischemia or infarction of the glans seems imminent. Prior to any invasive procedure, it is important to prepare the skin with Betadine. After reduction, topical and oral antibiotics should be considered.
• • A more recently described technique of reduction has gained popularity in the literature and is called the puncture technique. This method requires the use of a 21-gauge needle to puncture one or several openings into the edematous foreskin to subsequently allow edematous fluid to escape from the puncture sites after manual compression of the penis and foreskin. One single puncture has been reported effective but multiple punctures have also been described. Manual reduction is easily accomplished after enough edematous fluid has been expressed from the foreskin.
  • The more classic invasive approach involves vertically incising the dorsal aspect of the constricting preputial ring. This dorsal slit procedure will free the constricting ring and allow for easy reduction of the paraphimosis.
  • The injection of 1.0-cc aliquots of hyaluronidase (using a tuberculin syringe) into one or more sites of the edematous prepuce has been described as an effective method to quickly reduce foreskin edema, subsequently leading to easy reduction. It is thought that hyaluronidase disperses extracellular edema by modifying the permeability of intercellular ground substance in connective tissue. The use of this method is contraindicated in those with the presence of infection or cancer, since the technique may result in the spread of bacteria or malignant cells. Uncommon reported side effects associated with the use of hyaluronidase include ecchymosis, anaphylaxis, shock, and hypovolemia when given intravascularly. It is worthwhile to mention that some consider the key to this method of reduction is not the effects of the hyaluronidase, but rather, the punctures made by the syringe needle, as described in the puncture technique.
  • Rarely, emergent circumcision is performed by a urologist to achieve the necessary reduction of a paraphimosis.

Consultations

A paraphimosis is a urologic emergency. Attempts to reduce the paraphimosis must be performed. If the less invasive measures described fail to reduce the paraphimosis, a urologic consultation is required.

FOLLOW-UP

Section 7 of 8  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• References

Further Outpatient Care

• Phimosis
• • If a phimosis is causing urinary obstruction, referral to a urologist is necessary to perform circumcision or other plastic surgical technique, referred to as preputial plasty, to enlarge the preputial opening without actually removing tissue. Some advocate the use of steroid creams as a noninvasive effective treatment for acquired phimosis, whereas, the use of nonsteroidal ointments has also been noted to be of benefit in the treatment of acquired phimosis.
  • Otherwise, a congenital phimosis should be left alone.
  • Only the usual cleaning, without forceful retraction of the foreskin is necessary.
  • Proper foreskin hygiene should be suggested to the adult and the child with acquired phimosis.
• Paraphimosis
• • After emergent reduction, referral to a urologist for eventual circumcision is mandatory since the condition is likely to recur.
  • Generally, circumcision is performed after the edema is resolved.

Complications

• Gangrene of the glans
• Posthitis (inflammation of the prepuce)

Prognosis

• Complete resolution is expected with appropriate treatment.

Patient Education

• Parental education of normal childhood congenital phimosis, even into the school-aged years, is very important. This education should stress the danger of forcibly retracting the foreskin for hygienic purposes. After time, the adhesions present between the inner prepuce and the glans will lyse on their own.
• Patients and parents of children with acquired phimosis should be educated on the importance of proper genital hygiene with reduction of the foreskin after each cleaning. In addition, they should be made aware of the problems that may result from an acquired phimosis, such as paraphimosis, obstructed urinary stream, hematuria, or preputial pain.
• All providers of adult care should be made aware of the risk of paraphimosis associated with bladder catheterization. They should be reminded to always reduce the foreskin after cleaning and catheterization.
• For excellent patient education resources, visit eMedicine's Men's Health Center. Also, see eMedicine's patient education articles Foreskin Problems and Circumcision.

REFERENCES

Section 8 of 8

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• References

• Atilla MK, Dundaroz R, Odabas O. A nonsurgical approach to the treatment of phimosis: local nonsteroidal anti-inflammatory ointment application. J Urol. Jul 1997;158(1):196-7. [Medline].
• Brendler, CB. Evaluation of the urologic patient. In: Walsh PC, et al, eds. Campbell's Urology. 7th ed. Philadelphia: WB Saunders;1997: 1-142. [Medline].
• DeVries CR, Miller AK, Packer MG. Reduction of paraphimosis with hyaluronidase. Urology. Sep 1996;48(3):464-5. [Medline].
• Elder JS. Congenital anomalies of the genitalia. In: Walsh PC, et al, eds. Campbell's Urology. 7th ed. Philadelphia: WB Saunders;1997. [Medline].
• Gairdner D. The fate of the foreskin, a study of circumcision. British Medical Journal. 1949;2:1433-7.
• Green M, Stange GR. Paraphimosis reduction. In: Henretig FM, King C, eds. Textbook of Pediatric Emergency Procedures. Baltimore:1997: 1007-10. [Medline].
• Hamdy FC, Hastie KJ. Treatment for paraphimosis: the ''puncture'' technique. Br J Surg. Oct 1990;77(10):1186. [Medline].
• Imamura E, ALIA. Phimosis of infants and young children in Japan. Acta Paediatr Jpn. Aug 1997;39(4):403-5. [Medline].
• Jones SA, Flynn RJ. An unusual (and somewhat piercing) cause of paraphimosis. Br J Urol. Nov 1996;78(5):803-4. [Medline].
• Kerwat R, Shandall A, Stephenson B. Reduction of paraphimosis with granulated sugar. Br J Urol. Nov 1998;82(5):755. [Medline].
• Litzky GM. Reduction of paraphimosis with hyaluronidase [letter; comment]. Urology. Jul 1997;50(1):160. [Medline].
• Monsour MA, Rabinovitch HH, Dean GE. Medical management of phimosis in children: our experience with topical steroids. J Urol. Sep 1999;162(3 Pt 2):1162-4. [Medline].
• O'Donnell, JA II. Phimosis and paraphimosis. In: Barkin RM, et al, eds. Pediatric Emergency Medicine. 2nd ed. St. Louis: Mosby;1997: 1152-3. [Medline].
• Oster J. Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child. Apr 1968;43(228):200-3. [Medline].
• Williams JC, Morrison PM, Richardson JR. Paraphimosis in elderly men. Am J Emerg Med. May 1995;13(3):351-3. [Medline].

Article Last Updated: Apr 11, 2006