Basics
Description
- Phimosis is the inability to retract the prepuce (foreskin) after puberty due to a narrow preputial opening.
- Infants and prepubertal children rarely have true phimosis but rather a normal physiologic phimosis.
- Paraphimosis is the entrapment of the prepuce in a retracted position.
Epidemiology
- The incidence of phimosis is 0.4 cases per 100 boys per year.
- Phimosis affects 0.6 boys prior to their 16th birthday.
Risk Factors
- Phimosis
- Forced retraction of the prepuce
- Lichen sclerosis
- Paraphimosis
- Prolonged retraction of the prepuce
Pathophysiology
- Phimosis
- As the constriction of the phimosis worsens, urine is trapped in the foreskin and ballooning of the prepuce occurs. In severe cases, urine will fill the entire prepucial space and extend down the shaft.
- Paraphimosis
- Prolonged retraction of the prepuce around the glans causes edema of the prepuce and the glans. The edema makes it harder to correct the phimosis and causes significant pain for the child.
General Prevention
Boys should be instructed to return the foreskin to covering the glans after cleaning to prevent paraphimosis.
Diagnosis
History
- Phimosis
- Parent may report ballooning of the prepuce during voiding.
- Parent may report having to squeeze the prepuce to clear all the trapped urine.
- Paraphimosis
- Parent will report cleaning the penis during a diaper change, pulling the foreskin back, and then being unable to return it to its normal position covering the glans.
- Child may pull the foreskin back and then be unable to return the foreskin to its normal position.
Physical Exam
- Phimosis
- Gentle attempt to retract the foreskin to evaluate the size of the preputial opening
- A child who cannot retract foreskin after onset of puberty has phimosis.
- Dry, white patchy areas of the foreskin indicate lichen sclerosis and seen with phimosis 50% of the time.
- Paraphimosis
- Tender penis with marked edema of the prepuce (foreskin)
- Tight collar around the glans
- Long duration of the retracted skin will compromise the blood supply of the prepuce and glans.
- There are case reports of gangrene.
- Consider calling child protective services if there is gangrene.
Diagnostic Tests & Interpretation
Lab
Not needed
Imaging
Not needed
Diagnostic Procedures/Other
Not needed
Differential Diagnosis
- Physiologic phimosis
- A child who has not gone through puberty will have a normal physiologic phimosis. This will change as he nears puberty and the foreskin will be easier to retract over time.
- There may be small lumps of white material under the glans that are desquamated skin cells that are not infection and slowly work their way out of the preputial cavity. This desquamated skin helps with skin separation.
Alert
Early (before puberty), forced retraction of the foreskin before the foreskin is naturally ready to retract may cause phimosis.
Treatment
Medication
- Phimosis
- Topical steroids t.i.d. for 6 weeks; use a small bead size amount
- Fluticasone propionate, 0.05%
- Betamethasone propionate, 0.1%
- Triamcinolone cream
- This also treats lichen sclerosis.
- Topical tacrolimus is 2nd-line treatment for lichen sclerosis.
- Paraphimosis
- Should be considered an emergency
- Sedation and reduction by applying pressure to the glans and prepuce
Additional Therapies
- Phimosis
- Circumcision
- Performed when medical treatment fails
- Paraphimosis
- Dorsal slit is performed if compression fails.
- Dorsal incision of the prepuce: under sedation
General Measures
- Phimosis
- Refer to pediatric urologist if patient fails 2 months of medical management.
- Paraphimosis
- Refer to pediatric urologist immediately if unable to return the foreskin to covering the glans without sedation.
- Keep the patient in the ER, as sedation will most likely be necessary.
Ongoing Care
Follow-up Recommendations
- Phimosis
- Follow-up in 2 months after use of steroids
- Paraphimosis: If foreskin is back in normal position:
- Follow up with pediatric urologist in 2 weeks.
- There should be no retraction of the foreskin in that time frame.
- Consider use of topical steroids to avoid development of severe phimosis.
Prognosis
- Phimosis
- Use of steroids is successful 70 " 90% of the time.
- Paraphimosis
- High risk of development of severe phimosis
- May require circumcision in the future
Additional Reading
- DeVries CR, Miller AK, Packer MG. Reduction of paraphimosis with hyaluronidase. Urology. 1996;48(3):464 " 465.
- Gausche M. Genitourinary surgical emergencies. Pediatr Ann. 1996;25(8):458 " 464. [View Abstract]
- Edwards S. 2001 National guideline on the management of balanitis. http://www.pdfdrive.net/2001-national-guideline-on-the-management-of-balanitis-bashh-e7997290.html. Accessed February 15, 2015.
Codes
ICD09
- 605 Redundant prepuce and phimosis
ICD10
- N47.1 Phimosis
- N47.2 Paraphimosis
SNOMED
- 449826002 Phimosis (disorder)
- 13758004 paraphimosis (disorder)
- 253854008 congenital phimosis (disorder)
FAQ
- Q: Can a child have phimosis as a newborn?
- A: Physiologic phimosis (inability to retract the foreskin) is normal in prepubertal children. It occurs because of incomplete separation of skin between the glans and the inner prepuce. It does not require treatment.