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Phimosis and Paraphimosis, Pediatric

Basics

Description

- 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.

- 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

  • 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

  • PhimosisForced retraction of the prepuceLichen sclerosis
  • ParaphimosisProlonged retraction of the prepuce

Pathophysiology

  • PhimosisAs 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.
  • ParaphimosisProlonged 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

  • PhimosisParent may report ballooning of the prepuce during voiding.Parent may report having to squeeze the prepuce to clear all the trapped urine.
  • ParaphimosisParent 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

  • PhimosisGentle attempt to retract the foreskin to evaluate the size of the preputial openingA 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.
  • ParaphimosisTender penis with marked edema of the prepuce (foreskin)Tight collar around the glansLong 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 phimosisA 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

  • PhimosisTopical steroids t.i.d. for 6 weeks; use a small bead size amountFluticasone propionate, 0.05%Betamethasone propionate, 0.1%Triamcinolone creamThis also treats lichen sclerosis.Topical tacrolimus is 2nd-line treatment for lichen sclerosis.
  • ParaphimosisShould be considered an emergencySedation and reduction by applying pressure to the glans and prepuce

Additional Therapies

  • PhimosisCircumcisionPerformed when medical treatment fails
  • ParaphimosisDorsal slit is performed if compression fails.Dorsal incision of the prepuce: under sedation

General Measures

  • PhimosisRefer to pediatric urologist if patient fails 2 months of medical management.
  • ParaphimosisRefer 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

  • PhimosisFollow-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

  • PhimosisUse of steroids is successful 70 " 90% of the time.
  • ParaphimosisHigh risk of development of severe phimosisMay 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.