Phimosis and Paraphimosis

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management

Definition

  • Phimosis: inability to retract the foreskin over the glans penis due to tightness.
  • Paraphimosis: a urological emergency where the retracted foreskin becomes trapped behind the glans, leading to oedema and potential vascular compromise.

Aetiology

Phimosis:

  • Physiological: normal in young boys; resolves by age 5-7 years.
  • Pathological: secondary to scarring, infection, or chronic inflammation (e.g., balanitis xerotica obliterans).

Paraphimosis:

  • Occurs when the foreskin is forcibly retracted and left in position.
  • May be caused by improper catheterisation, penile trauma, or chronic inflammation.

Pathophysiology

Phimosis:

  • Chronic inflammation or scarring leads to loss of foreskin elasticity.
  • Repeated infections can worsen the narrowing.

Paraphimosis:

  • Retracted foreskin constricts the penile shaft, impairing lymphatic and venous drainage.
  • Progressive oedema develops, leading to arterial compression and potential ischaemia.

Risk Factors

  • Poor hygiene.
  • Recurrent balanitis (inflammation of the glans).
  • Diabetes mellitus (predisposes to infections).
  • Previous forceful foreskin retraction.
  • Indwelling urinary catheters.
  • Penile trauma.

Signs and Symptoms

Phimosis:

  • Difficulty retracting the foreskin.
  • Ballooning of the foreskin during urination.
  • Recurrent infections (balanitis, urinary tract infections).
  • Discomfort or pain during erections.

Paraphimosis:

  • Painful, swollen glans with a tight, constricting band of foreskin.
  • Dark or discoloured glans (indicating ischaemia).
  • Inability to return the foreskin to its normal position.
  • Urinary retention (in severe cases).

Investigations

  • Clinical diagnosis: based on physical examination.
  • Urine dipstick: if urinary symptoms suggest infection.
  • Blood glucose: consider in recurrent balanitis (to screen for diabetes).

Management

1. Phimosis:

  • Topical corticosteroids: betamethasone 0.05% cream applied twice daily for 4–6 weeks.
  • Gentle manual stretching: encourage gradual foreskin retraction.
  • Hygiene advice: cleanse under the foreskin regularly once retractable.
  • Circumcision: indicated for persistent symptomatic cases or recurrent balanitis.
  • Preputioplasty: a less invasive surgical alternative to circumcision.

2. Paraphimosis (Urological Emergency):

  • Manual reduction:
    • Apply cold compress to reduce oedema.
    • Use local anaesthetic gel.
    • Gently compress the glans while pulling the foreskin forward.
  • Osmotic methods: apply sugar solution or soaked gauze to reduce swelling.
  • Needle puncture technique: if manual reduction fails, multiple small punctures in the oedematous foreskin allow drainage.
  • Dorsal slit procedure: considered if paraphimosis is severe and reduction is unsuccessful.
  • Elective circumcision: offered after resolution to prevent recurrence.

3. Complication Management:

  • Treat infections promptly with antibiotics if balanitis is present.
  • Address underlying causes, such as diabetes control in recurrent cases.

4. Lifestyle and Prevention:

  • Avoid forceful foreskin retraction in children.
  • Educate patients on proper penile hygiene.
  • Consider circumcision for recurrent infections or scarring.
RenalmypanotesPhimosis and Paraphimosis