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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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