Chapter 128

A phimosis is a condition in which the foreskin cannot be retracted behind the glans of the penis. In males younger than four years of age, it is normal for the foreskin to be unretractable. In older boys and adults, the foreskin can usually be retracted without difficulty.1 Surgical recourse for a phimosis has been known for hundreds of years.2 A Byzantine surgeon by the name of Oribasius, in the fourth century AD, gave a seemingly well-acquainted description of a technique involving forced dilation of the constrictive foreskin, scalloping out of its inner surface, then stretching it over a parchment-wrapped lead tube placed between the filleted skin and the glans.2 Techniques for management of a phimosis in the Emergency Department are simple and remain an important intervention directed to relieving urinary obstruction.

At birth there is a physiologic phimosis in the majority of male neonates. This is due to natural adhesions that exist between the foreskin and the glans of the penis. During the first 3 to 4 years of life, as the penis grows, epithelial debris (smegma) accumulates under the foreskin and gradually separates the foreskin from the glans. Intermittent penile erections aid in allowing the foreskin to eventually become retractable. The foreskin of most males will retract easily by the age of four. Forcible retraction should be categorically discouraged as this can result in scarring and constriction.1 For a nonobstructive phimosis in children, topical steroids and topical conjugated equine estrogen have shown excellent results in releasing the stubborn physiologic adhesions between the foreskin and the glans.3,4

A phimosis can be the cause of other problems or be a result of other medical conditions. Once acquired, a phimosis can become a paraphimosis if the foreskin is retracted and not promptly reduced. It can result in urinary tract infections from bacterial colonization of the phimosis or secondary to urinary obstruction. Other complications of a phimosis include recurrent balanitis, local infection, urinary retention, carcinoma of the penis, and easy growth of venereal warts and other sexually transmitted diseases. A phimosis may also be secondary to many of the disease processes just mentioned. It may also be due to local trauma (known as Tristram Shandy syndrome) or the congenital lack of conversion to a mobile foreskin.5 Penile carcinoma deserves special mention. Coexistent phimosis is seen in up to 52 percent of cases of penile carcinoma. The need for timely follow-up should be impressed upon the patient regardless of the intervention required in the Emergency Department.6

The sole indication for release of a phimosis is urinary obstruction that cannot be relieved by passing a urethral catheter.

The ability to pass a urinary catheter (Foley or coudé) into the bladder eliminates the acute need for the reduction of a phimosis. Patients with bleeding disorders, gross infections of the foreskin, who are immunocompromised, or who have lesions of the foreskin should ...

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