Foreskin Problems

Phimosis and paraphimosis are two conditions that can occur, which tighten the penile foreskin.

Sometimes, when the foreskin of the penis of an uncircumcised or improperly circumcised boy or man is caused by two conditions, 1) phimosis and 2) paraphimosis.

Phimosis: This condition occurs when the foreskin cannot be retracted (pulled back) behind the head (glans) of the penis. This is called phimosis. It is usually a condition found in children and occasionally adults. Physiological phimosis is a normal condition that occurs mainly during the first year of life when the foreskin is not retractable in these young males. This may occur until about 3 years of age. This condition is not a congenital problem such as a buried penis (the penis is located beneath the abdominal skin). Phimosis can often lead to a painful type of infection called balanitis.

Paraphimosis: This condition, paraphimosis, is somewhat the opposite of phimosis. The foreskin, after being pulled back, becomes trapped and then swollen behind the head (glans) of the penis. The swelling can lead to blockage of blood flow to the penis, which can lead to gangrene of the penile shaft and head distal to the welling. paraphimosis is considered a true medical emergency. Circumcision (surgical removal of the foreskin) at birth or revision of a prior circumcision can prevent this condition.

Symptoms and signs may develop problems with the foreskin that usually appears swollen.

With phimosis, the male child may have any or all of the following signs and symptoms:

1. Difficulty with urination
2. Pain upon urination
3. Blood in the urine
4. Pain in the penis

With paraphimosis, males can have these additional symptoms:

1. Penile pain (particularly in the glans)
2. Penile discoloration (this occurs after blood flow is cut off); penis may become whitish, bluish, gray, or black in color.

Causes for phimosis include infection, poor hygiene, and previous foreskin injury.

Any condition or activity that results in prolonged foreskin retraction can lead to the development of paraphimosis.

• An improperly circumcised penis
• Frequent insertion of bladder catheters
• Vigorous sexual activity, including masturbation
• Males forget to return the foreskin to its normal position after retracting it (for example, an elderly patient who needs self-catheterization).

• Phimosis usually does not require emergency medical treatment and many mild occurrences resolve without medical intervention. However, if the person has any urinary symptoms, for example, difficulty urinating or burning upon urination, then a doctor should be contacted within 12-24 hours. In certain circumstances, treating phimosis can lead to paraphimosis, which does require immediate medical attention.
• With paraphimosis, if a person cannot return the foreskin to its original position and the glans or foreskin becomes progressively more painful, swollen, or discolored, seek immediate medical attention.
• Paraphimosis is a medical emergency. If not treated immediately, it can result in gangrene of the glans and foreskin. Apply ice to the penis to reduce swelling; however, if the ice and direct pressure technique do not relieve the problem rapidly, go immediately to the nearest hospital's Emergency Department or a doctor's office.

The doctor often starts the examination by getting a detailed history of the problem, especially if it has occurred previously, and for male adults, a sexual history. Then the doctor will likely continue the examination as follows.

• In considering phimosis, the doctor may do at least two tests:
  • A full genital examination
  • A urinalysis to look for evidence of infection (if indicated)
• Paraphimosis can mimic other medical conditions so the doctor may find or inquire about the following:
• A constricting foreign body (usually a piece of hair wrapped around the penis, seen most often in infants); in adults, it can occur with certain sexual practices.
• Insect bites
• Contact dermatitis
• Infection

At this time, there is no recommended home therapy for phimosis except to practice good hygiene. Keep the groin area clean and dry.

Self-care treatment for paraphimosis includes applying ice to the penis to reduce swelling. One method is to place ice in a rubber glove and then place the penis inside the glove. After cold application, apply pressure to the glans while simultaneously pulling forward on the foreskin. If this does not resolve the problem, then immediately contact a doctor or go to an Emergency Department. If this is a recurrent problem, contact a doctor for an appointment.

Phimosis home treatment: A doctor can use certain tools to attempt to open or expand the stuck foreskin. Usually, a doctor will do this only if there are problems urinating.

Paraphimosis treatment: The doctor may repeat the ice with a direct pressure technique. If that does not free the foreskin, the doctor will, in most instances, contact a urologist for surgical treatment.

A local anesthetic will be introduced into the penis with a fine needle. An incision then will be made through the area of constriction, allowing the foreskin to return to its original position. However, there are other methods available that do not involve incisions; these may be performed in an Emergency Department or a doctor's office, although many doctors choose to have a urologist perform these procedures.

• Osmotic method: This technique uses the concept that fluids will flow from a lower osmotic area to a higher osmotic area. A hypertonic solution will cause the fluid from the penis to flow towards the hypertonic solution applied to the penis, therefore reducing the swelling.
• Hyaluronidase method: This method uses injections of hyaluronidase into swollen tissue.
• Aspiration method: This method uses a penile tourniquet and needle aspiration of about 12 ml of blood from the penis to reduce swelling.
• Puncture method: This method uses needles to puncture holes to allow edema fluid to escape from the swollen foreskin.

For either phimosis or paraphimosis, the person should follow up with a see to a urologist. To prevent phimosis from returning, parents should discuss with their doctor if circumcision is indicated. Circumcision is occasionally performed in adult males that develop recurrent foreskin problems.

With either condition, timely treatment usually resolves the problem. However, if either problem is neglected, the outlook can be poor, with recurrent urinary and kidney infections, gangrene, and even potential loss of the penis (by auto-amputation or dry gangrene).

• Phimosis only affects uncircumcised males. Circumcision is the definitive preventive measure against this disorder. For those who choose to remain uncircumcised, proper hygiene can reduce the risk of developing phimosis.
• Paraphimosis has no effective preventive measures beyond proper hygiene and circumcision.