History

Parents of patients with physiologic phimosis may bring in the patient after noting an inability to retract the foreskin during routine cleaning or bathing. Parents may also be alarmed by "ballooning" of the prepuce during urination — a normal finding.

Pathologic phimosis may be detected in males who report painful erections, hematuria, recurrent urinary tract infections, preputial pain, or a weakened urinary stream. (See below.)

Physiologic phimosis versus pathologic phimosis.

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Paraphimosis classically presents with a painful, swollen glans penis in the uncircumcised or partially circumcised patient. A preverbal infant may present only with irritability. Occasionally, the paraphimosis may be an incidental finding noted by a caretaker of a debilitated patient. (See below.)

Paraphimosis.

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Paraphimosis is classically seen in one of the following populations^{[24, 25]}

Children whose foreskins have been forcefully retracted or who forget to reduce their foreskin after voiding or bathing
Adolescents or adults who present with paraphimosis in the setting of vigorous sexual activity^[26]
Men with chronic balanoposthitis
Patients with indwelling catheters in whom caretakers forget to replace the foreskin after catheterization or cleaning

Urinary obstruction is a late feature.

Physical

Phimosis includes the following:

The foreskin cannot be retracted proximally over the glans penis.
In physiologic phimosis, the preputial orifice is unscarred and healthy appearing.
In pathologic phimosis, a contracted white fibrous ring may be visible around the preputial orifice

Physiologic phimosis versus pathologic phimosis.
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Paraphimosis includes the following:

The foreskin is retracted behind the glans penis and cannot be replaced to its normal position.
The foreskin forms a tight, constricting ring around the glans.
Flaccidity of the penile shaft proximal to the area of paraphimosis is seen (unless there is accompanying balanoposthitis or infection of the penis).
With time, the glans becomes increasingly erythematous and edematous.
The glans penis is initially its normal pink hue and soft to palpation. As necrosis develops, the color changes to blue or black and the glans becomes firm to palpation.

