Phimosis

Aka: Phimosis, Tight Foreskin, Foreskin Stenosis, Physiologic Phimosis, Foreskin Does Not Retract

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II. Definitions

  1. Phimosis
    1. Foreskin Stenosis prevents retraction over glans penis
    2. Contrast with the emergency Paraphimosis in which the foreskin cannot be reduced

III. Causes

  1. Physiologic Phimosis
    1. Phimosis is normal in infants
      1. Normal foreskin (preputial skin)
      2. Resolves spontaneously in most boys by age 3-4 years of age
      3. Forced retraction in this age group can result in a Paraphimosis (emergency)
    2. School age (age>3-4 years): 90% of boys can fully retract foreskin
    3. Puberty: 99% of boys can fully retract foreskin
  2. Pathologic Causes of distal prepuce scarring
    1. Trauma
    2. Dermatitis
    3. Balanitis

IV. Signs

  1. Unable to retract foreskin over glans penis

V. Complications

  1. Urine obstruction with urine retention
  2. Balanitis
  3. Dyspareunia in males
  4. Pain on Erection
  5. Urinary Tract Infection

VI. Management

  1. Treat Balanitis or Balanoposthitis if present
  2. Emergent Temporizing measures until Urology evaluation (cases of Urinary Retention)
    1. Foreskin Dilation (Hemostat)
    2. Foley Catheter
    3. Dorsal slit cut at 12:00 (similar approach to initial step in Circumcision)
      1. Performed under Dorsal Penile Nerve Block
      2. Apply clamp at 12:00 position (dorsal penis) to allow for Hemostasis
      3. Remove clamp and cut the crushed tissue with sterile scissor
  3. Emergent Urology referral indications
    1. Urinary Retention (urinary obstruction) refractory to above (unable to void)
    2. Associated Cellulitis of foreskin
  4. Topical Corticosteroids
    1. Indications
      1. Persistent Phimosis in age >=5 years
    2. Protocol (using a Class IV Topical Corticosteroid)
      1. Triamcinolone Acetonide (Kenalog) 0.1% cream applied twice daily for 4 to 8 weeks
    3. Efficacy of 4 to 8 weeks of treatment
      1. Complete resolution (NNT 5) or partial resolution (NNT 11)
      2. Longstanding resolution >6 months after treatment (NNT 3)
    4. References
      1. Moreno (2024) Cochrane Database Syst Rev 1(1):CD008973 +PMID: 38269441 [PubMed]
  5. Circumcision indications
    1. Persistent or recurrent Phimosis
    2. Recurrent Balanoposthitis or Balanitis

VII. References

  1. Herman and Arhancet (2020) Crit Dec Emerg Med 34(10): 17-21
  2. Majoewsky (2012) EM:Rap-C3 2(9): 2
  3. Lundquist (2001) Emerg Med Clin North Am 19(3):529-46 [PubMed]

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