What is the difference between phimosis and paraphimosis in terms of symptoms, treatment, and management?

Phimosis vs Paraphimosis: Key Differences

Phimosis is the inability to retract the foreskin over the glans penis, while paraphimosis is a urologic emergency where the retracted foreskin becomes trapped behind the corona and cannot be returned to its normal position. 1, 2

Phimosis

Definition and Presentation

• Phimosis is characterized by inability to fully retract the foreskin over the glans penis, which may lead to painful erections, erectile dysfunction, and urinary issues 1
• Presents with tightening of the foreskin, difficulty with retraction, and potential ballooning during urination in children 3, 1
• Can cause discomfort during sexual activity, painful erections, and changes in urinary stream 1, 4

Causes

• Approximately 30% of adult phimosis cases are caused by lichen sclerosus 1
• Other causes include chronic inflammation, balanitis, penile trauma, and poor hygiene 1
• Physiologic phimosis in children is normal and usually resolves by age 16 years 4

Treatment Approach

• First-line treatment is topical corticosteroid therapy with clobetasol propionate 0.05% ointment applied once daily for 1-3 months to the tight preputial ring 3, 5
• For children, use betamethasone 0.05% ointment twice daily for 4-6 weeks 3
• Use an emollient as both soap substitute and barrier preparation during treatment 3, 5
• If topical steroids fail after 1-3 months, circumcision is indicated 3, 5
• Phimosis caused by lichen sclerosus may be less responsive to topical steroids and have higher likelihood of requiring surgical intervention 3, 1

Paraphimosis

Definition and Presentation

• Paraphimosis is a urologic emergency where the foreskin becomes trapped behind the corona, forming a tight constricting band of tissue 2, 4
• The tight ring of preputial skin acts like a tourniquet, causing vascular occlusion and edema of the glans 6
• Presents as a painful, swollen glans with inability to return the foreskin to its normal position 6, 2
• If not treated quickly, can lead to necrosis of the glans 6

Causes

• Often iatrogenically induced when the prepuce is not returned to cover the glans following penile manipulation (catheterization, examination, sexual activity) 2
• Can occur in uncircumcised or incompletely circumcised males 2, 7
• Untreated phimosis increases the risk of developing paraphimosis 1

Treatment Approach

• Treatment begins with immediate manual reduction after edema reduction 2, 4
• Apply ice packs and manual compression to reduce edema distal to the constricting ring 2, 7
• 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 manual reduction 7
• If manual reduction fails, perform dorsal slit procedure followed by subsequent circumcision 6, 8
• Prevention is key: always return the prepuce to cover the glans following any penile manipulation 2

Critical Distinctions

Urgency

• Phimosis is a chronic condition that can be managed electively with medical therapy 3, 1
• Paraphimosis is a urologic emergency requiring immediate intervention to prevent glans necrosis 6, 2, 4

Direction of Problem

• Phimosis: foreskin cannot be retracted backward over the glans 1, 8
• Paraphimosis: foreskin is retracted and cannot be returned forward to its normal position 2, 8

Complications

• Phimosis complications: painful erections, sexual dysfunction, urinary obstruction, increased risk of penile cancer (2-9% with lichen sclerosus) 1
• Paraphimosis complications: glans necrosis, urinary obstruction, irreversible tissue damage if not promptly treated 6, 2

Common Pitfalls

• Many phimosis patients are referred for circumcision without an adequate trial of topical steroids 3
• Always consider lichen sclerosus as a cause of phimosis, especially if resistant to treatment 3, 1
• Failure to return the foreskin to its normal position after catheterization or examination is the most common cause of iatrogenic paraphimosis 2
• If circumcision is performed for either condition, always send the foreskin for histological examination to exclude penile intraepithelial neoplasia 3, 1