fimosis2
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http://emedicine.medscape.com/article/777539-overview
Background
Phimosis refers to the inability to retract the distal foreskin over the glans penis. Physiologic
phimosis occurs naturally in newborn males. Pathologic phimosis defines an inability to retract the
foreskin after it was previously retractible or after puberty, usually secondary to distal scarring of the
foreskin.
Paraphimosis is the entrapment of a retracted foreskin behind the coronal sulcus. Paraphimosis is a
disease of uncircumcised or partially circumcised males.
Pathophysiology
The uncircumcised male penis comprises the penile shaft, the glans penis, the coronal sulcus, and
the foreskin/prepuce, as shown below.
Anatomy of the penis.
Physiologic phimosis results from adhesions between the epithelial layers of the inner prepuce and
glans. These adhesions spontaneously dissolve with intermittent foreskin retraction and erections,
so that as males grow, physiologic phimosis resolves with age.
Poor hygiene and recurrent episodes of balanitis or balanoposthitis lead to scarring of preputial
orifices, leading to pathologic phimosis. Forceful retraction of the foreskin leads to microtears at the
preputial orifice that also leads to scarring and phimosis. Elderly persons are at risk of phimosis
secondary to loss of skin elasticity and infrequent erections.
Patients with phimosis, both physiologic and pathologic, are at risk for developing paraphimosis
when the foreskin is forcibly retracted past the glans and/or the patient or caretaker forgets to
replace the foreskin after retraction. Penile piercings increase the risk of developing paraphimosis if pain and swelling prevent reduction of a retracted foreskin.
With time, impairment of venous and lymphatic flow to the glans leads to venous engorgement and
worsening swelling. As the swelling progresses, arterial supply is compromised, leading to penile
infarction/necrosis, gangrene, and eventually, autoamputation.
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Epidemiology
Frequency
United States
Up to 10% of males will have physiologic phimosis at 3 years of age, and a larger percentage of
children will have only partially retractible foreskins. One to five percent of males will have
nonretractible foreskins by age 16 years.[1, 2]
Race
No known racial predilection exists for phimosis and paraphimosis.
Sex
Phimosis and paraphimosis affects males only.
Age
Phimosis and paraphimosis can occur at any age.
Parents of patients with physiologic phimosis may bring in the patient after noting an inability to
retract the foreskin during routine cleaning or bathing. Parents may also be alarmed by "ballooning"
of the prepuce during urination a normal finding.
Pathologic phimosis may be detected in males who report painful erections, hematuria, recurrent
urinary tract infections, preputial pain, or a weakened urinary stream. (See below.)
Physiologic phimosis versus pathologic phimosis.
Paraphimosis classically presents with a painful, swollen glans penis in the uncircumcised or partially
circumcised patient. A preverbal infant may present only with irritability. Occasionally, the
paraphimosis may be an incidental finding noted by a caretaker of a debilitated patient. (See below.)
Paraphimosis.
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Paraphimosis is classically seen in one of the following populations:[3]
Children whose foreskins have been forcefully retracted or who forget to reduce their foreskin after
voiding or bathing
Adolescents or adults who present with paraphimosis in the setting of vigorous sexual activity[4]
Men with chronic balanoposthitis
Patients with indwelling catheters in whom caretakers forget to replace the foreskin after
catheterization or cleaning
Urinary obstruction is a late feature.
Physical
Phimosis
The foreskin cannot be retracted proximally over the glans penis.
In physiologic phimosis, the preputial orifice is unscarred and healthy appearing.
In pathologic phimosis, a contracted white fibrous ring may be visible around the preputial orifice
Physiologic phimosis versus pathologic phimosis.
Paraphimosis
The foreskin is retracted behind the glans penis and cannot be replaced to its normal position.
The foreskin forms a tight, constricting ring around the glans.
Flaccidity of the penile shaft proximal to the area of paraphimosis is seen (unless there is
accompanying balanoposthitis or infection of the penis).
With time, the glans becomes increasingly erythematous and edematous.
The glans penis is initially its normal pink hue and soft to palpation. As necrosis develops, the color
changes to blue or black and the glans becomes firm to palpation.
