Phimosis and Paraphimosis
EAU Guidelines on Paediatric Urology. Last updated: Apr 2025.
Phimosis
Definition
Phimosis refers to the inability to retract the prepuce (foreskin) over the glans penis.
Aetiology
Phimosis can be physiological or pathological: [Ref1] [Ref2]
| Type | Features | Causes |
|---|---|---|
| Physiological |
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At birth, the prepuce is non-retractile
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| Pathological |
|
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Complications
Key complications: [Ref]
- Paraphimosis (see below)
- UTI
- Balanitis / balanoposthitis
- ↑ Risk of penile cancer (controversial)
Management
Indications to Treat
- Symptomatic phimosis (e.g. causing painful erections, recurrent balanitis, UTIs, obstructive urinary symptoms)
- Asymptomatic phimosis generally does NOT require treatment
- Exception: consider treatment in asymptomatic infants who are at risk of recurrent UTIs due to upper urinary tract abnormalities
Physiological phimosis (in 2-4 y/o) does NOT require treatment, they often resolve spontaneously.
Management Options
1st line: topical steroid
- The steroid should be applied directly into the narrow ring under gentle retraction (BD for 4-8 weeks)
- High success rate >80%
Surgical management: circumcision or preputioplasty
- Surgical management is indicated if preferred by caregivers or failed to resolve with topical steroids
- Circumcision is strongly recommended in cases of balanitis xerotica obliterans
Avoid forced retraction of a narrow foreskin to prevent scar formation and secondary pathological phimosis.
Note that circumcision is NOT routinely recommended in the UK
Contraindications for circumcision:
- Acute local infection
- Congenital anomalies of the penis (esp. hypospadias, buried penis, congenital penile curvature) – as the foreskin may be required for a reconstructive procedure
Paraphimosis
Definition
Paraphimosis is a urological emergency where a retracted prepuce (foreskin) cannot be returned to cover the glans penis.
Aetiology
In children, it is most commonly caused by forced / improper retraction of the foreskin (esp. in those with phimosis)
In adults, it is most commonly iatrogenic, where the foreskin is retracted but then is NOT returned promptly over the glans in: [Ref]
- Urinary catheterisation (caregivers must routinely replace the foreskin immediately after changing catheters)
- Penile examination / cleaning
- Instrumentation / procedures (e.g. cystoscopy)
Clinical Features
The diagnosis is established clinically by direct visualisation of a tight constricting band of foreskin proximal to the glans and the inability to easily reduce the retracted foreskin manually [Ref]
Key other features: [Ref]
- Pain and tenderness of the glans penis
- Swelling and erythema of the glans and retracted foreskin
- The proximal penile shaft typically remains flaccid and unremarkable
Complications
The constricting band leads to impairment of distal venous and lymphatic drainage → ↓ arterial blood flow → ischemia (+/- necrosis) [Ref]
A dark / dusky / bluish / black colour of the glans implies possible ischaemia or even necrosis [Ref]
Management
The goal of acute management is to reduce the constricting band of the foreskin back over the glans: [Ref]
| 1st line: manual reduction | Attempt manual reduction after compressing the glans and swollen foreskin for a few minutes
Alternatives to manual compression (to reduce swelling):
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| If manual reduction failed → surgical intervention | Immediate management: surgical slit (making a longitudinal incision of the constricting band of edematous foreskin)
Followed by definitive management to prevent recurrence:
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