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  Phimosis
 
Author: Jonathan Jarow Last modified: October 13, 2001
DIAGNOSTIC CRITERIA

  EPIDEMIOLOGY

  • It is common for the foreskin to be unretractable in males under age 4 years.
  • Phimosis may lead to chronic inflammation
  • Phimosis may lead to penile cancer.
  • paraphimosis occurs when the foreskin has been retracted over the glans penis causing restriction of blood flow and vascular engorgement.
  • By 3 years of age, 90% of foreskins are retractable.
  • Less than 1% of males have phimosis by 17 years of age.

  RISK FACTORS

  • Diabetes mellitus

  SIGNS AND SYMPTOMS

  • Ballooning of the foreskin with micturition.
  • Recurrent balanitis or balanoposthitis.
  • Skin lacerations and bleeding of the foreskin with sexual activity.

  DIFFERENTIAL DIAGNOSIS

  • Paraphimosis: due to prolonged retraction of the foreskin over the glans penis.
  • Balanitis: Inflammation of the glans penis and foreskin - can lead to the development of phimosis.

  LABORATORY FINDINGS

  • There are no laboratory findings since this is a physical examination diagnosis.
  • Patients with phimosis should be screened for diabetes mellitus with a fasting blood sugar.
 
TREATMENT
CIRCUMCISION
  • Contraindicated in neonates with hypospadias.
  • Commonly performed under local anesthesia in adults.
  • Outpatient procedure.
  • Performed under general anesthesia in children.
  • Main complications are bleeding and infection.
  • Hidden penis can occur in obese patients, dorsal slit is the preferred procedure in this patient population.
DORSAL SLIT
  • Preserves foreskin tissue while allowing full retraction of the foreskin.
  • Can be performed in the office or emergensy department to release paraphimosis.
FORCEFUL RETRACTION
  • Usually not indicated because of a high rate of recurrent adhesions
  • Can be performed in office under local anesthesia, EMLA cream.
 
IMPORTANT POINTS/RECOMMENDATIONS
  • Circumcision appears to reduce the risk of sexually transmitted disease.
  • Circumcision appears to reduce the risk of HIV transmission to HIV negative female sexual partners.
  • Uncircumcised patients with good hygeine do not appear to be at increased risk of penile cancer.
 
REFERENCES
  1. Oster, J ;  Further fate of the foreskin: Incidence of preputial adhesions, phimosis, and smegma amongst Danish school boys. ;  Arch, Dis. Child 1968;43:200.

  2. Berdeu D, Sauze L, Ha-Vinh P, Blum-Boisgard C. ;  Cost-effectiveness analysis of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect. ;  BJU Int 2001 Feb;87(3):239-44

  3. Van Howe RS. ;  Cost-effective treatment of phimosis. ;  Pediatrics 1998 Oct;102(4):E43

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