What are phimosis and paraphimosis in children. How are these foreskin conditions diagnosed and treated. What complications can arise from phimosis and paraphimosis. When should parents seek medical attention for their child’s foreskin issues.

Defining Phimosis and Paraphimosis: Foreskin Complications in Young Boys

Phimosis and paraphimosis are two distinct yet related conditions affecting the foreskin of the penis in children. These issues can cause discomfort and, in some cases, lead to more serious complications if left untreated.

Phimosis occurs when the foreskin cannot be retracted or pulled back from the tip of the penis. This condition is relatively common in young boys and often resolves naturally as they grow older. On the other hand, paraphimosis is a more urgent condition where the foreskin, once retracted, cannot be returned to its original position. This can impede normal blood flow to the penis and potentially result in serious complications.

Key Differences Between Phimosis and Paraphimosis

• Phimosis: Inability to retract the foreskin
• Paraphimosis: Inability to return the retracted foreskin to its original position
• Phimosis: Generally not an emergency
• Paraphimosis: Considered a medical emergency requiring immediate attention

Causes of Phimosis and Paraphimosis in Children

Understanding the underlying causes of these conditions is crucial for proper management and prevention. While some cases may be natural occurrences, others can result from improper handling or underlying medical issues.

Phimosis: Natural Development and Potential Complications

Phimosis is often a normal part of penile development in young boys. The foreskin is typically adherent to the glans (head of the penis) at birth and gradually separates over time. This process can take several years, and it’s not uncommon for boys to have some degree of phimosis until they reach their teenage years.

However, phimosis can also occur as a result of:

• Premature forceful retraction of the foreskin
• Formation of fibrous scar tissue due to injury or infection
• Skin conditions affecting the foreskin

Paraphimosis: A Result of Improper Foreskin Management

Paraphimosis typically occurs when the foreskin is retracted behind the corona (the ridge of the glans) and becomes too tight to be pulled forward again. This can happen due to:

• Improper cleaning techniques
• Medical procedures involving catheterization
• Sexual activity

Is paraphimosis always caused by human intervention? While most cases of paraphimosis are indeed the result of manual retraction of the foreskin, some instances can occur spontaneously, especially in children with pre-existing phimosis or other foreskin abnormalities.

Recognizing the Symptoms of Phimosis and Paraphimosis

Identifying the symptoms of phimosis and paraphimosis early can help prevent complications and ensure timely treatment. Parents and caregivers should be aware of the signs associated with these conditions.

Common Symptoms of Phimosis

• Inability to fully retract the foreskin by age 3 (though this can vary)
• Ballooning of the foreskin during urination
• Discomfort or pain when attempting to retract the foreskin

Telltale Signs of Paraphimosis

• Swelling of the glans (tip of the penis)
• Pain and discoloration (dark red or blue) of the glans
• Difficulty urinating or decreased urine stream
• Inability to return the retracted foreskin to its original position

Can phimosis cause pain during urination? While phimosis itself may not directly cause pain during urination, it can lead to a condition called ballooning, where urine gets trapped under the foreskin. This can cause discomfort and may increase the risk of urinary tract infections.

Diagnostic Approaches for Phimosis and Paraphimosis

Accurate diagnosis of phimosis and paraphimosis is crucial for determining the appropriate course of treatment. Healthcare providers employ various methods to assess these conditions and rule out other potential issues.

Medical History and Physical Examination

The diagnostic process typically begins with a thorough medical history and physical examination. The healthcare provider will ask about the child’s symptoms, their duration, and any factors that may have contributed to the condition. During the physical exam, the doctor will carefully inspect the penis and foreskin to assess the degree of retraction and any signs of inflammation or infection.

Additional Diagnostic Measures

In some cases, additional tests may be necessary to confirm the diagnosis or rule out other conditions. These may include:

• Urine tests to check for infections
• Imaging studies (rarely needed) to assess the structure of the penis and surrounding tissues
• Skin cultures if a fungal or bacterial infection is suspected

How do doctors differentiate between physiological and pathological phimosis? Physiological phimosis is a normal developmental stage where the foreskin is not yet retractable. Pathological phimosis, on the other hand, is characterized by scarring, thickening, or other abnormalities of the foreskin. Doctors can usually distinguish between the two through careful examination and by considering the child’s age and medical history.

