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

Defining Phimosis and Paraphimosis: Foreskin Problems in Boys

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

What is Phimosis?

Phimosis is a condition where the foreskin cannot be retracted or pulled back from the tip of the penis. This is a common occurrence in young boys and is often considered normal in newborns and infants. As a child grows, the foreskin typically becomes more pliable and can be retracted more easily.

What is Paraphimosis?

Paraphimosis, on the other hand, occurs when the foreskin is retracted behind the corona (the ridge of the penis head) but cannot be returned to its original position. This condition can potentially restrict blood flow to the penis and is considered a medical emergency.

Causes of Phimosis and Paraphimosis in Children

Understanding the underlying causes of these conditions is crucial for proper management and prevention.

Why does phimosis occur?

Phimosis can be physiological or pathological. Physiological phimosis is normal in young children and typically resolves on its own as the child grows. Pathological phimosis may be caused by:

• Forceful retraction of the foreskin before it’s ready, leading to scarring
• Recurrent infections or inflammation of the foreskin
• Skin conditions affecting the genital area

What leads to paraphimosis?

Paraphimosis usually occurs when the foreskin is left retracted for an extended period, causing swelling and constriction. This can happen due to:

• Improper cleaning techniques
• Medical procedures involving catheterization
• Curiosity-driven manipulation by the child

Recognizing Symptoms of Phimosis and Paraphimosis

Identifying the signs of these conditions early can prevent complications and ensure timely treatment.

What are the symptoms of phimosis?

The primary symptom of phimosis is the inability to retract the foreskin fully. Other signs may include:

• Ballooning of the foreskin during urination
• Difficulty urinating or a weak urine stream
• Recurrent infections under the foreskin

How does paraphimosis present?

Paraphimosis symptoms are often more acute and may include:

• Swelling and discoloration of the penis tip
• Severe pain in the affected area
• Inability to return the foreskin to its original position
• Difficulty urinating

Diagnosing Foreskin Problems in Children

Accurate diagnosis is essential for appropriate treatment of phimosis and paraphimosis.

How are these conditions diagnosed?

Diagnosis typically involves a physical examination by a healthcare provider. The doctor will assess the appearance of the foreskin and its ability to retract. In some cases, additional tests may be necessary to rule out underlying conditions or complications.

Are any special tests required?

While most cases can be diagnosed through physical examination alone, some situations may warrant further investigation:

• Urine tests to check for infections
• Skin swabs to identify any bacterial or fungal presence
• In rare cases, imaging studies to assess the extent of any complications

Treatment Options for Phimosis and Paraphimosis

The approach to treatment varies depending on the severity of the condition and the age of the child.

How is phimosis treated?

Treatment for phimosis may include:

1. Gentle stretching exercises to gradually loosen the foreskin
2. Application of topical steroid creams to reduce inflammation and promote skin elasticity
3. In persistent cases, surgical options such as circumcision or preputioplasty may be considered

What is the treatment for paraphimosis?

Paraphimosis requires immediate medical attention. Treatment approaches include:

1. Manual reduction of the foreskin after applying lubricant and ice to reduce swelling
2. If manual reduction fails, a small incision may be necessary to relieve the constriction
3. In severe cases or recurrent episodes, circumcision might be recommended

Preventing Complications: Long-term Management and Care

Proper care and attention can help prevent recurrence and complications of foreskin problems.

How can parents prevent foreskin issues?

Prevention strategies include:

• Proper hygiene practices without forceful retraction of the foreskin
• Regular check-ups with a pediatrician to monitor foreskin development
• Education on proper cleaning techniques as the child grows

What are the potential complications if left untreated?

Untreated phimosis and paraphimosis can lead to serious complications such as:

• Urinary tract infections
• Balanitis (inflammation of the penis head)
• In severe cases of paraphimosis, tissue necrosis and permanent damage to the penis

When to Seek Medical Attention for Foreskin Problems

Knowing when to consult a healthcare provider is crucial for timely intervention and prevention of complications.

When should parents be concerned about their child’s foreskin?

Parents should seek medical advice if:

• The child experiences pain or discomfort during urination
• There is persistent redness, swelling, or discharge from the foreskin
• The foreskin cannot be retracted by age 5-7 (though this can vary)
• The retracted foreskin cannot be returned to its normal position

Is paraphimosis always an emergency?

