Phimosis and Paraphimosis

What is Phimosis?

Phimosis is a medical condition in which a male is unable to retract the foreskin covering the head of the penis.1  Phimosis is classified into two separate conditions: pathological phimosis and physiological phimosis. We will elaborate on their differences later on. Being able to differentiate between the conditions is crucial as they differ in their approach to treatment.2 Phimosis can typically appear as a tight ring or band around the head of the penis that prevents the foreskin from being retracted.

Symptoms

  • Difficulty retracting the foreskin
  • Inability to pull the foreskin behind the glans (head) of the penis
  • General pain or discomfort
  • Redness of the foreskin and/or penis
  • Pain or discomfort during sexual activity
  • Decreased or weakened urine stream
  • Painful urination 

Diagnosis

An accurate diagnosis can be made during a physical examination performed by a medical professional.

Causes

Physiological phimosis can be normal for uncircumcised males in their early childhood. The foreskin or prepuce is a thin layer of skin that typically extends about 1cm beyond the glans penis. Separation of the foreskin from the glans happens gradually and begins during gestation, but remains incomplete at birth. The foreskin is typically fused at birth by a thin membrane known as the synechia to the head of the penis. During toddler years or early childhood, this natural adhesion will begin to break down and the prepuce will differentiate from the head of the penis. This condition is normal as only around 4% of males are born with a fully retracted foreskin, and roughly 50% of newborn males are born with foreskin that cannot be retracted far enough to visualize the urethra.3 In order for full retraction to occur, the widening of the foreskin must occur. 2   In early childhood, the opening of the foreskin typically remains tight and non-elastic in order to protect the developing penis.7 Full retraction occurs naturally after recurrent erections and hardening of the skin caused by keratinization into pubescent years. This illustrates that even retractable foreskins are not always fully retractable at young age as some males at the age of 6 still show signs of foreskin adhesion and full retraction typically will occur after the age of 10. 3

Acquired or pathological phimosis, on the other hand, is rare and occurs later in life and can be caused by a variety of conditions, including scarring, inflammation, and infection of the prepuce. Pathological phimosis typically does not resolve naturally and is linked to certain complications such as irritation and/or bleeding of the penis, ballooning of the foreskin during urination that causes painful or forced urination, painful erections, recurrent urinary tract infections, paraphimosis or recurrent infections of the foreskin.1

Treatment and Prevention

Treatment for physiological phimosis is minimal, as the condition is normal for young males. The majority of patients seen for tight foreskin issues have physiological phimosis and are assured of the commonness of their condition. Caring for the uncircumcised penis requires minimal effort in early infancy, as the foreskin should never be forcefully retracted. Forceful retraction of the foreskin may cause small tears that can lead to scarring and more serious foreskin problems. Once the foreskin becomes retractable with age, caring for the uncircumcised penis is simple and only requires gently retracting of the foreskin when urinating and bathing. The foreskin should be washed with warm soapy water and dried with a clean towel. It is important to return the foreskin to its original position over the glans post-cleaning in order to avoid acquiring paraphimosis.

Proper hygiene is essential to avoid phimosis as well as the build-up of smegma. Smegma is a whitish substance that is found on the head of the penis and under the foreskin and is composed of skin cells and oils.4 While usually harmless, if  it is not cleaned properly and allowed to accumulate, smegma can cause complications. Conditions related to physiologic phimosis include cysts related to the build-up of smegma. Brief and painless “ballooning” of the prepuce during urination is also common. Ballooning occurs when the foreskin separates from the head of the penis but the opening in the foreskin remains narrow. This causes the urine to fill up the empty between the glans and the foreskin during urination.7 These are normal and benign variations of physiological phimosis and resolve naturally with gentle retraction and cleansing of the foreskin. Treatment of physiological phimosis is very similar to daily hygiene care and usually requires no further interventions. Patients may be prescribed a low dose corticosteroid to speed up the process, but is usually not necessary.2

Treatment for pathological phimosis may vary and patients are typically referred to a urology specialist for proper evaluation and treatment. It is essential to visit a physician for treatment and diagnosis if phimosis does not resolve naturally with gentle retractions and cleaning, as this may be an indication of pathological phimosis.  Topical corticosteroids can also be used for pathological phimosis and requires treatment twice daily for up to six-eight weeks to work effectively. Circumcision of the foreskin is typically not required but may be recommended by a urologist if other treatment options fail to work. Circumcision is a medical process that involves removal of the foreskin.

What is Paraphimosis?

Paraphimosis warrants immediate action and is considered a urological emergency. Paraphimosis occurs when the foreskin is extremely tight and becomes trapped behind the corona, often causing a tight band to form that constricts blood flow to the area.5

Symptoms

•    Extremely tight foreskin

•    Inability to pull the foreskin behind the glans of the penis

•    Extreme pain or discomfort

•    Difficulty urinating or pain during urination

•    Foreskin becomes stuck and will not return (easily or at all) to its original position

•    Swelling (edema) of the foreskin or penis

Diagnosis

An accurate diagnosis can be made during a physical examination performed by a medical professional.

Causes

Paraphimosis is far less common than phimosis and is usually iatrogenic in etiology (i.e., occurs after a medical procedure or examination).  Common causes of paraphimosis include installations of catheters, penile examinations, or cystoscopy (i.e., an endoscopy of the bladder through the urethra6). The most common cause is by installation of a catheter, a small tube placed inside the urethra that usually aids with urinary problems. The foreskin is typically retracted for this procedure and paraphimosis may occur if the foreskin is not retracted to its original position.  Less common causes of paraphimosis include self-injury to the penis or prolonged penile erections.

 

Treatment

Treatment for paraphimosis requires urgent medical attention. The primary purpose of treatment is to reduce the swelling of the penis and to return the prepuce back to its original position. Topical analgesics or oral narcotics may be required to avoid pain from treatment. Treatment options may vary and can include applying manual pressure and ice to the penis, pharmaceutical interventions, and puncture techniques that involve creating a minimally invasive puncture wound to allow the dissemination of built-up fluid. Other treatments are possible, but it is imperative to seek medical attention immediately to avoid any trauma to the penile tissue. 5

References

1. "Phimosis." UCSF Department of Urology. N.p., n.d. Web. 18 Apr. 2016.

2. McGregor, Thomas B., John G. Pike, and Michael P. Leonard. "Pathologic and Physiologic Phimosis: Approach to the Phimotic Foreskin." Canadian Family Physician. College of Family Physicians of Canada, n.d. Web. 18 Apr. 2016.

3. Duncan Wilcox, MD. "Care of the Uncircumcised Penis." Care of the Uncircumcised            Penis. N.p., n.d. Web. 18 Apr. 2016.

4. Cashin-Garbutt, April. "What Is Smegma?" News Medical. N.p., n.d. Web. 18 Apr. 2016.

5. Choe, Jong M., MD. "Paraphimosis: Current Treatment Options." - American Family Physician. N.p., n.d. Web. 18 Apr. 2016.

6. "Urology Care Foundation - What Is Cystoscopy?" Urology Care Foundation - What Is Cystoscopy? N.p., n.d. Web. 18 Apr. 2016.

7. Coias, Jennifer. "Peaceful Parenting: Ballooning in the Intact Child." Peaceful Parenting: Ballooning in the Intact Child. N.p., 2011. Web. 31 May 2016.

Last Updated 18 April 2016. 

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