Phimosis and Paraphimosis
Summary
Phimosis is the inability to retract the foreskin over the glans penis. It is physiological (normal) in infants and young children but becomes pathological when it persists in older children or adults due to scarring (often from balanitis xerotica obliterans/BXO).
Paraphimosis is a urological emergency where the foreskin is retracted behind the glans and becomes trapped, causing venous congestion and oedema of the glans with risk of ischaemia if not reduced promptly. It is often iatrogenic (failure to replace the foreskin after catheterisation or examination).
Treatment of phimosis depends on the cause (topical steroids for mild, circumcision for BXO or recurrent balanitis), while paraphimosis requires immediate manual reduction or surgical intervention if this fails.
Key Facts
- Phimosis: Inability to retract foreskin
- Physiological: Normal <2 years; Resolves in most by puberty
- Pathological: Scarring (BXO), Recurrent balanitis
- Paraphimosis: Foreskin stuck behind glans → Oedema → Ischaemia
- Emergency: Paraphimosis requires urgent reduction
- Treatment: Steroids (phimosis), Circumcision (BXO), Manual reduction (paraphimosis)
Clinical Pearls
"Paraphimosis is an Emergency": Failure to reduce paraphimosis within hours can lead to glans necrosis.
"Always Replace the Foreskin": After catheterisation or examination, always ensure the foreskin is replaced to prevent paraphimosis.
"BXO = Circumcision": Balanitis xerotica obliterans (lichen sclerosus) is a definitive indication for circumcision.
"Ice and Sugar Shrink the Glans": Osmotic and cold techniques (ice, sugar, mannitol-soaked gauze) reduce oedema to facilitate manual reduction of paraphimosis.
Phimosis
- Normal in infancy
- 10% of boys at age 3
- 1% at age 17
Paraphimosis
- Exact incidence unknown
- Often iatrogenic
- Peak: Adolescence, Elderly (catheterisation)
Risk Factors
| Condition | Risk Factor |
|---|---|
| Phimosis | Recurrent balanitis, BXO, Poor hygiene, Diabetes |
| Paraphimosis | Failure to replace foreskin, Catheterisation, Piercing |
Phimosis
Physiological:
- Normal adherence of foreskin to glans in infancy
- Separates over time (by puberty in most)
Pathological:
- Scarring from recurrent balanitis
- Balanitis xerotica obliterans (BXO) / Lichen sclerosus — White, contracted scarring
- Forceful retraction causing scarring
Paraphimosis
- Foreskin retracted behind glans (and not replaced)
- Constricting band at coronal sulcus
- Venous congestion → Oedema of glans
- Arterial compromise (if severe/prolonged)
- Ischaemia and necrosis
Phimosis
| Feature | Description |
|---|---|
| Inability to retract foreskin | Varies from partial to complete |
| Ballooning during urination | In children (usually benign) |
| Pain | During erection, intercourse |
| Recurrent balanitis | Infection under foreskin |
| White scarring | BXO |
Paraphimosis
| Feature | Description |
|---|---|
| Swollen, oedematous glans | Boggy, congested |
| Foreskin retracted behind glans | Constricting band visible |
| Pain | Significant |
| Inability to reduce foreskin | |
| Colour change | Dusky, then ischaemic |
Phimosis
- Attempt gentle retraction (do not force)
- Look for BXO (white scarring, thickened ring)
- Look for balanitis (erythema, discharge)
Paraphimosis
- Oedematous, congested glans
- Tight band of foreskin behind corona
- Assess colour (pink = viable; dusky/black = ischaemia)
Usually Clinical Diagnosis
- No investigations required for straightforward cases
If Uncertain
| Indication | Investigation |
|---|---|
| Suspected malignancy | Biopsy |
| Recurrent balanitis | Swab for culture |
| Diabetes suspected | Blood glucose |
Phimosis Management
┌──────────────────────────────────────────────────────────┐
│ PHIMOSIS MANAGEMENT │
├──────────────────────────────────────────────────────────┤
│ │
│ PHYSIOLOGICAL (Children <2y): │
│ • Reassurance — Usually resolves │
│ • NO FORCED RETRACTION │
│ │
│ MILD PHIMOSIS: │
│ • Topical steroid cream (e.g., Betamethasone 0.05%) │
│ BD for 4-8 weeks + Gentle stretching │
│ • Success rate: 70-90% │
│ │
│ BXO / PATHOLOGICAL PHIMOSIS: │
│ • Circumcision (definitive) │
│ • Preputioplasty (alternative in selected cases) │
│ │
│ RECURRENT BALANITIS: │
│ • Treat infection (antifungal/antibiotic) │
│ • Circumcision if recurrent │
│ │
└──────────────────────────────────────────────────────────┘
Paraphimosis Management (EMERGENCY)
┌──────────────────────────────────────────────────────────┐
│ PARAPHIMOSIS MANAGEMENT │
├──────────────────────────────────────────────────────────┤
│ │
│ IMMEDIATE REDUCTION (MUST NOT DELAY): │
│ │
│ STEP 1: REDUCE OEDEMA │
│ • Apply ice │
│ • Apply granulated sugar (osmotic) │
│ • Compress glans firmly for 5-10 minutes │
│ │
│ STEP 2: MANUAL REDUCTION │
│ • Apply topical local anaesthetic (Instillagel) │
│ • Squeeze glans firmly with both hands │
│ • While squeezing, push glans back through foreskin │
│ • May need penile block for analgesia │
│ │
│ IF MANUAL REDUCTION FAILS: │
│ • Dorsal slit (cut foreskin dorsally under LA) │
│ • Releases constriction │
│ • Followed by circumcision later │
│ │
│ POST-REDUCTION: │
│ • Replace foreskin completely │
│ • Discuss future circumcision (prevent recurrence) │
│ │
└──────────────────────────────────────────────────────────┘
Of Phimosis
- Recurrent balanitis
- Urinary retention (rare)
- Paraphimosis (if partially retracted)
Of Paraphimosis
- Glans necrosis (if not reduced)
- Gangrene
- Urethral damage
Of Treatment
- Circumcision: Bleeding, Infection, Cosmetic
- Dorsal slit: May require circumcision later
Phimosis
- Physiological: Resolves in most by puberty
- Pathological: Excellent outcomes with circumcision
Paraphimosis
- Excellent if reduced early
- Poor if delayed (ischaemia, tissue loss)
Key Guidelines
- EAU: Paediatric Urology Guidelines
- BAUS: Guidance on Foreskin Problems
Key Evidence
Topical Steroids
- Effective for mild phimosis; avoids surgery in 70-90%
What is Phimosis?
Phimosis is when the foreskin cannot be pulled back over the head of the penis. This is normal in young children but can be a problem if it persists into adulthood or causes symptoms.
What is Paraphimosis?
Paraphimosis is when the foreskin gets stuck behind the head of the penis and becomes swollen. This is an emergency because it can cut off blood supply to the tip of the penis.
How is Phimosis Treated?
- Steroid creams often work
- Circumcision (removal of the foreskin) if cream doesn't work or if there is scarring
How is Paraphimosis Treated?
- The swelling must be reduced and the foreskin pushed back into place immediately
- If this doesn't work, a small cut may be made to release it
When Should I Seek Help?
- If the foreskin cannot be returned to its normal position after being pulled back
- Pain, swelling, or colour change of the penis
Primary Guidelines
- European Association of Urology. EAU Guidelines on Paediatric Urology. 2023.
- British Association of Urological Surgeons. Foreskin Information.
Key Studies
- Morales Concepción JC, et al. Topical steroids for phimosis. J Urol. 2016. PMID: 18423764