10-month-old with acute onset edema of the distal penis
Patient will present with → foreskin in the normal position that cannot be retracted (phimosis)
Patient will present with → entrapment of the foreskin in the retracted position (paraphimosis)
Mnemonic: Paraphimosis = Paramedics (Emergency). Phimosis = Family Practice (Non-emergent)
Phimosis – the foreskin is in its normal position and cannot be retracted
- In adults, phimosis may result from scarring after trauma, infection (such as balanitis), or prolonged irritation
Paraphimosis – is the 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!
The diagnosis is clinical
Erect phimosis—the foreskin is in the normal position and cannot be retracted
Paraphimosis is the entrapment of the foreskin in the retracted position
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 performed under local anesthesia can provide temporary relief from the condition. Circumcision is then done when edema has resolved.
"A good way to remember that paraphimosis is the emergent condition-> PARAphimosis needs a PARAmedic"
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 two fingers or over an erect penis for 2 to 3 wks with care not to cause paraphimosis is also successful
- If conservative measures are ineffective, circumcision is the preferred surgical option
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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?
Balanitis Hint: Balanitis is commonly seen with phimosis but specifically refers to the inflammation of the glans penis. | |
Hypospadias Hint: Hypospadias is a congenital condition associated with a ventral location of the urethral meatus proximal to the glans. | |
Paraphimosis | |
Phimosis Hint: Phimosis is the inability to retract the foreskin from its original position. | |
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?
Broad-spectrum antibiotics | |
Circumcision Hint: Circumcision may be performed but only after infection is cleared | |
Dorsal slit Hint: See A for explanation | |
Immediate retraction of the foreskin Hint: Because the foreskin cannot be retracted, it cannot be reduced. | |
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?
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. | |
Cancer prevention Hint: Although penile carcinoma occurs in those who have not been circumcised, it is due to poor hygiene and chronic infection. | |
Hypospadias Hint: Hypospadias itself does not require removal of the foreskin for treatment. | |
Paraphimosis | |
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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References: Merck Manual · UpToDate