Differential Diagnoses

McPhee AS, Stormont G, McKay AC. Phimosis. StatPearls. [Internet]. Treasure Island, FL: StatPearls Publishing; 2022 Jan. [Full Text].
McGregor TB, Pike JG, Leonard MP. Pathologic and physiologic phimosis: approach to the phimotic foreskin. Can Fam Physician. 2007 Mar. 53(3):445-8. [QxMD MEDLINE Link].
Sneppen I, Thorup J. Foreskin Morbidity in Uncircumcised Males. Pediatrics. 2016 May. 137 (5):[QxMD MEDLINE Link].
Dubin J, Davis JE. Penile emergencies. Emerg Med Clin North Am. 2011 Aug. 29(3):485-99. [QxMD MEDLINE Link].
Drake T, Rustom J, Davies M. Phimosis in childhood. BMJ. 2013 Jun 20. 346:f3678. [QxMD MEDLINE Link].
Bragg BN, Kong EL, Leslie SW. Paraphimosis. StatPearls. [Internet]. Treasure Island, FL: StatPearls Publishing; 2022 Jan. [Full Text].
McPhee AS, McKay AC. Phimosis. 2018 Jan. [QxMD MEDLINE Link]. [Full Text].
Zhou G, Jiang M, Yang Z, et al. Efficacy of topical steroid treatment in children with severe phimosis in China: a long-term single centre prospective study. J Paediatr Child Health. 2021 Dec. 57 (12):1960-5. [QxMD MEDLINE Link].
Flores S, Herring AA. Ultrasound-guided dorsal penile nerve block for ED paraphimosis reduction. Am J Emerg Med. 2015 Jun. 33 (6):863.e3-5. [QxMD MEDLINE Link].
Khan A, Riaz A, Rogawski KM. Reduction of paraphimosis in children: the EMLA® glove technique. Ann R Coll Surg Engl. 2014 Mar. 96 (2):168. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Vorilhon P, Martin C, Pereira B, Clément G, Gerbaud L. [Assessment of topical steroid treatment for childhood phimosis: review of the literature]. Arch Pediatr. 2011 Apr. 18(4):426-31. [QxMD MEDLINE Link].
Palmer LS, Palmer JS. The efficacy of topical betamethasone for treating phimosis: a comparison of two treatment regimens. Urology. 2008 Jul. 72(1):68-71. [QxMD MEDLINE Link].
Nascimento FJ, Pereira RF, Silva JL 2nd, Tavares A, Pompeo AC. Topical betamethasone and hyaluronidase in the treatment of phimosis in boys: a double-blind, randomized, placebo-controlled trial. Int Braz J Urol. 2011 May-Jun. 37(3):314-9. [QxMD MEDLINE Link].
Anand A, Kapoor S. Mannitol for paraphimosis reduction. Urol Int. 2013. 90(1):106-8. [QxMD MEDLINE Link].
Pedersini P, Parolini F, Bulotta AL, Alberti D. "Trident" preputial plasty for phimosis in childhood. J Pediatr Urol. 2017 Jun. 13 (3):278.e1-278.e4. [QxMD MEDLINE Link].
Burstein B, Paquin R. Comparison of outcomes for pediatric paraphimosis reduction using topical anesthetic versus intravenous procedural sedation. Am J Emerg Med. 2017 Apr 11. [QxMD MEDLINE Link].
Monarca C, Rizzo MI, Quadrini L, Sanese G, Prezzemoli G, Scuderi N. Prepuce-sparing plasty and simple running suture for phimosis. G Chir. 2013 Jan-Feb. 34 (1-2):38-41. [QxMD MEDLINE Link].
Moreno G, Corbalán J, Peñaloza B, Pantoja T. Topical corticosteroids for treating phimosis in boys. Cochrane Database Syst Rev. 2014 Sep 2. CD008973. [QxMD MEDLINE Link].
Siev M, Keheila M, Motamedinia P, Smith A. Indications for adult circumcision: a contemporary analysis. Can J Urol. 2016 Apr. 23 (2):8204-8. [QxMD MEDLINE Link].
Yue YW, Chen YW, Deng LP, et al. Design and development of a new type of phimosis dilatation retractor for children. World J Clin Cases. 2021 Jun 16. 9 (17):4159-65. [QxMD MEDLINE Link].
Chen CJ, Satyanarayan A, Schlomer BJ. The use of steroid cream for physiologic phimosis in male infants with a history of UTI and normal renal ultrasound is associated with decreased risk of recurrent UTI. J Pediatr Urol. 2019 Oct. 15 (5):472.e1-472.e6. [QxMD MEDLINE Link].
Hotonu S, Mohamed A, Rajimwale A, et al. Save the foreskin: outcomes of preputioplasty in the treatment of childhood phimosis. Surgeon. 2020 Jun. 18 (3):150-3. [QxMD MEDLINE Link].
Lundquist ST, Stack LB. Diseases of the foreskin, penis, and urethra. Emerg Med Clin North Am. 2001 Aug. 19(3):529-46. [QxMD MEDLINE Link].
Castagnetti M, Leonard M, Guerra L, Esposito C, Cimador M. Benign penile skin anomalies in children: a primer for pediatricians. World J Pediatr. 2015 Mar 9. [QxMD MEDLINE Link].
Raman SR, Kate V, Ananthakrishnan N. Coital paraphimosis causing penile necrosis. Emerg Med J. 2008 Jul. 25(7):454. [QxMD MEDLINE Link].
Kessler CS, Bauml J. Non-traumatic urologic emergencies in men: a clinical review. West J Emerg Med. 2009 Nov. 10(4):281-7. [QxMD MEDLINE Link].
Burstein B, Paquin R. Comparison of outcomes for pediatric paraphimosis reduction using topical anesthetic versus intravenous procedural sedation. Am J Emerg Med. 2017 Oct. 35 (10):1391-1395. [QxMD MEDLINE Link].
Choe JM. Paraphimosis: current treatment options. Am Fam Physician. 2000 Dec 15. 62(12):2623-6, 2628. [QxMD MEDLINE Link].
Little B, White M. Treatment options for paraphimosis. Int J Clin Pract. 2005 May. 59(5):591-3. [QxMD MEDLINE Link].
Benson M, Hanna MK. Prepuce sparing: Use of Z-plasty for treatment of phimosis and scarred foreskin. J Pediatr Urol. 2018 Jun 8. [QxMD MEDLINE Link].
Palmisano F, Gadda F, Spinelli MG, Montanari E. Glans penis necrosis following paraphimosis: A rare case with brief literature review. Urol Case Rep. 2018 Jan. 16:57-58. [QxMD MEDLINE Link]. [Full Text].
Afonso LA, Cordeiro TI, Carestiato FN, Ornellas AA, Alves G, Cavalcanti SM. High Risk Human Papillomavirus Infection of the Foreskin in Asymptomatic Men and Patients with Phimosis. J Urol. 2016 Jun. 195 (6):1784-9. [QxMD MEDLINE Link].
Huang YC, Huang YK, Chen CS, Shindel AW, Wu CF, Lin JH, et al. Phimosis with Preputial Fissures as a Predictor of Undiagnosed Type 2 Diabetes in Adults. Acta Derm Venereol. 2016 Mar 1. 96 (3):377-80. [QxMD MEDLINE Link].
Nobre YD, Freitas RG, Felizardo MJ, Ortiz V, Macedo A Jr. To circ or not to circ: clinical and pharmacoeconomic outcomes of a prospective trial of topical steroid versus primary circumcision. Int Braz J Urol. 2010 Jan-Feb. 36(1):75-85. [QxMD MEDLINE Link].
Manekar AA, Janjala N, Sahoo SK, et al. Phimosis - are we on right track?. Afr J Paediatr Surg. 2022 Oct-Dec. 19 (4):199-202. [QxMD MEDLINE Link].
Davis JR, Baaklini GT, Schwope RB. The "wet collar" sign: a case of paraphimosis on CT. Cureus. 2022 Apr. 14 (4):e24345. [QxMD MEDLINE Link].
Carilli M, Asimakopoulos AD, Pastore S, et al. Can circumcision be avoided in adult male with phimosis? Results of the PhimoStop^TM prospective trial. Transl Androl Urol. 2021 Nov. 10 (11):4152-60. [QxMD MEDLINE Link].
Tews M, Singer JI. Paraphimosis: Definition, pathophysiology, and clinical features. www.utdol.com. 9/20/2008;

