eMedicine Specialties > Emergency Medicine > Genitourinary

Phimosis and Paraphimosis

Author: Hina Z Ghory, MD, Chief Resident Physician, Department of Emergency Medicine, New York Presbyterian Hospital
Coauthor(s): Rahul Sharma, MD, MBA, Instructor in Medicine, Weill Medical College of Cornell University; Consulting Staff, Department of Emergency Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center
Contributor Information and Disclosures

Updated: Apr 29, 2009

Introduction

Background

Phimosis refers to the inability to retract the distal foreskin over the glans penis. Physiologic phimosis occurs naturally in newborn males. Pathologic phimosis defines an inability to retract the foreskin after it was previously retractible or after puberty, usually secondary to distal scarring of the foreskin.

Paraphimosis is the entrapment of a retracted foreskin behind the coronal sulcus. Paraphimosis is a disease of uncircumcised or partially circumcised males.

Pathophysiology

The uncircumcised males penis comprises the penile shaft, the glans penis, the coronal sulcus, and the foreskin/prepuce. (See Media file 1.)

Anatomy of the penis.

Anatomy of the penis.

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Anatomy of the penis.

Anatomy of the penis.


 
Physiologic phimosis results from adhesions between the epithelial layers of the inner prepuce and glans. These adhesions spontaneously dissolve with intermittent foreskin retraction and erections, so that as males grow, physiologic phimosis resolves with age.

Poor hygiene and recurrent episodes of balanitis or balanoposthitis lead to scarring of preputial orifices, leading to pathologic phimosis. Forceful retraction of the foreskin leads to microtears at the preputial orifice that also leads to scarring and phimosis. Elderly persons are at risk of phimosis secondary to loss of skin elasticity and infrequent erections.

Patients with phimosis, both physiologic and pathologic, are at risk for developing paraphimosis when the foreskin is forcibly retracted past the glans and/or the patient or caretaker forgets to replace the foreskin after retraction. Penile piercings increase the risk of developing paraphimosis if pain and swelling prevent reduction of a retracted foreskin.

With time, impairment of venous and lymphatic flow to the glans leads to venous engorgement and worsening swelling. As the swelling progresses, arterial supply is compromised, leading to penile infarction/necrosis, gangrene, and eventually, autoamputation.

Frequency

United States

Up to 10% of males will have physiologic phimosis at 3 years of age, and a larger percentage of children will have only partially retractible foreskins. One to five percent of males will have nonretractible foreskins by age 16 years.1,2

Race

No known racial predilection exists for phimosis and paraphimosis.

Sex

Phimosis and paraphimosis affects males only.

Age

Phimosis and paraphimosis can occur at any age.

Clinical

History

  • Parents of patients with physiologic phimosis may bring in the patient after noting an inability to retract the foreskin during routine cleaning or bathing. Parents may also be alarmed by "ballooning" of the prepuce during urination — a normal finding.
  • Pathologic phimosis may be detected in males who report painful erections, hematuria, recurrent urinary tract infections, preputial pain, or a weakened urinary stream. (See Media file 2.)
Physiologic phimosis versus pathologic phimosis.

Physiologic phimosis versus pathologic phimosis.

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Physiologic phimosis versus pathologic phimosis.

Physiologic phimosis versus pathologic phimosis.

  • Paraphimosis classically presents with a painful, swollen glans penis in the uncircumcised or partially circumcised patient. A preverbal infant may present only with irritability. Occasionally, the paraphimosis may be an incidental finding noted by a caretaker of a debilitated patient. (See Media file 3.)
Paraphimosis.

Paraphimosis.

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Paraphimosis.

Paraphimosis.

  • Paraphimosis is classically seen in one of the following populations:3
    • Children whose foreskins have been forcefully retracted or who forget to reduce their foreskin after voiding or bathing
    • Adolescents or adults who present with paraphimosis in the setting of vigorous sexual activity
    • Men with chronic balanoposthitis
    • Patients with indwelling catheters in whom caretakers forget to replace the foreskin after catheterization or cleaning
  • Urinary obstruction is a late feature.

Physical

  • Phimosis
    • The foreskin cannot be retracted proximally over the glans penis.
    • In physiologic phimosis, the preputial orifice is unscarred and healthy appearing.
    • In pathologic phimosis, a contracted white fibrous ring may be visible around the preputial orifice
Physiologic phimosis versus pathologic phimosis.

Physiologic phimosis versus pathologic phimosis.

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Physiologic phimosis versus pathologic phimosis.

Physiologic phimosis versus pathologic phimosis.

  • Paraphimosis
    • The foreskin is retracted behind the glans penis and can not be replaced to its normal position.
    • The foreskin forms a tight, constricting ring around the glans.
    • Flaccidity of the penile shaft proximal to the area of paraphimosis is seen (unless there is accompanying balanoposthitis or infection of the penis).
    • With time, the glans becomes increasingly erythematous and edematous.
    • The glans penis is initially its normal pink hue and soft to palpation. As necrosis develops, the color changes to blue or black and the glans becomes firm to palpation.

