3.1.

Phimosis
3.1.1.Epidemiology, aetiology and pathophysiology
At the end of the first year of life, retraction of the foreskin behind the glandular sulcus is
possible in approximately 50% of boys; this rises to approximately 89% by the age of three
years. The incidence of phimosis is 8% in six to seven year olds and just 1% in males aged
sixteen to eighteen years [9].
3.1.2.Classification systems
The phimosis is either primary with no sign of scarring, or secondary (pathological) to a
scarring such as balanitis xerotica obliterans (BXO) [9]. Balanitis xerotica obliterans, also
termed lichen sclerosis, has been recently found in 35% circumcised prepuce in children and
adolescents and in 17% of boys younger than ten years presenting with phimosis. The clinical
appearance of BXO in children may be confusing and does not correlate with the final
histopathological results. Lymphocyte-mediated chronic inflammatory disease was the most
common finding [10,11] (LE: 2b).
Phimosis has to be distinguished from normal agglutination of the foreskin to the glans,
which is a more or less lasting physiological phenomenon with clearly-visible meatus and
free partial retraction [12]. Separation of the prepuce from the glans is based on accumulated
epithelial debris and penile erections. Forceful preputial retraction should be discouraged to
avoid cicatrix formation [13].
Paraphimosis must be regarded as an emergency situation: retraction of a too narrow prepuce
behind the glans penis into the glanular sulcus may constrict the shaft and lead to oedema of
the glans and retracted foreskin. It interferes with perfusion distally from the constrictive ring
and brings a risk of preputial necrosis.
3.1.3.Diagnostic evaluation
The diagnosis of phimosis and paraphimosis is made by physical examination. If the prepuce
is not retractable, or only partly retractable, and shows a constrictive ring on drawing back
over the glans penis, a disproportion between the width of the foreskin and the diameter of
the glans penis has to be assumed. In addition to the constricted foreskin, there may be
adhesions between the inner surface of the prepuce and the glanular epithelium and/or a
fraenulum breve. Paraphimosis is characterised by a retracted foreskin with the constrictive
ring localised at the level of the sulcus, which prevents replacement of the foreskin over the
glans.
3.1.4.Management
Conservative treatment is an option for primary phimosis. The steroid therapies were more
effective over placebo and manual stretching [14]. A corticoid ointment or cream (0.05-0.1%)
can be administered twice a day over a period of 20-30 days with a success rate of > 90%
[15-18] (LE: 1b). A recurrence rate of up to 17% can be expected [19]. This treatment has no
side effects and the mean bloodspot cortisol levels are not significantly different from an
untreated group of patients [20] (LE: 1b). The hypothalamic pituitary-adrenal axis was not
influenced by local corticoid treatment [21]. Agglutination of the foreskin does not respond to
steroid treatment [16] (LE: 2).
Operative treatment of phimosis in children is dependent on the caregivers’ preferences and
can be plastic or radical circumcision after completion of the second year of life.
Alternatively, the Shang Ring may be used especially in developing countries [22]. Plastic
circumcision has the objective of achieving a wide foreskin circumference with full
retractability, while the foreskin is preserved (dorsal incision, partial circumcision, trident
preputial plasty) [23]. However, this procedure carries the potential for recurrence of
the phimosis [24]. In the same session, adhesions are released and an associated fraenulum
breve is corrected by fraenulotomy. Meatoplasty is added if necessary.
An absolute indication for circumcision is secondary phimosis. In primary phimosis, recurrent
balanoposthitis and recurrent urinary tract infections (UTIs) in patients with urinary tract
abnormalities are indications for intervention [25-28] (LE: 2b). Male circumcision
significantly reduces the bacterial colonisation of the glans penis with regard to both non-
uropathogenic and uropathogenic bacteria [29] (LE: 2b). Simple ballooning of the foreskin
during micturition is not a strict indication for circumcision.
Routine neonatal circumcision to prevent penile carcinoma is not indicated. A recent meta-
analysis could not find any risk in uncircumcised patients without a history of phimosis [30].
Contraindications for circumcision are: an acute local infection and congenital anomalies of
the penis, particularly hypospadias or buried penis, as the foreskin may be required for a
reconstructive procedure [31,32]. Circumcision can be performed in children with
coagulopathy with 1-5% suffering complications (bleeding), if haemostatic agents or a
diathermic knife are used [33,34]. Childhood circumcision has an appreciable morbidity and
should not be recommended without a medical reason and also taking into account
epidemiological and social aspects [35-39] (LE: 1b). Balanitis xerotica obliterans is
associated with meatal pathology (stenosis) after circumcision in up to 20% of boys and
adjuvant local steroid treatment is advised [11,40].
Treatment of paraphimosis consists of manual compression of the oedematous tissue with a
subsequent attempt to retract the tightened foreskin over the glans penis. Injection of
hyaluronidase beneath the narrow band or 20% mannitol may be helpful to release the
foreskin [41,42] (LE: 3-4). If this manoeuvre fails, a dorsal incision of the constrictive ring is
required. Depending on the local findings, a circumcision is carried out immediately or can
be performed in a second session.
3.1.5.Follow-up
Any surgery done on the prepuce requires an early follow-up of four to six weeks after
surgery.
3.1.6.Summary of evidence and recommendations for the management of phimosis

Summary of evidence LE

Treatment for phimosis usually starts after two years of age or 3

according to caregivers’ preference.

