A 5-year-old boy, Kayden, is brought in by his mother as she is concerned that there is something wrong with his penis – every time he tries to pass urine it balloons in his foreskin and goes all over the floor.
A non-retractile foreskin may be present in up to 10% of 4-year-olds
Parents should not try to forcibly retract the foreskin of their child as it may lead to paraphimosis
Most cases of phimosis resolve with time
Paraphimosis occurs when a retracted foreskin is unable to be returned to its normal position due to oedema of the glans and prepuce
Good hygiene and avoidance of irritants are the mainstays in treating balanitis
What is phimosis?
A non-retractile foreskin is the norm in neonates and may be present in 60% of boys under one year of age. By 4 years of age, 90% of boys are able to retract their foreskin. The majority of cases that present to either primary care or the emergency department are physiological phimosis. True phimosis is caused by forcible retraction of the foreskin leading to a tight circular band of scar tissue. Some studies suggest an increased incidence of balanitis xerotica obliterans (BXO).
When is phimosis a problem?
- The foreskin is non-retractable by puberty
- Previously retractable foreskin gets stuck
- Presence of ballooning of urine under foreskin on micturition
How do you treat phimosis?
Application of 0.05% betamethasone ointment bd applied to the tip of the foreskin for 4-6 weeks reduces localized inflammation and helps loosen any inner preputial adhesions from the underlying tissue thus making it easier to retract. The majority of children with phimosis will not need any surgical intervention. Children with BXO may be referred early for circumcision though it may recur.
What is paraphimosis?
When the foreskin is left in the pulled back position it can impair venous return from the glans leading to oedema. This may lead to ischaemia and necrosis if left untreated. It is commonly related to previous phimosis where a ring of tough fibrous scar tissue forms around the foreskin. Whilst its presentation is usually obvious do not forget to consider the diagnosis of a hair tourniquet.
How do you treat paraphimosis?
The foreskin should be returned to its normal position as quickly as possible. The pain should be relieved with parenteral/intranasal analgesia. Often lignocaine jelly (similar to that used for catheterisation) is enough to numb the pain whilst an ice pack is applied to help reduce oedema. Once these have had ten minutes to work use the thumb of your dominant hand to push down on the glans whilst sliding the foreskin back in place. If this does not work a flexible, self-adhering bandage may be used to compress oedema.
What surgical options are available?
In the majority of occasions, the simple measures described above should be effective for returning the foreskin to its natural position. For completeness sake, it is worth being aware of some of the surgical options available but these should only be carried out by experienced practitioners. For the older child, it may be necessary to perform a penile block (under sedation) in order to aid reduction. More brutal surgical techniques have been described, including multiple punctures of the glans to reduce oedema or performing a dorsal slit (cutting the fibrous ring of tissue). The child should then be referred to a paediatric surgeon for consideration for circumcision as a later date.
How can I remember which is which?
PARAchutes come down and so does the foreskin in PARAphimosis.
What is balanitis?
Balanitis is inflammation of the glans of the penis that is often accompanied by inflammation of the overlying foreskin. It is more common in boys that have not been circumcised.
What causes balanitis?
Balanitis may be either
- Contact or irritant balanitis – presents as generalized redness and swelling and is often due to detergents or bubble baths
- Candidal balanitis – often presents as redness around the glans with sparing of the meatus and cottage cheese-like debris that is easily rubbed off
- Bacterial balanitis – presents as redness and pain with a purulent exudate. It may be caused by Staph. aureus or Group A beta haemolytic strep species
A penile skin swab is not needed as the majority of cases clear up with empiric treatment.
How can it be treated?
- General methods – Parents should be advised to carefully wash in lukewarm, saltwater baths and dry the penis without forcibly retracting the foreskin. They should avoid detergents and bubble baths and if the boy is still in nappies they should change him frequently
- Suspected irritant balanitis with/without candidal colonisation – topical hydrocortisone cream 1% with added imidazole (miconazole/clotrimazole) bd for 14 days or until settled
- Suspected bacterial balanitis – Oral flucloxacillin for 7 days ± topical hydrocortisone 1% for discomfort. Topical antibiotics have no proven efficacy.
Most cases of balanitis are irritant in origin and respond well to simple measures. It can be tough to distinguish between irritant and infective forms and so treatment may need to be escalated if simple hygiene methods fail. If the symptoms are not improving after 7 days then a penile skin swab should be taken
Children with recurrent or chronic balanitis should be referred to a paediatrician or a dermatologist.
Kayden is diagnosed with phimosis and is prescribed four weeks of topic steroid cream. When he is seen for another matter a month later you enquire as to his problem and find that he no longer misses his target.
McGregor TB, Pike JG, Leonard MP. Pathologic and physiologic phimosis:approach to the phimotic foreskin. Can Fam Physician. 2007 Mar;53(3):445-8.
Shahid SK. Phimosis in children. ISRN Urol. 2012;2012:707329.
Pohlman GD, Phillips JM, Wilcox DT. Simple method of paraphimosis reduction revisited: point of technique and review of the literature. J Pediatr Urol. 2013 Feb;9(1):104-7.
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