We have mentioned before how knowledge of some “less glamorous conditions” can really help make your day go more smoothly in the ED. Knowing how to manage rectal prolapse, constipation, recurrent abdominal pain, or cerumen impaction may not be what got you motivated to go to work today, but being proficient at these topics does make your shift go more smoothly.  Similarly, it is not uncommon to see a patient with “penis problem.” This could be a big deal or completely normal. Let’s consider Phimosis for a minute.

Phimosis: What is it?

• Refers to the condition when the foreskin (prepuce) cannot be retracted over the glans penis.
• May be physiologic
  • Due to normal adhesion of the foreskin to the glans.
    • Common in male children up to 3 years of life.
    • Can be seen even into the teenage years.
  • Does not require surgical correction.
• May be pathologic
  • Due to scar tissue formation that prevents retraction of the foreskin.
  • Often associated with:
    • Recurrent balantitis or balanoposthitis
    • Balanitis xerotica oliterans from penile lichen sclerosis
  • Requires correction and, potentially, circumcision.

Phimosis: Physiologic vs Pathologic

• Physiologic Phimosis
  • Normal tissue adhesions prevent full retraction.
  • There is no scar tissue.
  • The preputial outlet is always closed and the glans is not visible, unless retractile force is applied to foreskin (and then only a small area of the glans, if any, is visible).
  • With gentle retractile force, the inner mucosal surface everts through outlet. [McGregor, 2007]
    • Said to “Open like a Flower” (the visual image is odd).
  • Ballooning can be seen with physiologic phimosis.
    • Occurs due to a tight orifice, but a distensible preputial sac.
    • Urination leads to ballooning of the prepuce.
    • Not found to be associated with obstructive voiding and not a mandate for circumcision. [Babu, 2004]
• Pathologic Phimosis
  • Scar tissue prevents retraction of the foreskin.
  • The scar tissue will often hold the preputial outlet open, exposing a portion of the glans without retractile force being applied.
  • Inner mucosal will not evert through the outlet when retractile force applied. [McGregor, 2007]

Phimosis: Management

• Management of physiologic phimosis
  • Education and reassurance!
  • Hygiene
    • Families and children should be taught to GENTLY retract the foreskin to the point of resistance during bathing and urination.
    • It should not be forcefully retracted (as this may lead to scarring!). [McGregor, 2007]
  • 6-8 week course of topical steroids can help accelerate the normal process if this is desired.
    • 0.1% triamcinolone applied to preputial outlet BID.
• Management of pathologic phimosis
  • Circumcision is the default answer, but…
  • Steroids have been shown to be effective in cases of mild scarring and can help avoid circumcision.
    • If phimotic ring persists after steroid therapy, then circumcision is necessary. [Esposito, 2008]

Moral of the Morsel

• Like fever, parents will not overlook a “problem with the penis,” so becoming well versed in the normal and abnormal and emergent conditions is helpful.
• The rate of circumcisions has declined and, hence, the number of patients with physiologic phimosis has increased.
• Look for scarring. Look exposed glans when no retractile force is applied. These are consistent with pathologic phimosis and require urologic follow-up.

References

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