Treatment Options for Phimosis and Paraphimosis in Children

The treatment approach for phimosis and paraphimosis depends on the severity of the condition, the child’s age, and any underlying factors contributing to the problem. From conservative management to surgical interventions, there are several options available.

Conservative Management of Phimosis

For many cases of phimosis, especially in younger children, conservative treatment is often the first line of approach. This may include:

• Gentle stretching exercises to gradually loosen the foreskin
• Application of topical steroid creams to reduce inflammation and promote skin elasticity
• Proper hygiene practices to prevent infections and irritation

Surgical Interventions for Persistent Phimosis

If conservative measures fail or if the phimosis is severe, surgical options may be considered:

• Preputioplasty: A procedure to widen the opening of the foreskin without removing it
• Circumcision: Complete removal of the foreskin, often reserved for cases where other treatments have failed

Emergency Management of Paraphimosis

Paraphimosis requires immediate medical attention to prevent complications. Treatment may involve:

• Manual reduction: Gently compressing the glans and pulling the foreskin forward
• Use of lubricants and cold compresses to reduce swelling
• In severe cases, a small incision in the foreskin may be necessary to relieve constriction

Is circumcision always necessary for treating phimosis? No, circumcision is not always necessary for treating phimosis. Many cases can be resolved with conservative measures or less invasive surgical procedures. Circumcision is typically considered when other treatments have failed or in cases of recurrent problems.

Potential Complications and Long-term Outlook

While phimosis and paraphimosis are often treatable conditions, they can lead to complications if left unaddressed. Understanding these potential issues and the long-term outlook can help parents make informed decisions about their child’s care.

Possible Complications of Untreated Phimosis and Paraphimosis

• Urinary tract infections due to trapped bacteria under the foreskin
• Difficulty urinating or pain during urination
• Increased risk of sexually transmitted infections later in life
• In severe cases of paraphimosis, tissue death (necrosis) of the glans can occur

Long-term Prognosis

The long-term outlook for children with phimosis and paraphimosis is generally positive, especially when the conditions are addressed promptly and appropriately. Most boys with phimosis will experience natural resolution as they grow older, while those who require treatment often have good outcomes with minimal long-term effects.

Can phimosis recur after treatment? While recurrence is possible, especially in cases treated conservatively, it is relatively uncommon. Proper follow-up care and adherence to recommended hygiene practices can help prevent recurrence in most cases.

When to Seek Medical Attention for Foreskin Issues

Knowing when to consult a healthcare provider about foreskin problems is crucial for preventing complications and ensuring timely treatment. While some degree of non-retractability is normal in young boys, certain signs warrant medical evaluation.

Signs That Require Immediate Medical Attention

• Severe pain or swelling of the penis
• Discoloration of the glans, especially if it appears dark red or blue
• Inability to urinate or significantly decreased urine flow
• Signs of infection, such as fever or pus-like discharge
• Foreskin that cannot be returned to its normal position after retraction

Routine Check-ups and Preventive Care

Regular check-ups with a pediatrician can help monitor the development of the foreskin and catch any potential issues early. Parents should also be educated on proper foreskin care and hygiene to prevent problems.

How often should parents check their child’s foreskin for potential issues? While routine genital examinations are part of regular pediatric check-ups, parents should be attentive to any changes or complaints from their child. However, it’s important not to force retraction of the foreskin, as this can cause injury and lead to problems.

Educating Parents and Caregivers: Proper Foreskin Care and Hygiene

Proper education about foreskin care is essential for preventing problems and ensuring healthy development. Parents and caregivers play a crucial role in maintaining their child’s genital health and should be well-informed about appropriate care techniques.

