Paraphimosis and Phimosis

Paraphimosis is a frequently encountered condition in the pediatric emergency department. Because of their age and lack of understanding, children have a tendency to neglect to reduce their foreskin following retraction at the time of micturition. Occasionally medical personnel will cause an iatrogenic paraphimosis by inadvertently leaving the foreskin retracted following insertion of an indwelling urethral catheter. Subsequent edema and venous congestion proximally could lead to decreased blood flow to the foreskin and glans (Fig. 8.36). It is imperative that the foreskin be reduced immediately to avoid further swelling. The best technique to treat a paraphimosis involves the use of sustained gradual pressure on the glans by both thumbs while the first and second digits reduce the edematous foreskin (Fig. 8.37). Wrapping the penis in gauze and applying a hypertonic solution (such as 3 % saline) for 20-30 min before will cause a dramatic reduction in the amount of edema and facilitate manual decompression. If unsuccessful, a dorsal slit may be necessary to incise the tight preputial ring in order to reduce the foreskin and relieve the venous congestion. Formal circumcision can be performed at a later date, if necessary. Children should not retract their foreskin for at least 2 weeks following reduction of a paraphimosis.

Although rarely a true urologic emergency, phimosis nonetheless causes significant parental concern and frequentlyresults in an emergency department consultation. It is important to differentiate physiologic phimosis from true or pathologic phimosis. Physiologic phimosis is a natural adherence of the inner prepuce to

Physiologic Phimosis
Fig. 8.36. Typical appearance of a boy with paraphimosis. Venous return from the glans is impaired and the prepuce is edematous and engorged distal to the phimotic ring
Swelling After Paraphimosis
Fig. 8.37. The proper technique to manually reduce paraphimosis. Sustained gentle pressure is required in order to reduce the edematous foreskin over the glans

the glans and, with interval growth, usually resolves spontaneously. Desuamation of epithelial cells and build-up of smegma aid in this process of preputial separation. On examination, the phimotic prepuce appears quite supple and there is no evidence of an indurated, thickened phimotic band, as visualized in true pathologic phimosis (Fig. 8.38). Although a course of topical mid-potency steroid cream, applied two to three times a day for 6 weeks, is effective for separating physiologic adhesions, circumcision is usually required for indurated, pathologically phimotic conditions (Yang et al. 2005). Occasionally, children with previously retractile foreskins may present with a history of progressive difficulty retracting the foreskin associated with significant induration and fibrosis. It is imperative to rule out (via circumcision or biopsy) balanitis xero-tica obliterans (BXO), also known as lichen sclerosis et atrophicus, in this patient population, as progressive meatal stenosis and ongoing obstructive voiding has been reported following circumcision (Gargollo et al. 2005). BXO has a characteristic whitish discoloration of

Boy Phimosis
Fig. 8.38. Pathological phimosis showing a thickened indurated phimotic band. This patient failed a course of topical steroid therapy and required circumcision

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Fig. 8.39. Pathological phimosis secondary to BXO. Note the whitish discoloration similar to the patient in Fig. 8.38. Both patients were found to have BXO on pathological analysis the prepuce and can involve both the glans and distal urethra (Fig. 8.39).

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