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)