More on Phimosis and Paraphimosis

Overview: Phimosis and Paraphimosis
Differential Diagnoses & Workup: Phimosis and Paraphimosis
Treatment & Medication: Phimosis and Paraphimosis
Follow-up: Phimosis and Paraphimosis
Multimedia: Phimosis and Paraphimosis
References
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References

  1. McGregor TB, Pike JG, Leonard MP. Pathologic and physiologic phimosis: approach to the phimotic foreskin. Can Fam Physician. Mar 2007;53(3):445-8. [Medline].

  2. Tews M, Singer JI. Paraphimosis: Definition, pathophysiology, and clinical features. www.utdol.com [database online]. UpToDate Online; 9/20/2008. Updated 6/11/2008.

  3. Lundquist ST, Stack LB. Diseases of the foreskin, penis, and urethra. Emerg Med Clin North Am. Aug 2001;19(3):529-46. [Medline].

  4. Choe JM. Paraphimosis: current treatment options. Am Fam Physician. Dec 15 2000;62(12):2623-6, 2628. [Medline].

  5. Little B, White M. Treatment options for paraphimosis. Int J Clin Pract. May 2005;59(5):591-3. [Medline].

  6. Palmer LS, Palmer JS. The efficacy of topical betamethasone for treating phimosis: a comparison of two treatment regimens. Urology. Jul 2008;72(1):68-71. [Medline].

  7. Atilla MK, Dundaroz R, Odabas O. A nonsurgical approach to the treatment of phimosis: local nonsteroidal anti-inflammatory ointment application. J Urol. Jul 1997;158(1):196-7. [Medline].

  8. Brendler, CB. Evaluation of the urologic patient. In: Walsh PC, et al, eds. Campbell's Urology. 7th ed. Philadelphia, Pa: WB Saunders Co; 1997:1-142.

  9. DeVries CR, Miller AK, Packer MG. Reduction of paraphimosis with hyaluronidase. Urology. Sep 1996;48(3):464-5. [Medline].

  10. Elder JS. Congenital anomalies of the genitalia. In: Walsh PC, et al, eds. Campbell's Urology. 7th ed. Philadelphia, Pa: WB Saunders Co; 1997.

  11. Gairdner D. The fate of the foreskin, a study of circumcision. Br Med J. Dec 24 1949;2(4642):1433-7, illust. [Medline].

  12. Green M, Stange GR. Paraphimosis reduction. In: Henretig FM, King C, eds. Textbook of Pediatric Emergency Procedures. Baltimore, Md: 1997:1007-10.

  13. Hamdy FC, Hastie KJ. Treatment for paraphimosis: the 'puncture' technique. Br J Surg. Oct 1990;77(10):1186. [Medline].

  14. Imamura E, ALIA. Phimosis of infants and young children in Japan. Acta Paediatr Jpn. Aug 1997;39(4):403-5. [Medline].

  15. Jones SA, Flynn RJ. An unusual (and somewhat piercing) cause of paraphimosis. Br J Urol. Nov 1996;78(5):803-4. [Medline].

  16. Kerwat R, Shandall A, Stephenson B. Reduction of paraphimosis with granulated sugar. Br J Urol. Nov 1998;82(5):755. [Medline].

  17. Litzky GM. Reduction of paraphimosis with hyaluronidase. Urology. Jul 1997;50(1):160. [Medline].

  18. Monsour MA, Rabinovitch HH, Dean GE. Medical management of phimosis in children: our experience with topical steroids. J Urol. Sep 1999;162(3 Pt 2):1162-4. [Medline].

  19. O'Donnell, JA II. Phimosis and paraphimosis. In: Barkin RM, et al, eds. Pediatric Emergency Medicine. 2nd ed. St Louis, Mo: Mosby; 1997:1152-3.

  20. Oster J. Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child. Apr 1968;43(228):200-3. [Medline].

  21. Treatment of Paraphimosis. Available at http://forum.doctissimo.fr/doctissimo/Prepuce-et-phimosis/cicatrice-operation-sujet_301_1.htm. Accessed October 21, 2008.

  22. Waseem M, Devas G. Photo Quiz. Resident and Staff Physician [serial online]. June 2007;53(6):Accessed October 21, 2008. Available at http://www.residentandstaff.com/issues/articles/2007-06_09.asp.

  23. Williams JC, Morrison PM, Richardson JR. Paraphimosis in elderly men. Am J Emerg Med. May 1995;13(3):351-3. [Medline].

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Further Reading

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Keywords

phimosis, paraphimosis, congenital phimosis, acquired phimosis, physiologic phimosis, pathologic phimosis, entrapment of a retracted foreskin, uncircumcised penis, incorrectly circumcised penis, foreskin, glans penis, balanitis, balanoposthitis, dorsal slit of foreskin

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Contributor Information and Disclosures

Author

Hina Z Ghory, MD, Chief Resident Physician, Department of Emergency Medicine, New York Presbyterian Hospital
Hina Z Ghory, MD is a member of the following medical societies: American Medical Women's Association and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Rahul Sharma, MD, MBA, Instructor in Medicine, Weill Medical College of Cornell University; Consulting Staff, Department of Emergency Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center
Rahul Sharma, MD, MBA is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St. Barnabas Hospital
Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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