Chapter 149. Phimosis Reduction

A phimosis is a condition in which the foreskin cannot be retracted behind the glans of the penis.1–19 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 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% 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 the surgical release of a phimosis is urinary obstruction that cannot be relieved by passing a urethral catheter. A dorsal slit of the foreskin should be performed only after failure of noninvasive techniques. Most patients with a phimosis rarely require any emergency intervention and should be referred to a Urologist on an outpatient basis.

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 have a urinary catheter placed into the bladder rather than an incision of the phimotic foreskin. If a catheter cannot be inserted into the urethra in these patients, a Urologist should be consulted prior to any invasive procedures. Patients with a nonobstructing phimosis should be referred for an elective circumcision and not have a dorsal slit procedure.

• Povidone iodine or chlorhexidine solution
• Gauze squares
• Sterile drapes
• 1% lidocaine without epinephrine
• Lidocaine Uro-jet
• 27 gauge needle
• 5 mL syringes
• Hemostats, straight or straight Kelly clamps
• Urinary catheters (Foley, coudé)
• Sterile gloves
• Sterile drapes
• Scissors
• #15 scalpel blade on a handle
• 3-0 or 4-0 chromic catgut or Vicryl on a noncutting needle
• Needle driver
• Petrolatum gauze
• 1 to 2 inch bandage
• Topical antibacterial ointment

The use of tissue glue of the type normally found in Emergency Departments has been studied in children undergoing circumcision.7 It was shown to increase infection, bleeding, and wound dehiscence when compared to suture. The use of suture must be recommended at this time to close the wound edges.

Explain the benefits, risks, potential complications, and aftercare of the procedure to the patient and/or their representative. An informed consent should be obtained and placed in the medical record.

Place the patient supine with their genitalia exposed. Prepare the penis for any intervention. Clean the penis of any dirt, debris, and discharge. Apply drapes to isolate the penis. Apply povidone iodine or chlorhexidine solution onto the penis. If possible, apply the solution under the foreskin using a cotton-tipped applicator if necessary. If the patient has pain in the area of the foreskin, or if a procedure other than catheter insertion is to be performed, the penis should be anesthetized. Refer to Chapter 146 for the complete details regarding penile anesthesia. Alternatively, infiltration of local anesthetic solution can be used to anesthetize the foreskin. Draw up 5 mL of local anesthetic solution without epinephrine into a syringe armed with a 27 gauge needle. Inject a subcutaneous wheal of local anesthetic solution 2 cm proximal to the distal end of the foreskin. Continue subcutaneous infiltration circumferentially around the penis with the local anesthetic solution. The patient may require intravenous sedation or procedural sedation prior to the injection of local anesthetic solution into the penis.

The use of topical anesthetics such as lidocaine jelly, prilocaine creams, or combinations (EMLA, LET, and LAT) is not recommended.8 The application of these mixtures requires an occlusive dressing and 60 to 90 minutes for the anesthetic effect, which may then be inadequate.

Topical Corticosteroids

Up to 85% of pathologic phimoses that are mild to moderate will respond to the application of topical steroids to the preputial orifice. It is reasonable for the Emergency Physician to prescribe 0.1% to 0.05% betamethasone dipropionate applied twice daily for 4 to 6 weeks with appropriate Urologic follow-up if there is no urinary obstruction or a urinary catheter can be placed.11 The application of topical corticosteroids is the most cost-effective treatment if the circumstances permit.19

Urethral Catheterization

Attempt to pass a size 16 or 18 French Foley or coudé catheter into the bladder. If this is too large, attempt to pass the largest possible catheter. Please refer to Table 145-1 for an age-based list of proper catheter sizes. Care should be taken to avoid forceful placement of the catheter between the foreskin and the glans. Correct catheter placement will be confirmed by an outflow of urine. Refer to Chapter 142 for a complete discussion of urethral catheterization.

Foreskin Dilation

Most simply, the opening of the prepuce can be stretched. The patient's penis should be thoroughly anesthetized prior to performing this procedure (Chapter 146). Consideration should also be given to administering intravenous analgesics, intravenous sedation, or procedural sedation (Chapter 129).

Insert the jaws of a closed hemostat just inside the foreskin. Slowly open the arms of the hemostat 2 to 3 mm. Palpate the foreskin to feel both jaws of the hemostat. If the jaws are not palpable, immediately remove the instrument as one of the jaws may be in the urethra. If both jaws of the hemostat are palpable, open the arms to dilate the opening of the foreskin. Remove the hemostat. Clean the glans and undersurface of the foreskin with povidone iodine or chlorhexidine solution. Insert, using strict aseptic technique, a urinary catheter if required (Chapter 142).

This approach is not the ideal technique as it carries significant risk of injury to the patient. Inadvertent placement of the hemostat jaw in the urethra can lacerate the urethra and glans of the penis. Dilating the foreskin can cause irregular tears. Injury may require operative intervention and circumcision to correct any iatrogenic trauma.

Dorsal Slit of the Foreskin

The preferred method to correct an obstructing phimosis in the Emergency Department is the dorsal slit procedure. The patient's penis should be thoroughly anesthetized prior to performing this procedure (Chapter 146). Consideration should also be given to administering intravenous analgesics, intravenous sedation, or procedural sedation (Chapter 129).

