Phimosis and Paraphimosis

Phimosis is a condition in which a male is unable to retract the distal foreskin over his glans penis. Phimosis is classified under two headings:

• Physiologic phimosis
• Pathologic phimosis

Physiologic Phimosis

It is a condition that presents itself in nearly all newborn males. According to statistics, by the age of three years, 10% of male children in the US still suffer from this condition. In 1% to 5% of males, the condition may persist till the age of sixteen.
Physiologic phimosis is caused due to the adhesions between the epithelial cells lining the inner surfaces of the prepuce and the glans. These adhesions break down spontaneously to form smegma pearls as the foreskin is intermittently retracted over the glans. As the child grows, the condition resolves on its own.
 

Pathologic Phimosis

It is a condition wherein the foreskin which was previously retractable cannot be retracted over the glans anymore. It is usually secondary t poor hygiene or recurrent balanitis or balanoposthitis which may lead to distal scarring of the foreskin. Trying to retract the foreskin forcefully may also lead to small tears at the opening of the prepuce. These tears may heal with scarring leading to pathologic phimosis. In the elderly people, infrequent erections and loss of the elasticity of the skin may also give rise to this condition.
 

Presentation of Phimosis

Physiologic phimosis may simply go unnoticed or the parents may be alarmed seeing the ballooning of the foreskin during the time of micturition. Pathologic phimosis may present with complaints of painful erections, blood in the urine, pain in the preputial region, a weak urinary stream or frequent urinary tract infections.
In physiologic phimosis, the preputial opening appears healthy and unscarred. However, in pathologic phimosis, a white fibrous band may be seen around the orifice.
 

Treatment of Phimosis

It is seldom an emergency situation. A wait and watch technique generally helps with physiologic phimosis. In case of pathologic phimosis, stress should be laid on the maintenance of personal hygiene. The preputial ring generally responds to topical steroids. In case of persistent infections, circumcision may be considered.
 

Paraphimosis

Paraphimosis is a condition seen in uncircumcised males wherein the retracted foreskin gets entrapped behind the coronary sulcus. It is usually seen under following circumstances:

• When the foreskin is forcefully retracted and the patient forgets to reduce it.
• After excessive sexual activity.
• In patients with indwelling catheters where the caregiver forgets to reduce the foreskin after inserting the catheter.
• In patients suffering from chronic balanoposthitis.

Presentation of Paraphimosis

• The foreskin which is retracted behind the glans, cannot be brought back to its original position and forms a tight ring which constricts the glans.
• As the time elapses, glans may become edematous. As necrosis sets in, the color of glans changes from pink to blue or black.
• The shaft of the penis proximal to the area affected by paraphimosis becomes flaccid except in case of balanoposthitis.

Treatment of Paraphimosis

Paraphimosis is an emergency situation that needs to be attended immediately. The aim of the treatment is to reduce the foreskin to its original position by maneuvering it over the swollen glans. As the condition is painful, local anesthesia may be useful. Manual reduction is tried first. In case it fails, alternate techniques like osmotic reduction, injection of hyaluronidase, puncture method, etc. are employed. If these too prove futile, then emergency circumcision is the last resort.
 
Reference:
http://emedicine.medscape.com/article/777539-overview