PANCE Blueprint Genitourinary (5%)

Paraphimosis/phimosis

Patient will present with foreskin in normal position that cannot be retracted (phimosis).

Patient will present with → entrapment of the foreskin in the retracted position (paraphimosis).

phimosis and paraphimosisPhimosis – foreskin in normal position and cannot be retracted

Paraphimosisis entrapment of the foreskin in the retracted position; it is a medical emergency.

Paraphimosis can occur when the foreskin is left retracted (behind the glans penis). Retraction may occur during catheterization or physical examination. If the retracted foreskin is somewhat tight, it functions as a tourniquet, causing the glans to swell, both blocking the foreskin from returning to its normal position and worsening the constriction.

Always remember to reduce the foreskin after urethral catheterization.

Diagnosis is clinical

Paraphimosis → should be regarded as an emergency, because constriction leads quickly to vascular compromise and necrosis of the glans penis.

Firm circumferential compression of the glans with the hand may relieve edema sufficiently to allow the foreskin to be restored to its normal position. If this technique is ineffective, a dorsal slit done using a local anesthetic relieves the condition temporarily. Circumcision is then done when edema has resolved.

Phimosis → is normal in children and typically resolves by age 5.

Treatment is not required in the absence of complications such as balanitis, UTIs, urinary outlet obstruction, unresponsive dermatologic disease, or suspicion of carcinoma.

Betamethasone cream 0.05% bid to tid applied to the tip of the foreskin and the area touching the glans for 3 mo is often effective. Stretching the foreskin gently with 2 fingers or over an erect penis for 2 to 3 wk with care not to cause paraphimosis is also successful. If conservative measures are ineffective, circumcision is the preferred surgical option.

In adults, phimosis may result from balanoposthitis or prolonged irritation. Risk of UTI, penile cancer, HIV, and sexually transmitted diseases is increased. The usual treatment is circumcision.

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Question 1
Which of the following conditions is defined as the inability to reduce the foreskin of the penis once it has been retracted?  
A
Balanitis
Hint:
Balanitis is commonly seen with phimosis but specifically refers to the inflammation of the glans penis.
B
Hypospadias
Hint:
Hypospadias is a congenital condition associated with a ventral location of the urethral meatus proximal to the glans.
C
Paraphimosis
D
Phimosis
Hint:
Phimosis is the inability to retract the foreskin from its original position.
E
Urethral meatal stricture
Hint:
Urethral meatal stricture occurs following inflammation of the urethra from chronic infection or trauma.
Question 1 Explanation: 
Paraphimosis is the condition in which the foreskin (prepuce) cannot be reduced back over the glans once it has been retracted. Chronic inflammation is commonly the cause. Balanitis is commonly seen with phimosis but specifically refers to the inflammation of the glans penis. Phimosis is the inability to retract the foreskin from its original position. Urethral meatal stricture occurs following inflammation of the urethra from chronic infection or trauma. Hypospadias is a congenital condition associated with a ventral location of the urethral meatus proximal to the glans.
Question 2
What is the initial treatment of choice for an adult patient diagnosed with phimosis?
A
Broad-spectrum antibiotics
B
Circumcision
Hint:
Circumcision may be performed but only after infection is cleared
C
Dorsal slit
Hint:
See A for explanation
D
Immediate retraction of the foreskin
Hint:
Because the foreskin cannot be retracted, it cannot be reduced.
E
Oral antifungal agents
Hint:
See A for explanation
Question 2 Explanation: 
Phimosis is a condition in which, usually due to poor hygiene and bacterial causes, the foreskin cannot be retracted over the glands. Broad-spectrum antibiotics are first-line treatment and the dorsal slit is only performed if drainage of the penis is needed on an urgent basis. Circumcision may be performed but only after infection is cleared. Because the foreskin cannot be retracted, it cannot be reduced.
Question 3
Which of the following is an indication for circumcision?
A
Balanoposthitis
Hint:
Balanoposthitis can lead to phimosis when chronic but because it can be treated easily with medications and proper hygiene, is not itself an indication for circumcision.
B
Cancer prevention
Hint:
Although penile carcinoma occurs in those who have not been circumcised, it is due to poor hygiene and chronic infection.
C
Hypospadias
Hint:
Hypospadias itself does not require removal of the foreskin for treatment.
D
Paraphimosis
E
Peyronie disease
Hint:
Peyronie disease affects the shaft of the penis and does not involve the foreskin in any way that would indicate a need for removal.
Question 3 Explanation: 
In some countries, circumcisions are routinely performed usually for religious or cultural reasons. Paraphimosis, phimosis, and infection are the only true indications. Balanoposthitis can lead to phimosis when chronic but because it can be treated easily with medications and proper hygiene, is not itself an indication for circumcision. Hypospadias itself does not require removal of the foreskin for treatment. Although penile carcinoma occurs in those who have not been circumcised, it is due to poor hygiene and chronic infection. Peyronie disease affects the shaft of the penis and does not involve the foreskin in any way that would indicate a need for removal.
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