Physiologic phimosis occurs naturally in newborn males. Pathologic phimosis defines an inability to retract the foreskin after it was previously retractible or after puberty, usually secondary to distal scarring of the foreskin.
Paraphimosis is the entrapment of a retracted foreskin behind the coronal sulcus. Paraphimosis is a disease of uncircumcised or partially circumcised males.
The uncircumcised male penis comprises the penile shaft, the glans penis, the coronal sulcus, and the foreskin/prepuce, as shown below.
Physiologic phimosis results from adhesions between the epithelial layers of the inner prepuce and glans. These adhesions spontaneously dissolve with intermittent foreskin retraction and erections, so that as males grow, physiologic phimosis resolves with age.
Poor hygiene and recurrent episodes of balanitis or balanoposthitis lead to scarring of preputial orifices, leading to pathologic phimosis. Forceful retraction of the foreskin leads to microtears at the preputial orifice that also leads to scarring and phimosis.
Elderly persons are at risk of phimosis secondary to loss of skin elasticity and infrequent erections.
Patients with phimosis, both physiologic and pathologic, are at risk for developing paraphimosis when the foreskin is forcibly retracted past the glans and/or the patient or caretaker forgets to replace the foreskin after retraction. Penile piercings increase the risk of developing paraphimosis if pain and swelling prevent reduction of a retracted foreskin.
With time, impairment of venous and lymphatic flow to the glans leads to venous engorgement and worsening swelling. As the swelling progresses, arterial supply is compromised, leading to penile infarction/necrosis, gangrene, and eventually, autoamputation.
The foreskin cannot be retracted proximally over the glans penis.
In physiologic phimosis, the preputial orifice is unscarred and healthy appearing.
In pathologic phimosis, a contracted white fibrous ring may be visible around the preputial orifice
The foreskin is retracted behind the glans penis and cannot be replaced to its normal position.
The foreskin forms a tight, constricting ring around the glans.
Flaccidity of the penile shaft proximal to the area of paraphimosis is seen (unless there is accompanying balanoposthitis or infection of the penis).
With time, the glans becomes increasingly erythematous and edematous.
The glans penis is initially its normal pink hue and soft to palpation. As necrosis develops, the color changes to blue or black and the glans becomes firm to palpation.
In the United States, circumcision is the surgical treatment of choice for correction of phimosis. In European countries, however, preputioplasty is often used.
Although these techniques are outside the scope of this discussion, patients should be aware that these prepuce-preserving methods exist.
Adult circumcision can be performed under local or regional anesthesia and commonly involves either the dorsal slit or the sleeve technique. In China, however, standardization with a device known as the Shang Ring has proven effective, with a substantial decrease in both operative time and anesthetic requirements.
The dorsal slit is often useful in patients with phimosis, and the sleeve technique may allow for better hemostasis in patients with large subcutaneous veins.
A properly performed circumcision eliminates phimosis, as well as the risks of paraphimosis and frenular tears or bleeding associated with sexual intercourse.
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