From the Guidelines
Phimosis and paraphimosis are penile conditions that require prompt recognition and management to prevent complications, with risk factors including poor hygiene, recurrent infections, diabetes, forceful retraction attempts, and congenital narrowing of the preputial opening, as well as certain piercings, particularly those involving the glans penis 1. The management of these conditions should prioritize preventing tissue ischemia and promoting proper foreskin care.
- Risk factors for phimosis include:
- Poor hygiene
- Recurrent infections
- Diabetes
- Forceful retraction attempts
- Congenital narrowing of the preputial opening
- Lichen sclerosus, as indicated by the British Association of Dermatologists guidelines for the management of lichen sclerosus, 2018 1
- Risk factors for paraphimosis include:
- Uncircumcised men with piercings, particularly those involving the glans penis or urethra 1
- Inadequate foreskin care
- Forceful retraction attempts Management of phimosis in children often begins conservatively with gentle retraction during bathing and topical steroids, which resolves 70-90% of cases, while adults or resistant cases may require circumcision 1. For paraphimosis, immediate intervention is necessary to prevent complications, with manual reduction attempted first, followed by a penile block with 1% lidocaine without epinephrine if necessary, and dorsal slit procedure or emergency circumcision for severe cases 1. Patients should be educated about proper hygiene and appropriate foreskin care to prevent recurrence, including gentle cleaning and avoiding forceful retraction, particularly in young children where physiologic phimosis is normal until around age 3-5 years. It is essential to consider the potential complications of body piercings, particularly genital piercings, and to advise patients on the risks and proper aftercare to minimize these complications 1.
From the Research
Risk Factors for Phimosis and Paraphimosis
- Phimosis is a condition in which the prepuce cannot be retracted over the glans penis, and it is common in male patients up to 3 years of age, but often extends into older age groups 2
- Balanoposthitis, a common inflammation occurring in 4-11% of uncircumcised boys, can be a risk factor for phimosis 2
- Balanitis xerotica obliterans, an infiltrative skin condition, can cause a pathological phimosis and is considered to be the only absolute indication for circumcision 2
Management Options for Phimosis
- Topical steroid therapy is an effective alternative to circumcision for the treatment of phimosis, with success rates of 67%-95% 3, 4
- Manual retraction therapy and preputioplasty are also effective alternatives to circumcision for the treatment of phimosis 2
- Topical corticosteroids may increase the complete resolution of phimosis after four to eight weeks of treatment, and may increase long-term complete resolution of phimosis assessed six or more months after treatment 5
Management Options for Paraphimosis
- When manipulation is not effective, a dorsal slit should be done, which is usually followed by circumcision 2
- In situ devices, which crush the foreskin and simultaneously create haemostasis, seem feasible, safe and effective in treating paraphimosis while reducing the operative time compared to traditional circumcision 6
Treatment Outcomes
- Topical steroid therapy has been shown to be effective in treating phimosis in boys, with 74% of boys having fully retractable foreskins after 1 month of treatment, and 18% having a partial response at 1 month 3
- The use of topical corticosteroids may have few or no adverse effects, and may increase complete and partial resolution of phimosis when assessed after four to eight weeks of treatment 5