Basic Principles of Foreskin Care

• Clean the penis externally with warm water during regular bathing
• Avoid using soap directly on the foreskin, as it can cause irritation
• Never forcefully retract the foreskin; allow it to separate naturally over time
• Teach older boys to gently retract and clean under the foreskin once it becomes naturally retractable

Common Misconceptions About Foreskin Care

There are several myths and misconceptions surrounding foreskin care that can lead to improper practices. Some of these include:

• The belief that the foreskin needs to be retracted and cleaned from birth
• The idea that all boys should be able to retract their foreskin by a certain age
• The notion that inability to retract the foreskin always requires medical intervention

What is the appropriate age to begin teaching boys about foreskin hygiene? The appropriate age to begin teaching boys about foreskin hygiene varies, but generally, it’s advisable to start introducing the concept around age 3-4. However, actual retraction and cleaning under the foreskin should only begin when the foreskin has naturally become retractable, which can occur at widely varying ages.

By understanding the nuances of phimosis and paraphimosis, recognizing symptoms early, and knowing when to seek medical attention, parents and caregivers can ensure the best possible outcomes for their children’s genital health. Proper education and regular check-ups are key to preventing complications and promoting healthy development of the foreskin.

Phimosis and Paraphimosis in Children

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DIAGNOSIS

TREATMENT

NEXT STEPS

What is phimosis and paraphimosis in children?

Phimosis and paraphimosis are problems with the foreskin of the
penis. Phimosis is when a foreskin can’t be pulled down (retracted) from the tip of the
penis. This is a common problem in young boys. Paraphimosis is when the foreskin is
retracted but can’t move back up. This can prevent normal blood flow in the penis, and
may cause serious problems.

What causes phimosis and paraphimosis in a child?

Phimosis is caused by a tightening
of the opening of the foreskin. This is normal in a newborn baby. Over time the foreskin
loosens and can be pulled down more easily. By age 17, most boys will be able to fully
retract their foreskin. Phimosis can also occur if the foreskin is forced back before it
is ready. This can cause a fibrous scar to form. This can stop the foreskin from
retracting in the future.

Paraphimosis is caused when the
foreskin is retracted behind the crown (corona) of the penis. The foreskin is too tight
to be moved back to the tip of the penis.

What are the symptoms of phimosis and paraphimosis in a child?

Symptoms can be a bit different in
each child.

The most common symptoms of phimosis include:

• Bulging of the foreskin when
  urinating
• Not able to fully retract the foreskin by age 3. In some boys this may take longer.

The most common symptoms of paraphimosis include:

• Swelling of the tip of the penis when
  the foreskin is pulled back
• Pain
• Not able to pull the foreskin back
  over the tip of the penis
• Tip of the penis is dark red or blue
  in color
• Pain when urinating
• Decreased urinary stream

The symptoms of phimosis and
paraphimosis can seem like other health conditions. Have your child see his healthcare
provider for a diagnosis. A paraphimosis is an emergency medical condition. Seek medical
care right away if you think your child has paraphimosis.

How are phimosis and paraphimosis diagnosed in a child?

The healthcare provider will ask about your child’s symptoms and health history. He or she will give your child a physical exam. The physical exam will include examining the penis and foreskin.

How are phimosis and paraphimosis treated in a child?

Treatment will depend on your child’s symptoms, age, and general health. It will also depend on how severe the condition is.

Treatment for repeated phimosis may include:

• Putting a steroid cream on the
  foreskin up to 3 times a day for 1 month. This is to loosen the skin.
• Having surgery to remove all or part
  of the foreskin (circumcision) for a child age 10 or older who still has bulging of
  the foreskin when urinating

Treatment for paraphimosis may include:

• Lubricating the foreskin and tip of the penis, then gently squeezing the tip of the penis while pulling the foreskin forward
• Making a small cut (incision) in the foreskin
• Having surgery to remove all or part of the foreskin (circumcision)

Talk with your child’s healthcare providers about the risks, benefits, and possible side effects of all treatments.

What are possible complications of phimosis and paraphimosis in a child?

Possible complications can include:

• Pain
• Infection
• Trouble urinating
• Death of tissue (necrosis) in the tip of the penis

When should I call my child’s healthcare provider?