Yes, paraphimosis is considered a medical emergency. If a retracted foreskin cannot be returned to its normal position, immediate medical attention is necessary to prevent potential tissue damage and other complications.

Addressing Concerns: Psychological Impact and Patient Education

Foreskin problems can be a source of anxiety for both children and parents. Proper education and support are essential components of care.

How can healthcare providers address patient and parent concerns?

Healthcare providers can support patients and families by:

• Providing clear, age-appropriate explanations of the condition and treatment options
• Offering reassurance about the normalcy of foreskin variations and development
• Discussing potential psychological impacts and offering resources for support if needed

What role does patient education play in managing foreskin problems?

Patient education is crucial for effective management and prevention of foreskin issues. It involves:

• Teaching proper hygiene practices to both children and parents
• Explaining the normal development of the foreskin and what changes to expect
• Providing guidance on when to seek medical attention

By fostering open communication and providing comprehensive education, healthcare providers can help alleviate concerns and ensure better outcomes for children with foreskin problems.

Understanding phimosis and paraphimosis in children is essential for parents and healthcare providers alike. These conditions, while common, require careful attention and appropriate management to prevent complications and ensure the well-being of affected children. With proper care, education, and timely intervention, most foreskin problems can be effectively addressed, allowing for normal development and function.

Phimosis and Paraphimosis in Children

ABOUT

CAUSES
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.

Foreskin Care Questions

Is this your child’s symptom?

• Foreskin and penis care questions in boys not circumcised
• Includes questions about foreskin retraction
• Smegma questions are covered

Types of Foreskin Retraction Problems

• The foreskin usually causes no problems.
• Paraphimosis. Forceful retraction can cause the foreskin to get stuck behind the glans. The glans is the head of the penis. This can cause severe pain and swelling and is a medical emergency.
• Cut. If retraction is forceful, it can cause a small cut. This cut may cause a small amount of bleeding and pain.
• Infection. Sometimes, the cut causes the space under the foreskin to become infected. The main symptom is a red and tender foreskin. Pus may also come out to the foreskin opening.

When to Call for Foreskin Care Questions

Call Doctor or Seek Care Now

• Severe pain
• Red foreskin with fever
• Your child looks or acts very sick
• You think your child needs to be seen, and the problem is urgent

Contact Doctor Within 24 Hours

• Red foreskin, but no fever
• Swollen foreskin
• Pus from end of foreskin
• Painful foreskin
• You think your child needs to be seen, but the problem is not urgent

Contact Doctor During Office Hours

• Urine stream looks abnormal
• You have other questions or concerns

Self Care at Home

• Questions about normal foreskin care
• Questions about foreskin retraction
• Questions about smegma (whitish material) under the foreskin

Seattle Children’s Urgent Care Locations

If your child’s illness or injury is life-threatening, call 911.

• 
  
  
  
  
  Bellevue
  
  
  
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  Everett
  
  
  
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  Federal Way
  
  
  
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  Seattle
  
  
  
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  Virtual Urgent Care
  
  
  

