Phimosis and Paraphimosis

Almost all boys have a non-retractile foreskin at birth. The inner foreskin is attached to the glans. Foreskin adhesions break down and form smegma pearls (white cysts under the foreskin) which are then extruded. The foreskin does not retract before the age of 2 years. The process of retractility is spontaneous and does not require manipulation.¹ Phimosis is not a problem unless it causes problems such as urinary obstruction, haematuria or local pain.

Epidemiology

• The majority of boys will have a retractile foreskin by 10 years of age and 95% by 16-17 years of age.¹
• Phimosis results when the prepuce is tight and is unable to be pulled forward over the glans. This is often the result of chronic infection caused by poor hygiene.
• Poor hygiene and enthusiastic attempts to correct congenital phimosis increase the risk of developing pathological phimosis.
• Phimosis usually occurs in uncircumcised males but can occur after circumcision where any excessive skin becomes sclerotic.
• In older diabetic patients it often results from chronic balanoposthitis that is inflammation of the glans and prepuce.
• Female phimosis is an uncommon and poorly recognised condition. A study from a sexual dysfunction clinic found that clitoral phimosis was present in 22%.² This may have been contributing to dyspareunia.
• A study from Liverpool concluded that the incidence of pathological phimosis in boys was 0.4 cases/1000 boys per year, or 0.6% of boys affected by their 15th birthday. This is much lower than previous estimates and 8 times this proportion of English boys are currently circumcised for 'phimosis'. They suggest that the diagnosis is made far too often.³

Presentation

There may be swelling redness and tenderness of the prepuce with purulent discharge.

Investigations

A swab may be taken to confirm the nature of infection but attention is towards physical cleaning rather than antibiotics.

Management¹

• Physiological phimosis:
  • No intervention is necessary.
  • Advise parents against forcibly retracting it in congenital phimosis as this can result in scar formation and an acquired phimosis.
  • Wait until after puberty and resist requests for circumcision.
  • Personal hygiene is very important. Advise cleaning under the foreskin and always reduce it to cover the glans after cleaning.
  • Topical steroid application to the preputial ring to treat ‘phimosis’ has reported success rates between 33% – 95%.
• Pathological phimosis:
  • Intralesional steroid injection, long term antibiotics, carbon dioxide laser therapy, radial preputioplasty alone or with intralesional injection of steroid have all been described but there are no randomised trials of efficacy and long term outcome.
  • It may be necessary to slit the dorsal or ventral foreskin to improve drainage or perform "preputial plasty".⁴
  • Most paediatric urologists circumcise the foreskin for pathological phimosis.

Circumcision¹

• Indications:
  • Absolute:
    • Penile malignancy
    • Traumatic foreskin injury where it cannot be salvaged
  • Medical:
    • Balanitis Xerotica Obliterans
    • Severe recurrent attacks of balanoposthitis
    • Recurrent febrile UTI’s with an abnormal urinary tract
  • Non-therapeutic ‘ritual’ circumcision
• Complications:
  • Bleeding (1.5%)
  • Local sepsis (8.5%)
  • Oozing (36%)
  • Discomfort > 7 days (26%)
  • Meatal scabbing or stenosis
  • Removal of too much or too little skin
  • Urethral injury
  • Amputation of the glans
  • Inclusion cyst
  • There is conflicting evidence with respect to penile sensation, sexual function and satisfaction
  • in adult men following circumcision

Complications of phimosis

• Phimosis is a risk factor for penile carcinoma.
• Circumcision has a beneficial effect on the incidence of invasive carcinoma of penis but not carcinoma in situ.⁵
• Balanitis xerotica obliterans may require not just circumcision but dilatation of the urethral meatus or meatoplasty.
• Accumulated smegma may be an important carcinogen for penile carcinoma.⁶
• Herpes virus is the most likely candidate for the association of sexually transmitted carcinoma of cervix.⁷

Occurs when a tight prepuce is retracted and then is unable to be replaced as the glans swells. This is a urological emergency. Always check there is no encircling foreign body constricting venous return, such as a ring, rubber band or hair.

Risk factors

• A tight prepuce causes swelling when it is retracted.
• Penile piercing can lead to paraphimosis but the commonest cause is urinary catheterisation when after inserting the catheter there is failure to replace the foreskin over glans after the procedure.

Presentation

• There is oedema around the constricting band that is usually the prepuce.
• There may be pain on erection.

Management

• Gentle compression with a saline soaked swab followed by reduction of the prepuce over the glans is usually successful.
• Gradual manual reduction of the prepuce over the glans is done by placing both index fingers on the dorsal border of the penis and thumbs on the glans. The glans is pushed back while the index fingers pull the prepuce back over the glans.
• This technique can be facilitated by trying to achieve reduction of swelling first. Ice may be applied. Manual compression is archived by asking the patient to squeeze the glans for anything from 5 to 30 minutes. Osmotic reduction involves application of a swab soaked in 50% dextrose to swollen area for an hour.
• If simple methods fail then refer urgently to a urologist.
• Alternatives include multiple punctures in the oedematous foreskin or injection of hyaluronidase prior to compression reduction. General anaesthesia may be required.¹
• If local anaesthetic is required it must not contain adrenaline.
• Paraphimosis is not an indication for circumcision as after reduction, the foreskin continues to develop normally.

Complications

Failure to remove the constricting band of paraphimosis will result in necrosis of the glans.