Insert the bottom jaw of a straight hemostat between the foreskin and glans at the 12 o'clock position (Figure 149-1A). For those individual patients or cultural situations where dorsal incision of the foreskin, much less excision, is cosmetically unacceptable, a ventral approach may be substituted which will yield an apparently uncircumcised penis without obstructive symptoms.9 Advance the hemostat until the tip of the jaw is at the coronal sulcus (Figure 149-1A). The coronal sulcus is where the foreskin attaches to the penis. Depending on the etiology of the phimosis, adhesions may be encountered. These should be gently broken as the hemostat is advanced. The skin of the foreskin is relatively thin and the jaw of the hemostat should be easily palpated. The tip of the jaw should be seen to tent the skin at the coronal sulcus when properly placed (Figure 149-1B). It cannot be overemphasized that the Emergency Physician must be confident that the instrument has not been inadvertently placed in the urethra. If the jaw of the hemostat cannot be felt and cannot be seen tenting the skin of the foreskin, remove the hemostat and reinsert it.

Once properly placed, close the hemostat to crush the foreskin at the 12 o'clock position. Allow the hemostat to remain closed for 2 to 3 minutes to thoroughly crush the foreskin. Remove the hemostat. Insert a scissors and advance it with the same attention to position the tip at the coronal sulcus. Incise the crushed tissue to the level of the coronal sulcus (Figure 149-1C). If straight scissors are not available, a #15 blade may be used to cut the crushed skin after another instrument is placed underneath the foreskin to protect the glans from injury. This method of using a scalpel blade is dangerous and not recommended because control is reduced and the potential for error is unnecessarily increased.

Retract the cut foreskin. This will leave an open wound edge on both sides of the midline (Figure 149-1D). Suture the open wound edges using 3-0 or 4-0 chromic gut suture in an interrupted or running pattern. Begin suturing from the midline to the distal end of the incision (Figure 149-1E).5 Return the foreskin to its “resting” position to guard against a newly acquired iatrogenic paraphimosis. Generously apply a topical antibacterial ointment over the suture line and loosely cover it with a bandage of petrolatum gauze and gauze squares. Apply a piece of tape to hold the dressing on the penis. The tape should not be applied circumferentially as this can cause ischemia to the penis.

Should it be desired, a complete circumcision can be performed after the dorsal slit incision. Using two hemostats, make a series of crushing bites along the foreskin at the level of the coronal sulcus. Use caution not to crush the skin on the shaft of the penis. Using scissors, cut the foreskin along the crushed tissue. Approximate the wound edges using 3-0 or 4-0 chromic gut in an interrupted pattern. Carcinoma should always be considered as an etiology of a phimosis and all excised tissue sent to pathology for histologic evaluation.18

Preputioplasty

The preputioplasty is an alternative surgical treatment to the more radical dorsal slit and circumcision. This tissue-sparing surgical technique can achieve full resolution of a phimosis. Although not typically performed in the Emergency Department, the preputioplasty is a conservative, less traumatic, and less invasive procedure. The procedure consists of one or more short longitudinal incisions which release the stenosis and they are then closed transversely allowing a widening of the phimotic ring and loosening of foreskin (Figure 149-2).13

Clean, prep, anesthetize, and prepare the penis as described previously. Retract the foreskin until it is completely proximal to the glans (Figure 149-2B). The phimotic ring will constrict the penile shaft (Figure 149-2B). Carefully make a superficial incision in the phimotic ring with a #15 scalpel blade or fine scissors (Figure 149-2B). The phimotic ring will open. Allow the wound to ooze for a few minutes. Close the wound using 3-0 or 4-0 chromic gut suture in an interrupted pattern (Figure 149-2C). Return the loosened foreskin over the glans (Figure 149-2D). Generously apply a topical antibacterial ointment over the suture line and loosely cover it with a bandage of petrolatum gauze and gauze squares. Apply a piece of tape to hold the dressing on the penis. The tape should not be applied circumferentially as this can cause ischemia to the penis.

Regardless of the technique, observe the patient in the Emergency Department for 45 to 60 minutes to confirm hemostasis. Observe the patient for full recovery from any sedation or procedural sedation techniques as per hospital policy.

The patient may be discharged with Urologic follow-up within 48 hours. Instruct the patient to return to the Emergency Department immediately if the wound is red, has a discharge, is swollen, or if fever develops. The patient should be given oral analgesics for pain control. Patients should be discharged on oral antibiotics whose spectrum covers skin flora. Cephalexin, 500 mg orally four times a day, is usually adequate. Between discharge and examination by a Urologist, the patient should practice gentle daily washing of the penis with soap, avoid placing any powders or creams in the area, and check the wound three to four times daily for signs of infection. Sexual intercourse and masturbation should be avoided until the incisions have completely healed.

The dorsal slit procedure will result in a “beagle-ear” like deformity. While not problematic in most cases, it may increase the chance of getting the foreskin entrapped in a zipper. The Urologist will often perform an elective circumcision for cosmetic purposes.

Direct mechanical injury to the glans or urethra by inadvertent placement of instruments into the urethra could be devastating but is easily avoidable by following proper technique. Increased bleeding may result if the skin is not crushed by the hemostat before it is cut with the scissors.5 It is also important to avoid advancing the clamp, and therefore the incision, beyond the comfortable limitation of the coronal sulcus. Otherwise, the skin on the penile shaft will be cut. This can result in a cosmetic defect and possibly skin sloughing requiring a skin graft. Lacerations to the penile shaft skin should be sutured with an absorbable suture. Wound infection and dehiscence are a possibility with any incision and greatly reduced in conscientious patients.

From a variety of disease processes, the endpoint of a phimosis causing urinary obstruction lends itself to simple correction by the Emergency Physician. If there is not complete urinary obstruction, a trial of topical corticosteroids is simple, cost effective, and may result in the resolution of the phimosis. Careful performance of the described techniques will result in an excellent functional and aesthetic foreskin repair.