Care Advice for Foreskin Care

1. What You Should Know About the Foreskin:
   • At birth, the foreskin is attached to the head of the penis (glans). It is attached by a layer of cells.
   • Over time, the foreskin will separate from the head of the penis. This is a natural process and occurs over 5 to 10 years. It slowly loosens up (retracts) a little at a time.
   • Normal erections during childhood cause most of the change by stretching the foreskin.
   • If your boy has a normal urine stream, any foreskin movement is normal.
   • There should be no rush to achieve full retraction. This always occurs on its own by puberty.
   • Here is some care advice that should help.
2. Before Age 1 Year – How to Clean:
   • During the first year of life, only clean the outside of the foreskin.
   • Don’t make any attempts at retraction.
   • Don’t put any cotton swabs into the opening.
3. After Age 1 Year – How to Clean:
   • As the foreskin becomes able to retract on its own, cleanse beneath it. This helps to prevent infections. Exception: your child’s doctor has told you not to retract the foreskin until child is older.
   • Wash the exposed part of the glans gently with warm water. Then, dry it.
   • Do not use soap or leave soapy water under the foreskin. This can cause redness and swelling.
   • Wipe away any whitish material (smegma) that you find there.
   • It can be done once per week during bathing.
4. Foreskin Partial Retraction – How to:
   • Begin gentle partial retraction at 1 to 2 years of age.
   • Gently pull the skin on the shaft of the penis backward towards the stomach.
   • This will make the foreskin open up. You will be able to see part of the glans. The glans is the tip of the penis.
   • Be gentle. Retraction should never cause pain or crying.
5. Reposition the Foreskin:
   • After cleansing, always pull the foreskin forward to its normal position.
6. Avoid Forceful Retraction:
   • This can cause bleeding or tears of the tissue.
   • It also may cause the foreskin to become stuck behind the penis head.
   • Retraction is too hard if it causes any pain or crying.
7. Teach Child to Retract (Age 6):
   • By age 6, teach your son to retract his own foreskin.
   • Teach him to clean beneath it once a week during bathing.
   • This will help to prevent poor hygiene and infection.
8. Pain Following Recent Attempt at Retraction:
   • The attempt to retract the foreskin has probably caused a small cut or tear. Raw surfaces are painful.
   • Cover the raw area with a layer of antibiotic ointment (such as Polysporin).
   • If you don’t have one, use petroleum jelly (such as Vaseline).
   • Once the raw surface is protected from the air, the pain should go away. The pain should slowly improve over a few hours.
   • Continue twice a day until healed. This takes about 1 or 2 days.
9. The No-Retraction Approach to the Foreskin:
   • Some doctors advise that a parent should never attempt to retract the foreskin. They also say never clean under the foreskin.
   • They teach that only the boy himself should ever retract his foreskin. This teaching should occur after puberty or about age 12.
   • They teach that the foreskin will naturally retract on its own during puberty. This is usually true.
   • The advice against parent retraction is more common in Europe.
   • It is a safe option. It prevents too much or forceful retraction.
   • But, the gentle partial retraction for cleansing (described in this guide) is also safe.
   • Ask your child’s doctor for his or her thoughts.
10. Smegma – General Information:
    • Smegma is the small pieces of whitish material found under the foreskin.
    • Smegma is made up of dead skin cells. These cells are shed from the lining of the foreskin and the penis. It becomes trapped under the foreskin.
    • Smegma is normal and harmless. It is not a sign of an infection. It is produced in small amounts throughout life.
    • Smegma can build up under the foreskin. This happens if the foreskin is not pulled back and cleaned regularly.
    • Smegma also can occur before the foreskin becomes retractable. It looks like small white lumps. It lies under the foreskin that is still stuck to the penis head. It can’t be removed at this stage.
    • If it lies beyond the level of foreskin retraction, it should be left alone. Wait until normal separation exposes it. Then, gently wipe it away.
    • Caution. During the first year of life, do not make any attempts at foreskin retraction. Leave the smegma alone.
11. Call Your Doctor If:
    • Pain lasts more than 24 hours
    • Foreskin looks infected
    • Other foreskin problems occur
    • You think your child needs to be seen

And remember, contact your doctor if your child develops any of the ‘Call Your Doctor’ symptoms.

Disclaimer: this health information is for educational purposes only. You, the reader, assume full responsibility for how you choose to use it.

Last Reviewed: 07/04/2023

Last Revised: 12/30/2022

Copyright 2000-2023. Schmitt Pediatric Guidelines LLC.

90,000 diagnostics and treatment at the Research Institute of Urology. ON THE. Lopatkin.

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 phimosis and paraphimosis in men

Phimosis and paraphimosis are narrowing of the foreskin of the penis. With phimosis, it is impossible to expose the head of the penis. Paraphimosis, on the contrary, is a complication in which the head is difficult to “close”. Its narrowing occurs due to the infringement of the foreskin during intercourse or masturbation.

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Contents

• Description of phimosis and paraphimosis

• Symptoms of phimosis and paraphimosis

• Diagnosis of phimosis and paraphimosis

• Treatment of phimosis and paraphimosis in children and adults

Description of phimosis and paraphimosis

Phimosis in adults persists from childhood, and may develop during their puberty, as well as appear as a result of various injuries and inflammatory processes in the genital organs. As a result, there is a discrepancy between the development of the foreskin and the penis, which prevents the opening of the glans, since the opening in the foreskin is smaller and narrower than the size of the penis. As a result, the penis cannot pass through it, and the opening will be painful and difficult.

