From the Guidelines
Phimosis and paraphimosis are penile conditions that require prompt recognition and appropriate management to prevent complications and improve quality of life. The initial treatment for phimosis involves gentle stretching exercises and topical steroid cream (betamethasone 0.05% or clobetasol 0.05%) applied twice daily for 4-8 weeks, as supported by the British Association of Dermatologists' guidelines 1. If conservative measures fail, circumcision is the definitive treatment for phimosis, as it can cure the disease and prevent further complications, such as urinary retention, infection, and balanoposthitis 1. Paraphimosis, on the other hand, is a urologic emergency that requires immediate intervention to prevent glans ischemia and necrosis. Manual reduction should be attempted first by applying firm, steady pressure on the edematous glans while pulling the foreskin forward, and if this fails, a dorsal slit procedure or emergency circumcision may be necessary 1. Diagnosis is primarily clinical, based on physical examination findings, and proper hygiene education and regular medical follow-up are essential components of management for both conditions. Children with physiologic phimosis typically don't require intervention unless they experience recurrent infections or urinary problems, and long-term follow-up is necessary for patients with active ongoing disease to monitor for signs of complications, such as penile intraepithelial neoplasia (PeIN) or squamous cell carcinoma (SCC) 1. Key points to consider in the management of phimosis and paraphimosis include:
- Gentle stretching exercises and topical steroid cream as initial treatment for phimosis
- Circumcision as the definitive treatment for phimosis
- Manual reduction as the first line of treatment for paraphimosis
- Regular medical follow-up and proper hygiene education to prevent complications
- Long-term follow-up for patients with active ongoing disease to monitor for signs of complications.
From the Research
Phimosis and Paraphimosis: Overview
- Phimosis is a condition where the prepuce cannot be retracted over the glans penis, common in male patients up to 3 years of age, but can extend into older age groups 2.
- Paraphimosis is a condition where the foreskin is left retracted, often iatrogenically induced, and can be prevented by returning the prepuce to cover the glans following penile manipulation 3.
Complications
- Balanoposthitis is a common inflammation occurring in 4-11% of uncircumcised boys, and balanitis xerotica obliterans is an infiltrative skin condition that causes pathological phimosis 2.
- Paraphimosis can lead to urologic emergencies, and prevention and early intervention are key elements in its management 3, 4.
Diagnosis
- Phimosis can be diagnosed by assessing the ability to retract the prepuce, and paraphimosis can be diagnosed by the presence of a tight band of constricting tissue behind the corona 2, 3.
- Important urethral anomalies, such as hypospadias and epispadias, can be revealed after treatment for phimosis 5.
Treatment
- Topical corticosteroids, such as betamethasone, are a highly efficacious and safe treatment for phimosis, with an 84.5% response rate in one study 5.
- Topical corticosteroids offer an effective alternative for treating phimosis in boys, with a significant increase in complete or partial clinical resolution of phimosis compared to placebo 6.
- Paraphimosis can be treated with reduction of edema, mechanical compression, pharmacologic therapy, puncture technique, and dorsal slit, with prevention and early intervention being key elements in its management 3, 4.
- Circumcision is generally undertaken for religious practice, as a prophylactic measure, or for immediate medical indication, such as balanitis xerotica obliterans 2.