Call the healthcare provider if your child has:

• Symptoms that don’t get better, or get worse
• New symptoms

Key points about phimosis and paraphimosis in children

• Phimosis and paraphimosis are problems with the foreskin of the penis.
• Phimosis is when a foreskin can’t be pulled down (retracted) from the tip of the penis. This is a common problem in young boys.
• Paraphimosis is when the foreskin is retracted but can’t move back up. This can prevent normal blood flow in the penis, and may cause serious problems.
• Treatment for either problem may include steroid cream, lubrication, or surgery to remove the foreskin.
• Possible complications can include trouble urinating and death of tissue (necrosis) in the tip of the penis.

Next steps

Tips to help you get the most from a visit to your child’s healthcare provider:

• Know the reason for the visit and what you want to happen.
• Before your visit, write down questions you want answered.
• At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you for your child.
• Know why a new medicine or treatment is prescribed and how it will help your child. Also know what the side effects are.
• Ask if your child’s condition can be treated in other ways.
• Know why a test or procedure is recommended and what the results could mean.
• Know what to expect if your child does not take the medicine or have the test or procedure.
• If your child has a follow-up appointment, write down the date, time, and purpose for that visit.
• Know how you can contact your child’s provider after office hours. This is important if your child becomes ill and you have questions or need advice.

Phimosis | UCSF Department of Urology

What is Phimosis?

Phimosis is defined as the inability to retract the skin (foreskin or prepuce) covering the head (glans) of the penis. Phimosis may appear as a tight ring or “rubber band” of foreskin around the tip of the penis, preventing full retraction. Phimosis is divided into two forms: physiologic and pathologic. Current incidence of phimosis is about 1% in 7^th grade boys.

Physiologic phimosis: Children are born with tight foreskin at birth and separation occurs naturally over time. Phimosis is normal for the uncircumcised infant/child and usually resolves around 5-7 years of age, however the child may be older.

Pathologic phimosis: Phimosis that occurs due to scarring, infection or inflammation. Forceful foreskin retraction can lead to bleeding, scarring, and psychological trauma for the child and parent. If there is ballooning of the foreskin during urination, difficulty with urination, or infection, then treatment may be warranted.

Care of Uncircumcised Penis:

No special care is required for foreskin in infancy. The foreskin should not be forcibly retracted, however gentle retraction is okay. In the first few years of life, gentle retraction with cleansing underneath the foreskin is sufficient during diaper changes or bathing and will result in progressive retraction over time. Once the child is older and the foreskin retracts fully, he will learn to retract, cleanse and dry underneath the foreskin as part of his hygiene routine. After retraction, the foreskin should be pulled back over the head of the penis and returned to the normal position.

Smegma:

Smegma is a collection of skin cells from the glans penis and inner foreskin that is often noted with retraction of the foreskin. This natural skin shedding helps to separate the foreskin from the head of the penis. Smegma may appear as white pearls underneath the skin, which can easily be washed off once the foreskin is retracted.

How is phimosis diagnosed and evaluated?

In physiologic phimosis, benign (non-life threatening) conditions may occur that are common in uncircumcised males, including; cysts related to smegma production/trapping and transient painless ballooning of the foreskin during urination. These are considered normal variations that usually resolve with daily gentle manual retraction. 

Pathologic phimosis that does not resolve naturally or causes other complications, including; penile irritation or bleeding, ballooning of the foreskin with urination resulting in forceful/difficult urination, urinary retention, painful urination (dysuria), painful erections, recurrent infections of the foreskin (balanoposthitis), paraphimosis (foreskin stuck in the retracted position behind the head of the penis), or urinary tract infections may require further treatment. Your medical provider will refer your child to a pediatric urologist for further evaluation.

How is phimosis treated?

Treatments for phimosis vary depending on the child and severity of phimosis. Treatments may include: gentle daily manual retraction, topical corticosteroid ointment application or circumcision.