Media Gallery

Anatomy of the penis.
Physiologic phimosis versus pathologic phimosis.
Paraphimosis.
Dorsal slit procedure.

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Author

Hina Z Ghory, MD Assistant Medical Director, Emergency Department, East Orange General Hospital

Hina Z Ghory, MD is a member of the following medical societies: American College of Emergency Physicians, Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

Rahul Sharma, MD, MBA, FACEP Medical Director and Associate Chief of Service, NYU Langone Medical Center, Tisch Hospital Emergency Department; Assistant Professor of Emergency Medicine, New York University School of Medicine

Rahul Sharma, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Association for Physician Leadership, Phi Beta Kappa, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Gil Z Shlamovitz, MD, FACEP Professor of Clinical Emergency Medicine, Keck School of Medicine of the University of Southern California; Chief Medical Information Officer, Keck Medicine of USC

Gil Z Shlamovitz, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Jerry R Balentine, DO, FACEP, FACOEP Vice President, Medical Affairs and Global Health, New York Institute of Technology; Professor of Emergency Medicine, New York Institute of Technology College of Osteopathic Medicine

Jerry R Balentine, DO, FACEP, FACOEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, American College of Osteopathic Emergency Physicians, American Association for Physician Leadership, American Osteopathic Association

Disclosure: Nothing to disclose.

Sections Phimosis and Paraphimosis In the ED
Overview
Presentation
DDx
Treatment
Medication
Questions & Answers
Media Gallery
References

Phimosis and Paraphimosis In the ED Clinical Presentation

History

Physical

References

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