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Phimosis, Emergency Medicine

Basics

Description

  • True phimosis is the pathologic inability to retract the foreskin over the glans of the penis as a result of scarring.
  • The inability to retract a normal, supple foreskin is not true phimosis.
  • The foreskin is rarely retractable at birth due to normal adhesions between the glans and the inner prepuce.
  • ¢ ¼90% are retractable by 3 yr of age, and 99% are retractable by 17 yr, as the epithelial cells that comprise smegma are shed.
  • Parents should be instructed not to forcibly retract the foreskin.

Etiology

Possible causes of true phimosis include:

  • Trauma from forcible retraction of the foreskin
  • Repetitive bouts of diaper dermatitis
  • Recurrent balanoposthitis
  • Poor hygiene
  • Poorly performed circumcision
  • Congenital anomalies

Diagnosis

Signs and Symptoms

  • Dysuria, hematuria
  • Poor urinary stream
  • Whitish, narrowed preputial opening of the foreskin
  • Edema, erythema, and tenderness of prepuce
  • Balanoposthitis (inflammation of the glans and foreskin)
  • Ballooning of foreskin on urination in severe cases

Physical Exam

Exam should include an evaluation for potential complications:

  • Obstruction and vascular compromise of glans
  • Occur only in the most extreme cases

Essential Workup

  • In the majority of cases, no workup is necessary.
  • In patients with severe stenosis, the complication of an obstructive uropathy may occur. This should be investigated by:Evaluation of kidney function:Renal sonogram
  • Phimosis secondary to recurrent balanoposthitis should prompt a workup for diabetes mellitus:Urinalysis, serum glucose, or glycosylated hemoglobin (Hgb A1C)

Differential Diagnosis

  • Preputial adhesions are normal in young children.
  • Balanoposthitis without phimosis

Treatment

Pre-Hospital

  • Pre-hospital personnel and family members should be instructed not to attempt retraction of the foreskin prior to medical evaluation.
  • Unwarranted attempts may traumatize a normal, nonretractable prepuce or convert the situation to a more emergent paraphimosis.

Initial Stabilization/Therapy

None required in most cases

Ed Treatment/Procedures

  • Relieve obstructive uropathy, if present, with urethral catheterization or suprapubic aspiration.
  • If vascular flow to the glans is compromised, a dorsal slit must be made in the foreskin:Performed after achieving adequate penile block (see Paraphimosis for more detailed description of procedure)This is rarely necessary in phimosis.
  • Potent topical steroids for a multiweek course have been reported to successfully reduce phimosis:Betamethasone dipropionate 0.05 " 0.1%: Apply to preputial orifice twice daily for 4 " 6 wk.

For foreskin incision, procedural sedation will likely be needed in place of penile block.

Medication

Pain control as required

Follow-Up

Disposition

Admission Criteria

  • Obstructive uropathy
  • Severe balanoposthitis with ischemia or necrosis

Discharge Criteria

  • Ability to urinate
  • Adequate urologic follow-up

Issues for Referral

Urologic follow-up for response to steroid therapy, dilation of the preputial opening, operative repair, or elective circumcision as necessary

Followup Recommendations

Physiologic phimosis requires waiting for age-appropriate development and continued preputial hygiene.

Pearls and Pitfalls

  • Foreskin is normally nonretractable from the neonatal period to age 3 yr.
  • Do not forcibly retract foreskin especially in children 3 " 17 yr, as phimosis may still be physiologically normal.
  • Vascular compromise of the glans penis requires a dorsal slit to the foreskin to prevent necrosis.

Additional Reading

  • Donohoe JM, Burnette JO, Brown JA. Paraphimosis treatment. eMedicine. Available at http://www.emedicine.medscape.com/article/442883. Updated October 7, 2009.
  • Ghory HZ, Sharma R. Phimosis and paraphimosis. eMedicine. Available at http://www.emedicine.medscape.com/article/777539. Updated April 28, 2010.
  • Huang CJ. Problems of the foreskin and glans penis. Clin Ped Emerg Med. 2009;10:56 " 59.
  • Marx JA, Hockberger RS, Walls RM. Rosens Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis, MO: Mosby; 2009:2201 " 2202.
  • Ramos-Fernandez MR, Medero-Colon R, Mendez-Carreno L. Critical urologic skills and procedures in the emergency department. Emerg Med Clin North Am. 2013;31(1):237 " 260.

See Also (Topic, Algorithm, Electronic Media Element)

Codes

ICD9

605 Redundant prepuce and phimosis

ICD10

N47.1 Phimosis

SNOMED

  • 449826002 Phimosis (disorder)
  • 266571009 acquired phimosis (disorder)
  • 253854008 congenital phimosis (disorder)