Differentials
Anasarca
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Angioedema
Balanitis
Bites, Insects
Cellulitis
Dermatitis, Contact
Foreign body tourniquet, including hair, thread, metallic object, or rubber bands
Penile carcinoma
Penile fracture
Penile hematoma
Emergency Department Care
Patients with phimosis rarely require any emergency intervention and should be referred to a
urologist as on an outpatient basis prior to development of irreversible penile damage.
A paraphimosis is a urologic emergency and needs to be attended to immediately. Many techniques
of paraphimosis reduction have been described in case studies, though none have been tested in
randomized control trials.[5] The main goal of each method is to reduce the foreskin to its naturallyoccurring 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, a penile block using lidocaine hydrochloride without epinephrine or, especially in
children, conscious sedation. Sterile technique should be used for all invasive procedures.
The authors recommend attempting to reduce the paraphimosis in the following sequence, from
least to most invasive. The urologist should be involved early on in all cases of paraphimosis that
require more than minimally invasive methods of reduction.
Manual reduction
Manual reduction is performed by placing both index fingers on the dorsal border of the penis
behind the retracted prepuce and both thumbs on the end of the glans. The glans is pushed back
through the prepuce with the help of constant thumb pressure while the index fingers pull the
prepuce over the glans.
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This technique may be facilitated by the use of ice and/or hand compression on the foreskin, glans,
and penis to minimize edema of the glans prior to manual reduction. Soaking the penis in a glove full
of ice for 5 minutes before attempting manual reduction has been reported to be effective 90% of
the time.[5]
An elastic bandage can also be wrapped from the glans to the base of the penis for 5-7 minutes to
minimize edema.[6]
Noncrushing clamps can be placed on the constricting portion of the foreskin atthe 3- and 9-o'clock
positions to apply gentle continuous symmetrical traction.[7] Also see, Paraphimosis Reduction.
Osmotic method
Substances with a high solute concentration can be used to osmotically draw out fluid from the
edematous glans and foreskin prior to manual reduction. Granulated sugar spread over the glans
and foreskin for 2 hours has been shown to facilitate manual reduction.[7] Alternatively, a swab
soaked in 50 mL of 50% dextrose (more readily available in the ED) can be wrapped around the glans
and foreskin for an hour prior to attempting reduction.[7] A major drawback of these methods is
that they are time consuming.
Puncture method
This method requires the use of a 21- to 26-gauge needle to puncture openings into the foreskin to
allow edematous fluid to escape from the puncture sites during manual compression. Successful
reductions have been reported with single and up to 20 punctures.[7]
Hyaluronidase method
The puncture method can be enhanced by the injection of 1-mL aliquots of hyaluronidase (using a
tuberculin syringe) into one or more sites of the edematous prepuce. It is thought that
hyaluronidase disperses extracellular edema by modifying the permeability of intercellular 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.
Drawbacks to this method include the risk of anaphylaxis and shock and the lack of availability of
hyaluronidase in many EDs.
Aspiration
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A tourniquet is applied to the shaft of the penis. A 20-gauge needle is then used to aspirate 3-12 mL
of blood from the glans, parallel to the urethra. This reduces the volume of the glans sufficiently to
facilitate manual reduction.
Vertical incision
If none of the above methods are successful, the constricting band of the foreskin should be incised
using a 1-2 cm longitudinal incision between two straight hemostats placed in the 12-o'clock position
for hemostasis.[6] This frees the constricting ring and allows for easy reduction of the paraphimosis.
The incised margins can then be reapproximated using 4/0 nylon sutures. Also see, Dorsal Slit of the
Foreskin and Nerve Block, Dorsal Penile. (See below.)
Dorsal slit procedure.
Emergent circumcision
This is a last resort, to be performed by a urologist, to achieve the necessary reduction of a
paraphimosis.
Medication Summary
Up to 85% of cases of mild-to-moderate phimosis have been shown to respond to application of
topical steroids to the preputial orifice, although some studies have suggested that this response
rate may decline several months after the regimen is completed.[8] An initial attempt at medical
intervention has been shown to reduce costs by 27.3% in comparison with primary circumcision as a
treatment of phimosis in infants and children.[9] Complications of medication use are limited to
preputial pain and hyperemia.
The ED physician may choose to recommend 0.1 -0.05% betamethasone dipropionate applied to thepreputial orifice twice a day for 4-6 weeks
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