Topical corticosteroid therapy:

Medical providers may recommend topical steriod ointment application for children with phimosis.  This is an effective treatment in most males. These topical ointments are used to help soften the tight foreskin around the penis, so the foreskin may be easily retracted. Your provider will demonstrate how to apply the ointment to the tight ring of foreskin and/or head of the penis. The ointment is massaged into the affected areas twice daily for 6-8 weeks along with manual stretching/retraction twice daily. Once the foreskin can be fully retracted, the ointment is discontinued and manual daily retraction (during warm baths and urination for the potty trained child) will prevent phimosis from reoccurring.   The most common corticosteroids used are hydrocortisone 2.5%, betamethasone 0.05%, triamcinolone 0.01%, and fluticasone propionate 0.05%.

Circumcision:

Male circumcision refers to the surgical removal of the foreskin.  Circumcision is often not required for treatment of phimosis. In some rare cases your pediatric urologist may recommend circumcision due to failure of steroid ointment, pathologic phimosis, paraphimosis (foreskin stuck in the retracted position behind the head of the penis), recurrent urinary tract infections, or severe/recurrent balanoposthitis.

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Table of contents

Pediatric urology deals with the diagnosis and treatment of diseases and defects of the genitourinary and urinary systems in children. Today, according to expert estimates, every fourth child in the Russian Federation has urological problems. Pediatric urology is aimed at early detection of pathologies and their treatment. All parents should remember that they must be very attentive to the health of their children, because many urological diseases often begin without any obvious symptoms. If diseases of the genitourinary system are not cured in a timely manner in early childhood, then in adulthood a person may encounter irreversible processes that will be expensive and difficult to treat, and sometimes impossible.

Your child was diagnosed with: phimosis ?

We offer you a brief but very detailed overview of this disease. It was prepared by employees of the Children’s Uroandrological Department of the N.A. Lopatkin – a branch of the Federal State Budgetary Institution “NMITs Radiology” of the Ministry of Health of Russia.

Introduction

Phimosis (narrowing of the foreskin) is one of the most common diseases in the practice of a pediatric urologist and pediatric surgeon. The term phimosis is of Greek origin, meaning (muzzle, muzzle), this is a pathological condition in which it is impossible to expose the glans penis. The main cause of phimosis in patients is the presence of a dense, scarring ring of the foreskin.

Classification of phimosis

Physiological phimosis.

There are physiological, hypertrophic and cicatricial narrowing of the foreskin. Treatment, this pathology, only operational, by excision of scar tissue. However, this does not mean that all children need surgery. The congenital narrow opening of the preputial sac at the point of transition of the outer leaf of the foreskin to the inner one is a “physiological” narrowing of the foreskin.

In this situation, the skin of the foreskin does not have cicatricial changes, it is soft and stretches well. When trying to quickly or roughly remove the head, radial

cracks in the junction of the inner and outer layers of the foreskin.
Hypertrophic phimosis or proboscis foreskin: a condition in which there is excess foreskin, when trying to expose the glans penis, the prepuce is pulled into the proboscis. Children with hypertrophic phimosis are usually malnourished and overweight.

Hypertrophic or proboscis phimosis

Cicatricial phimosis is a condition of the foreskin in which there are cicatricial changes in the foreskin (radial white stripes), when trying to remove the head, a dense cicatricial ring was determined, which did not allow examining the head. Inflammatory diseases of the foreskin (balanoposthitis, fungal inflammation) or trauma of the foreskin (rough, simultaneous removal of the glans penis) can lead to such a situation.
Paraphimosis is a pathological condition characterized by the abduction of the narrow foreskin behind the glans penis, at the level of the coronal sulcus, it can pinch the frenulum and cause swelling of the glans penis. Paraphimosis requires emergency care, since prolonged compression leads to impaired blood circulation and there is a risk of developing necrosis (death) of the head.

