Phimosis and Paraphimosis In the ED Clinical Presentation

Updated: Oct 06, 2022
  • Author: Hina Z Ghory, MD; Chief Editor: Gil Z Shlamovitz, MD, FACEP  more...
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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 below.)

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 below.)

Paraphimosis. Paraphimosis.

Paraphimosis is classically seen in one of the following populations [24, 25]

  • 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 [26]

  • 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.



Phimosis includes the following:

  • 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.

Paraphimosis includes the following:

  • The foreskin is retracted behind the glans penis and cannot 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.