There are several types of phimosis.

1 degree – occurs during the excitation of the penis. The foreskin moves apart with minimal effort, and in a calm state, the glans penis is able to open without difficulty and pain.

2nd degree – during excitation, the head is not exposed, but at rest it opens with the application of a small force.

3rd degree – in a calm state, the head is not exposed, in order to open it, it is necessary to make great efforts.

4 degree – the foreskin is significantly narrowed. Opening the glans penis, even to a small extent, is impossible. There are also problems with urination.

Paraphimosis occurs in most cases with an early attempt to retract the foreskin and release the glans penis. In adults, it also develops during masturbation or during intercourse. A possible cause of paraphimosis is an inelastic frenulum of the foreskin (the fold of skin that connects the glans penis and the foreskin). It makes it difficult to open the head and return the tissues to the opposite position.

The disease occurs in both children and adults.

Symptoms of phimosis and paraphimosis

The main symptom of phimosis is difficulty in exposing the glans penis, which may result in urinary problems.

During sexual intercourse, symptoms such as tearing of the foreskin, bleeding, a feeling of soreness, straining during urination, pain during erection, a feeling of skin tension, decreased potency due to psychological stress and sensation of pain may occur during intercourse.

A symptom of paraphimosis is the inability to return the foreskin to its original position, resulting in pain, swelling, and bluing of the organ. Also, the closure of the head can cause lymphatic or venous congestion and impaired arterial bleeding. Infringement of the head of the penis contributes to the growth of edema and an increase in the head itself, as a result, pain occurs even at the slightest touch. Urination is usually difficult. If the foreskin does not return to its original position for a long time, diseases such as ischemia, partial necrosis of the glans penis, or the development of gangrene develop.

Diagnosis of phimosis and paraphimosis

When diagnosing, an examination and palpation of the organ is carried out and the severity of the patient’s condition is determined. When making a diagnosis, there are usually no difficulties. With a disease of the fourth degree, when opening the head of the penis is almost impossible, the patient is sent for an ultrasound examination or advised to take an x-ray.

The diagnosis of paraphimosis is established in exactly the same way – on the basis of a visual examination of the patient.

Treatment of phimosis and paraphimosis in children and adults

In modern medicine, there are several signs of treatment for phimosis, but circumcision (circumcision) is the most effective, quick and simple. Circumcisio can be performed on patients with any stage of the disease. However, if the inflammatory process is running or there is a source of infection, this operation is undesirable. The operation itself is simple, takes a small amount of time, the recovery is fast, and after it is carried out, problems with the foreskin will no longer arise. In addition, operations are performed on the dissection of the foreskin in the presence of any complications.

Other methods may be classified as non-surgical. Namely: the use of drugs for some time, which helps to relieve swelling, reduce inflammation and increase tissue elasticity. Another way is stretching the foreskin. This method is carried out by hand or a special device. This method is ineffective, as it involves self-stretching of the flesh every day for several years. Moreover, this procedure must be done for several hours a day, which is extremely difficult for the patient, he quickly gives up, because he lacks motivation, and he does not see changes.

Since the development of phimosis is mainly a genetic disease, no special preventive measures can be recommended. Boys should in principle devote sufficient time to hygiene. And if phimosis appears, you should immediately consult a doctor.

First aid for phimosis consists of applying cold to the lesion due to pinching of the head, applying a bandage soaked in hypertonic solution (sodium chloride; salt dissolved in water), applying an elastic compressive bandage, applying local anesthesia, and so on. These activities not only reduce pain, but also contribute to the disappearance of edema.

Treatment of paraphimosis can be conservative or surgical. A longitudinal dissection of the pinching ring (incisio) is performed, and a puncture of edematous tissues (piercing and sampling of excess fluid) can also be performed. In order to avoid re-infringement of the glans penis, circumcision is performed after some time (using a laser or a radiosurgical scalpel). Conservative treatment involves bimanual reduction of the “closed” head. This treatment is good because the pathology is removed without surgery.