In primary phimosis, conservative treatment with a corticoid ointment 1b

or cream is a first line treatment with a success rate of more than 90%.

Recommendations LE Strength
 rating

Offer corticoid ointment or cream to treat primary 1b Strong

symptomatic phimosis. Circumcision will also solve the
problem.

Treat primary phimosis in patients with recurrent urinary 2b Strong

tract infection and/or with urinary tract abnormalities.

Circumcise in case of lichen sclerosus or scarred phimosis. 2b Strong

Treat paraphimosis by manual reposition and proceed to 3 Strong

surgery if it fails.

Avoid retraction of asymptomatic praeputial adhesions. 2b Weak

(European Association of Urology. Pediatric Urology)

Normal Anatomy and Function

 At birth, the normal foreskin (prepuce) is attached to the glans and has a tight opening
(preputial ring) at the distal end.  It is not retractable in most newborns.
 Retractability increases with age, with full retraction possible in
o 10% of boys at 1 year
o 50% of boys at 10 years
o 99% of boys at 17 years
 A non-retractable foreskin is a normal variant and needs no intervention. It is
different from true phimosis.
 The foreskin should never be forcibly retracted for cleaning. Once it becomes
freely retractable naturally, then the child should retract it as part of routine
bathing, ensuring immediate replacement over the glans to prevent
paraphimosis. See care of the normal uncircumcised penis patient information.

Smegma

 Smegma is a collection of desquamated epithelial cells and sebaceous matter that

collects between the glans penis and the foreskin.
 Before the foreskin becomes separate and retractable, it is common for smegma to
collect in small yellow/white lumps which may be visible or palpable through the
foreskin. These are normal, and need no intervention.
 Discharge of smegma from the foreskin opening is sometimes mistaken for pus.

Attachments
 Sometimes the normal process of separation is uneven and the foreskin becomes
partially retractable but with residual attachments to the glans.  These are normal and
need no intervention.
 This can lead to a day or two of soreness and dysuria.
Ballooning
 Some children with non-retractable foreskins notice ballooning during urination.
 This is usually of no consequence, but may cause minor urine trapping within the
foreskin with associated spotting of underpants and increased risk of balanitis.
 Treat if problematic:
o Topical steroid cream sparingly to preputial ring (tightest part of foreskin):
0.05% betamethasone tds for 6-12 weeks (NB: longer duration compared to
phimosis treatment).
o Success rate > 90%, recurrence rate up to 17%.
o Circumcision is not indicated unless pathologic phimosis.

Inflammation and infection

Balanitis and inflammation
 Minor redness and/or soreness of the tip of the foreskin is common and can be
managed with reassurance and avoidance of chemical/physical triggers.
 More extensive inflammation of the glans penis +/- foreskin is termed balanitis.
 Causes include:
o Chemical irritation: urine trapping, soiled nappies, soap residue.
o Physical trauma: forcible retraction.
o Candida nappy rash in infants.
 Treatment:
o Soaking in warm salt water settles swelling and discomfort.
o Barrier or 1% hydrocortisone cream (see also Nappy rash).
o Antifungal cream (clotrimazole, miconazole) if candida suspected.
o Oral analgesia may be needed.
o Topical antibiotic ointments and creams are not efficacious.
o Preputial retraction during acute inflammation should not be recommended as
this can lead to paraphimosis.

Infection and cellulitis

 Secondary bacterial infection can occur, with erythema or lymphangitis tracking
proximally down the penile shaft.  Associated dysuria is common.
 If fever is present, urine culture should be performed to exclude concomitant UTI.
 Streptococcus pyogenes (group A streptococcus) infection can cause a severe genital
rash that is weeping and raw.
 Treatment:
o Oral antibiotics – flucloxacillin 25 mg/kg (max 500mg) po, 6 hourly for 7 days
or cephalexin 25mg/kg po, 6 hourly for 7 days.
o Analgesia.
o Soaking in warm salt water may ease discomfort.
o Swabs are often contaminated. Treat on clinical merit.

