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.

The uncircumcised male penis comprises the penile shaft, the glans penis, the
coronal sulcus, and the foreskin/prepuce, as shown below.

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.
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

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.

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 is classically seen in one of the following populations[3, 4]

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 [5]
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.

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.
Patients with phimosis rarely require any emergency intervention and
should be referred to a urologist on an outpatient basis prior to
development of irreversible penile damage.
A paraphimosis is a urologic emergency and needs to be attended to
immediately. Many techniques of paraphimosis reduction have been
described in case studies, though none have been tested in randomized
control trials.[6] The main goal of each method is to reduce the foreskin to
its naturally occurring position over the glans penis by manipulating the
edematous glans and/or the distal prepuce. When necessary, all of the
following procedures can be facilitated by the use of local anesthesia, a
penile block[7] using lidocaine hydrochloride without epinephrine or,
especially in children, conscious sedation. Sterile technique should be used
for all invasive procedures.[8, 9]
 The authors recommend attempting to reduce the paraphimosis in the
following sequence, from least to most invasive. The urologist should be
involved early on in all cases of paraphimosis that require more than
minimally invasive methods of reduction.
Manual reduction
Manual reduction is performed by placing both index fingers on the dorsal
border of the penis behind the retracted prepuce and both thumbs on the
end of the glans. The glans is pushed back through the prepuce with the
help of constant thumb pressure while the index fingers pull the prepuce
over the glans.
This technique may be facilitated by the use of ice and/or hand
compression on the foreskin, glans, and penis to minimize edema of the
glans prior to manual reduction. Soaking the penis in a glove full of ice for
5 minutes before attempting manual reduction has been reported to be
effective 90% of the time.[6]
An elastic bandage can also be wrapped from the glans to the base of the
penis for 5-7 minutes to minimize edema.[10]
Noncrushing clamps can be placed on the constricting portion of the
foreskin at the 3- and 9-o'clock positions to apply gentle continuous
symmetrical traction.[11] Also see, Paraphimosis Reduction.
Osmotic method
Substances with a high solute concentration can be used to osmotically
draw out fluid from the edematous glans and foreskin prior to manual
reduction. Granulated sugar spread over the glans and foreskin for 2 hours
has been shown to facilitate manual reduction.[11] Alternatively, a swab
soaked in 50 mL of 50% dextrose (more readily available in the ED) can
be wrapped around the glans and foreskin for an hour prior to attempting
reduction.[11] A major drawback of these methods is that they are time
consuming.
Puncture method
This method requires the use of a 21- to 26-gauge needle to puncture
openings into the foreskin to allow edematous fluid to escape from the
puncture sites during manual compression. Successful reductions have
been reported with single and up to 20 punctures.[11]
Hyaluronidase method
The puncture method can be enhanced by the injection of 1-mL aliquots of
hyaluronidase (using a tuberculin syringe) into one or more sites of the
edematous prepuce. It is thought that hyaluronidase disperses extracellular
edema by modifying the permeability of intercellular substance in
connective tissue. The use of this method is contraindicated in those with
the presence of infection or cancer, since the technique may result in the
spread of bacteria or malignant cells. Drawbacks to this method include
the risk of anaphylaxis and shock and the lack of availability of
hyaluronidase in many EDs.
Aspiration
A tourniquet is applied to the shaft of the penis. A 20-gauge needle is then
used to aspirate 3-12 mL of blood from the glans, parallel to the urethra.
 This reduces the volume of the glans sufficiently to facilitate manual
reduction.
Vertical incision
If none of the above methods are successful, the constricting band of the
foreskin should be incised using a 1-2 cm longitudinal incision between
two straight hemostats placed in the 12-o'clock position for hemostasis.[10]
This frees the constricting ring and allows for easy reduction of the
paraphimosis. The incised margins can then be reapproximated using 4/0
nylon sutures. Also see, Dorsal Slit of the Foreskin and Nerve Block,
Dorsal Penile. (See below.)

Dorsal slit
procedure.
Emergent circumcision
This is a last resort, to be performed by a urologist, to achieve the
necessary reduction of a paraphimosis.
Up to 95% of cases of phimosis have been shown to respond to application
of topical steroids to the preputial orifice,[12] although some studies have
suggested that this response rate may decline several months after the
regimen is completed.[13] An initial attempt at medical intervention has
been shown to reduce costs by 27.3% in comparison with primary
circumcision as a treatment of phimosis in infants and children.[14]
Complications of medication use are limited to preputial pain and
hyperemia.
The ED physician may choose to recommend 0.1 -0.05% betamethasone
dipropionate applied to the preputial orifice twice a day for 4-6 weeks.[13]
Betamethasone valerate 0.1%, 0.2%, and 0.2% in combination with
hyaluronidase has also been shown to be effective. In one study, patients
 who initially had partial or no response to this regimen reached complete
response after 60 days of treatment.[15]
Anand and Kapoor reported on the use of the osmotic diuretic mannitol to
reduce paraphimosis. The procedure required no anesthesia and was
associated with minimal or no patient discomfort, according to the authors.
They compared it to multiple needle punctures and other nonosmotic
methods of reducing paraphimosis. A complete reduction of paraphimosis
occurred after mannitol-soaked gauze had been placed over the edematous
prepuce for about 30-45 minutes in 6 patients
Referral to outpatient urology follow-up is required in cases of pathologic
phimosis.[1] Not all cases of phimosis require circumcision. The urologist,
in consultation with the patient and his family, may try a course of topical
steroids or preputioplasty.
A paraphimosis that is reduced with minimal intervention by the ED
physician still requires outpatient urology follow-up in anticipation of
recurrences and evaluation for possible circumcision. Trauma to the
foreskin during reduction of a paraphimosis may lead to the development
of phimosis in up to 30% of patients