What are the treatments for paraphimosis and phimosis?

Treatment of Phimosis and Paraphimosis

Phimosis Treatment

Topical steroid therapy is the first-line treatment for phimosis, with circumcision reserved only for cases that fail medical management. 1

Initial Medical Management

• Apply clobetasol propionate 0.05% ointment once daily for 1-3 months directly to the tight preputial ring in adult males 1
• For children, use betamethasone 0.05% ointment twice daily for 4-6 weeks applied to the constricting band 1
• Use an emollient as both soap substitute and barrier preparation throughout treatment 1
• If improvement occurs but resolution is incomplete, continue treatment for an additional 2-4 weeks 1

Critical Diagnostic Consideration

• Always evaluate for lichen sclerosus (LS) as the underlying cause, particularly if white scarred areas are present or if the condition resists treatment 1, 2
• LS-related phimosis is less responsive to topical steroids and has higher likelihood of requiring surgical intervention 1

When Medical Management Fails

• Circumcision is indicated only after an adequate 1-3 month trial of topical steroids fails 1
• Many patients are inappropriately referred for circumcision without proper medical trial—this is a common pitfall to avoid 1
• All removed foreskin tissue must be sent for histological examination to exclude penile intraepithelial neoplasia and confirm diagnosis 1, 2

Long-Term Management

• For recurrence, repeat the topical steroid course for 1-3 months 1
• Patients with ongoing LS typically require 30-60g of clobetasol propionate 0.05% ointment annually for maintenance 1, 2
• Long-term clobetasol use in appropriate doses is safe without significant steroid-related damage 1

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Paraphimosis Treatment

Paraphimosis is a urologic emergency requiring immediate manual reduction; if this fails, surgical dorsal slit is necessary to prevent glans necrosis. 3

Immediate Manual Reduction Technique

• Compress the edematous glans to express fluid distally, then manually reposition the foreskin over the glans 4, 5
• Apply ice packs or compressive elastic bandages to reduce edema prior to reduction attempt 6
• Multiple puncture technique: Use an 18-gauge needle to puncture the edematous foreskin at multiple sites, followed by gentle manual compression to rapidly diminish swelling and permit reduction 6

Surgical Management for Failed Reduction

• Perform dorsal slit procedure when manual reduction fails or in cases with significant swelling or prolonged duration 3, 4
• The dorsal slit relieves the constricting ring and is typically followed by elective circumcision after inflammation resolves 3, 7
• This is classified as an emergency surgical condition that should not be postponed 3

Prevention of Recurrence

• Consider topical steroid therapy (betamethasone 0.05% ointment twice daily for 4-6 weeks) for patients with recurrent episodes or underlying phimosis 3
• Elective circumcision provides definitive management for recurrent paraphimosis 3
• Patients with underlying lichen sclerosus have higher likelihood of requiring surgical intervention and are less responsive to conservative measures 3
• If circumcision is performed in LS patients, continue topical corticosteroids postoperatively to prevent Koebnerization and further scarring 3

Common Pitfalls

• Paraphimosis occurs predominantly when phimosis is the underlying condition, affecting infants, toddlers, and elderly men with persistent or secondary phimosis 5
• Prompt treatment is essential as delayed intervention can lead to glans necrosis, urinary obstruction, or partial amputation 4, 8
• Consider penile piercing as a possible cause in young adults 3