Cicatricial phimosis

Treatment

The presence of physiological or hypertrophic phimosis in children, as a rule, does not require surgical treatment. The solution to these states is to apply gradual gentle stretching of the foreskin (avoiding even minimal tears and cracks) . Only in a small number of cases with hypertrophic phimosis is surgical assistance required.
Indications for surgical treatment are recurrent balanoposthitis and recurrent urinary tract infections against the background of anomalies in the development of the foreskin. Cicatricial phimosis is an absolute indication for surgical treatment. Operative treatment of phimosis consists in radical (full) or pastic (partial) circumcision of the foreskin of the child. When performing a partial circumcision, part of the foreskin is preserved, but this surgical intervention is accompanied by the risk of recurrence of the disease. During the operation, the adhesions (synechia) between the inner layer of the foreskin and the head are also separated, the plastic of the frenulum (elimination of its shortening) and meatoplasty (expansion of the external opening of the urethra) are performed. A contraindication to circumcision is the presence of congenital anomalies in the development of the penis and urethra (hypospadias, epispadias, hidden penis), since the foreskin can be a material for performing reconstructive plastic surgery.
In the case of paraphimosis, the physician compresses the edematous tissue of the foreskin and attempts to pull back the taut, tense skin of the foreskin through the glans penis. If the manipulation is ineffective, the compression ring is cut along the anterior-upper surface of the penis.

Where can children’s urological diseases be cured?

Treatment of diseases of the penis – symptoms and causes

There are quite a few types of conditions and diseases of the penis. Some of them are minor and do not cause much problems, and some require emergency medical care or surgery. Diseases of the penis can be congenital or develop over time.

General symptoms of diseases of the genital organ

• pain, swelling, burning;
• abnormal discharge;
• itchy rash, blisters, sores or small red dots;
• blood in urine or semen;
• an erection that lasts 4 hours or longer.

Types of diseases of the penis

The group of pathologies of the penis includes:

Balanitis (balanoposthitis)

Balanitis is an inflammation of the foreskin and glans penis. The most common causes are the presence of pathogenic flora (E. coli, staphylococci), candidiasis, papillomavirus, and poor hygiene (especially in uncircumcised men). Symptoms of balanitis may include penile pain, swelling, itching, rash, and foul-smelling discharge. If an infection is the cause, treatment will include antibiotics and antifungals. If balanitis is severe and recurs, circumcision may be the best treatment option.

Penile warts

The causative agent of the disease is the human papillomavirus. Despite the benign nature of the neoplasms, the risk of oncological diseases, including penile cancer, is high. Depending on the stage of the disease, warts are removed by surgery or laser therapy.

Epispadias

Epispadias is a rare birth defect characterized by the incomplete development of the urethra, resulting in an inability to properly expel urine from the body. Symptoms of epispadias in men include an abnormally located opening in the urethra, an enlarged pubic bone, curvature of the penis, urinary incontinence, and urinary tract infections. Cases range from mild to severe. In mild cases, surgery may not be required, but in most cases, epispadias requires surgical correction. The goal of treatment is to maximize the function of the penis as well as to give it a normal appearance. In cases where the bladder is affected, surgery should also create a pathway for the normal passage of urine and help maintain fertility.

Peyronie’s disease

Peyronie’s disease occurs when scar tissue called plaque forms inside the penis and makes the erection crooked and painful. In many men, an erect penis is slightly curved, and this does not cause any problems. But when it’s painful or the bend is significant, it can lead to erectile dysfunction and even make intercourse impossible. Signs of Peyronie’s disease include scar tissue that can be felt under the skin of the penis, significant bending of the penis, difficulty getting or maintaining an erection, penile pain and shortening. Sometimes Peyronie’s disease is mild and does not cause serious problems. In this case, treatment may not be required. However, if your penis hurts or bends causing problems during intercourse, see a urologist. If the disease is severe, surgical intervention is possible.

Phimosis and paraphimosis

This is a narrowing of the foreskin and the inability to expose the glans penis. Mostly of a physiological nature. It occurs in more than 90% of newborn boys. Physiological phimosis disappears by 6-7 years. Pathological phimosis develops as a result of trauma to the penis, poor hygiene. Paraphimosis is a narrowing of the foreskin under the head of the penis. It develops as a complication after phimosis. This pathology is eliminated exclusively by surgery. Symptoms of paraphimosis include the inability to return the foreskin to its normal position, difficulty with ejaculation and urination, discoloration or bruising of the penis, and swelling.

Priapism

Priapism is a persistent erection that lasts more than four hours and does not go away with orgasm.