Other conditions
 Persistent genital rash may be due to a dermatosis (psoriasis, eczema).  These children
may require referral to a paediatrician or paediatric dermatologist.
 A genital rash or penile discharge in a sexually active male raises other diagnostic
considerations. See Sexually transmitted infections.
Foreskin retractable problems
Phimosis
 Pathologic phimosis results from scarring of the preputial ring preventing retraction.
This is distinct from normal non-retractable foreskin described above.
 Features
o Obvious ring of scar tissue visible at foreskin opening.
o Foreskin not retractable at the conclusion of puberty.
o Previously retractable foreskin becomes non-retractable.
o Persistent ballooning of foreskin on urination in older children, with pinhole
foreskin opening, narrow urinary stream and no response to topical steroid
creams.
 Causes
o Most commonly due to repeated attempts to forcibly retract the foreskin
before it has become naturally retractable.
o Balanitis Xerotica Obliterans (BXO); an aggressive scarring condition (very
rare <8yo).
 Treatment
o Application of topical steroid cream (0.05% betamethasone cream 2-3 times
daily) should be trialled for 2-4 weeks
o If good response to steroids, continue for total of 6-12 weeks.
o If no / poor response to steroids, pathologic phimosis is likely. Refer to
Urology services.
 Red flag: urgent surgical referral is required is the child is unable to pass
urine.

Paraphimosis
 Paraphimosis is a urological emergency and brings a risk of preputial necrosis.
 Paraphimosis occurs when the foreskin is left in the retracted position. The foreskin
distal to the tight area becomes oedematous which makes it difficult to reduce the
foreskin over the glans.
 Paraphimosis can usually be corrected without surgery:
o Give oral analgesia and reassurance.
o Wrap a firm compression bandage (ideally 1 inch, for example Coban,
pictured) over the oedematous area, starting at penile tip.
o Leave bandage for 10-15 minutes (use a timer).
o Remove bandage and attempt to reduce foreskin over the glans. If
unsuccessful, repeat bandage for further 15 minutes and re-attempt.
o If manual reduction fails, obtain urgent surgical consult.
 Post reduction care:
o Circumcision is not indicated and follow-up is not necessary
o Advise the child and parents to avoid a repeat event:
 No retraction for a few days.
 Only the child to retract foreskin for cleaning.
 Ensure immediate complete replacement of foreskin over glans.
 Children with evidence of ischaemia (dusky or dark tissue) require
urgent review by a urologist.
Hair tourniquet
 In infants, hair or clothing fibres can wind around the penile shaft forming a
tourniquet.
 Presents as redness and swelling of the distal part of the penis with a demarcation line.
 Treatment: divide fibre or hair ring and check skin for integrity. Discuss with a senior
doctor if unsure.

Circumcision
 Circumcision is an operation to remove the foreskin and expose the glans.
 Medical indications for circumcision include pathologic phimosis or recurrent UTIs.
 Non-medically indicated circumcisions are performed by private practitioners. Parents
need to make an informed decision after carefully looking at all the facts about the
benefits and risks for their child.
 Circumcision should be done in a safe, child-friendly environment by properly trained
and qualified staff who are available to manage any post-operative complications. The
child should receive appropriate analgesia. Click here for the RACP Circumcision
Guide for Parents.

Post-circumcision problems
 It is common for the glans penis to be inflamed and crusted following circumcision.
This is due to the forcible separation of normal tissue layers.
 Liberal application of Vaseline to the nappy or a panty liner for a few days helps.
 Infection is uncommon, but can be serious. Treat as above.
 Bleeding is uncommon but if significant:
o Apply compression and obtain urgent surgical advice.
o Consider coagulopathy in significant bleeding after a circumcision.
 PlastiBell circumcision: any post-circumcision complications should be
discussed with a urologist for management advice.

Priapism
 Priapism is a prolonged penile erection lasting longer than 4 hours and is a rare
condition in childhood.
 The commonest causes of priapism in children are sickle cell disease (65%),
leukaemia (10%) and trauma (10%).
 Priapism lasting more than 4 hours can result in ischaemia and is a urological
emergency.
 In older children, possible management options are:
o Running up stairs
o Urination
o Cold bath
o Cold packs (NB: NOT to be used if child could have sickle cell disease)
 Counsel the child and parents about seeking medical attention early if above
measures don’t resolve priapism in < 2 hours. Otherwise arrange urology
outpatient follow up and Doppler ultrasonography to assess blood flow.

Consider consultation with local paediatric or paediatric urology team when

 The child is unable to pass urine for any reason.
 Paraphimosis: Children with evidence of ischaemia (dusky or dark tissue).
  Priapism (constant erection > 4 hours).
 Zipper injury that involves the glans.

Consider transfer when

Children requiring care above the level of comfort of the local hospital or their treating
medical team.

(This guideline has been adapted for statewide use with the support of the Victorian
Paediatric Clinical Network)

Phimosis
 When the foreskin cannot be retracted behind the glans penis (which is a normal
finding in children < 5 yrs).
 May be congenital or acquired; acquired is much more common and is caused by
accumulation of smegma beneath the foreskin due to poor hygiene; may also be
secondary to BXO or balanoposthitis.
 Histologic features: chronic inflammation, fibrosis, edema, and vascular congestion.
 Treatment: circumcision.

Paraphimosis
 When the foreskin has been retracted but now cannot be advanced back over the
glans.
 Cause: most often iatrogenic, following urinary tract instrumentation.
 Treatment: circumcision or emergent dorsal slit procedure.

(American Urological Asssociation)