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A phimosis is a condition in which the foreskin cannot be retracted behind the glans of the penis.119 It interferes with cleaning under the foreskin, allows the accumulation of secretions and debris (i.e., smegma) under the foreskin, and may predispose the patient to infections and possible malignancy.18 It is classified into two subgroups: physiologic and pathologic. Physiologic phimoses occurs naturally in newborns. In males younger than 4 years of age, it is normal for the foreskin to not be retractable. In older boys and adults, the foreskin can usually be retracted without difficulty.1 Pathologic phimoses is the inability to retract the foreskin after it was previously retractable or after puberty, usually secondary to scarring of the foreskin. Surgical treatment 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 Current techniques for the 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 (i.e., 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. Recurrent infections such as balanitis or balanoposthitis, repeated urinary catheterization, forceful foreskin retraction, and poor hygiene can lead to scarring of preputial orifices causing a pathologic phimosis. Pathologic phimosis may also arise in diabetics due to the presence of glucose in their urine giving rise to an infection of the foreskin. 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. Some males may report painful erections, hematuria, preputial pain, or a weakened urinary stream. Other complications of a phimosis include recurrent balanitis, other local infections, urinary retention, carcinoma of the penis, and easy growth of venereal warts and other sexually transmitted diseases. It may also be due ...

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