II. Definitions
- Phimosis
- Foreskin Stenosis prevents retraction over glans penis
- Contrast with the emergency Paraphimosis in which the foreskin cannot be reduced
III. Causes
- Physiologic Phimosis
- Phimosis is normal in infants
- Normal foreskin (preputial skin)
- Resolves spontaneously in most boys by age 3-4 years of age
- Forced retraction in this age group can result in a Paraphimosis (emergency)
- School age (age>3-4 years): 90% of boys can fully retract foreskin
- Puberty: 99% of boys can fully retract foreskin
- Phimosis is normal in infants
- Pathologic Causes of distal prepuce scarring
IV. Signs
- Unable to retract foreskin over glans penis
V. Complications
- Urine obstruction with urine retention
- Balanitis
- Dyspareunia in males
- Pain on Erection
- Urinary Tract Infection
VI. Management
- Treat Balanitis or Balanoposthitis if present
- Emergent Temporizing measures until Urology evaluation (cases of Urinary Retention)
- Foreskin Dilation (Hemostat)
- Foley Catheter
- Dorsal slit cut at 12:00 (similar approach to initial step in Circumcision)
- Performed under Dorsal Penile Nerve Block
- Apply clamp at 12:00 position (dorsal penis) to allow for Hemostasis
- Remove clamp and cut the crushed tissue with sterile scissor
- Emergent Urology referral indications
- Urinary Retention (urinary obstruction) refractory to above (unable to void)
- Associated Cellulitis of foreskin
-
Topical Corticosteroids
- Indications
- Persistent Phimosis in age >=5 years
- Protocol (using a Class IV Topical Corticosteroid)
- Triamcinolone Acetonide (Kenalog) 0.1% cream applied twice daily for 4 to 8 weeks
- Efficacy of 4 to 8 weeks of treatment
- Complete resolution (NNT 5) or partial resolution (NNT 11)
- Longstanding resolution >6 months after treatment (NNT 3)
- References
- Indications
-
Circumcision indications
- Persistent or recurrent Phimosis
- Recurrent Balanoposthitis or Balanitis
VII. References
- Herman and Arhancet (2020) Crit Dec Emerg Med 34(10): 17-21
- Majoewsky (2012) EM:Rap-C3 2(9): 2
- Lundquist (2001) Emerg Med Clin North Am 19(3):529-46 [PubMed]
