A 56-year-old uncircumcised man presents to the ED with a complaint of dysuria. He has some frequency, but denies abdominal pain, fever, chills, back pain, and scrotal and penile pain or swelling. He has no known medical problems, and is not sexually active.
Here is what you see when you ask the patient to fully retract his foreskin. What is this condition, and how would you treat it in the emergency department?
Phimosis, from the Greek phimos, is a condition in which adhesions between epithelial layers of the inner distal foreskin (prepuce) of the penis cannot be retracted from the glans of the penis in an uncircumcised man. During normal neonatal development, the inner prepuce and glans are adherent and the foreskin nonretractable. Usually these adhesions lysis with manual retraction or erection as the patient matures to pubertal age, meaning phimosis is a normal part of development in neonates, and in most cases, it resolves with maturation. Approximately 50 percent are able to retract the previously adherent foreskin by age 1, 90 percent are by age 3, and 99 percent are by 17. (J R Soc Med 2003;96:449.) The condition is considered pathologic when it occurs in patients who were previously able to completely retract the foreskin or when it occurs after puberty.
Risk factors for phimosis include lichen sclerosus et atrophicus (chronic inflammatory mucocutaneous disease), scarring of the foreskin (can be secondary to forceful retraction of foreskin causing microtears, post-piercing, post-prepuce crush injury, or inflammation), decreased frequency of foreskin retraction (more common in elderly who have less erections and decreased skin elasticity), and post-balanitis (inflammation of the glans usually secondary to poor hygiene, but can result from chronic catheterization) or balanoposthitis (inflammation of the foreskin and glans). (Pediatr Med Chir 2005;27[3-4]:91; BJU Int 2002;90:498; Genitourin Med 1996;72:155.) As many as 30 percent who have manual reduction of paraphimosis develop phimosis secondary to foreskin trauma. (Int J Clin Pract 2005;59:591.)
Patients with physiologic phimosis may complain of the inability to retract the patient's foreskin or temporary swelling of the distal foreskin during urination. Patient with pathologic phimosis may have distal foreskin pain, painful erections, pain with attempted and unsuccessful retraction, decreased urine stream, hematuria, urine retention, and frequent urinary tract infections.
The diagnosis of phimosis is clinical. Physiologic phimosis occurs in pre-pubertal individuals with healthy unscarred distal foreskin tissue that is pliable but unable to be retracted. Patients with pathologic phimosis who are post-pubertal and have taut distal glans ring, occasionally have a visible white fibrinous band preventing retraction. A few reports claim that difficulty in distinguishing the two forms exists. (Can J Urol 2005;12: 2598; Indian J Pediatr 2009;76:829.) The differential diagnosis of phimosis is limited to foreign body tourniquet, penile fracture or hematoma, anasarca, balanitis, penile carcinoma, or dermatitis.
Patients with phimosis are at risk for posthitis (inflammation of the foreskin) and urinary retention secondary to outflow obstruction, although this is rare. (Hinyokika Kiyo 2008;54:427.) Patients with phimosis have as much as a 65-fold increased risk of developing penile cancer. (World J Urol 2009;27:141.) They also are at risk for paraphymosis. This can occur when the taut foreskin is forcible retracted causing glans entrapment, which leads to venous and lymphatic engorgement, then compromised arterial flow, then subsequent ischemia/infarction, and autoamputation of the distal penis.
Asymptomatic phimosis does not typically require treatment. The treatment for physiologic phimosis is time and reassurance, with instructions on proper hygiene of the uncircumcised penis. Topical steroid cream (e.g., 0.1% triamcinolone topical cream) loosens the skin and decreases inflammation, and can be applied twice a day for four to eight weeks for more rapid results. Steroid treatment is successful in 65 percent to 95 percent of cases. (Pediatrics 1998;102:e43.) Steroids are not indicated in children under 1, with some recommending no treatment until the child is at least 5. (Arch Pediatr 2005;12:1424.) This technique also has been shown to reduce costs by nearly 30 percent, as opposed to treatment by circumcision. (Urology 2008;72:68; Int Braz J Urol 2010;36:75; Urol Nurs 2006; 26:181.)
Treatment for pathologic phimosis includes steroid creams, preputioplasty (prepuce-sparing surgical treatments, manual stretching, and circumcision. (Ned Tijdschr Geneeskd 2005;149 :2446.) Nonsurgical treatments are recommended as first-line therapy. Rarely does pathologic phimosis require emergent treatment in the emergency department, but outpatient follow-up with a urologist is prudent.
Patients with phimosis who require emergent catheterization may require a dorsal slit procedure, although circumcision is the definitive treatment of choice. To perform a dorsal slit in the foreskin, the distal penis is cleaned, prepped, and draped. The area is anesthetized locally or via a penile block using lidocaine without epinephrine. Mild procedural sedation also may be required. Both jaws of a hemostat are then carefully advanced proximally between the inner foreskin and glans cautiously disrupting any adhesions. One jaw of the hemostat is then placed in this new track, and advanced to the coronal sulcus (depression between proximal glans and distal foreskin), and the anesthetized skin crushed between the hemostats for three to five minutes. A cut is then made through the crushed foreskin tissue with straight scissors, releasing the phimosis (gentle manual reduction may be necessary). The urethra should be visualized at all times during the procedure to prevent inadvertent damage. The newly cut tissue on either side of the incision can be approximated with absorbable sutures to achieve hemostasis. The result will be a “beagle-ear” deformity. Care should be taken to place the foreskin in the natural anatomic position to prevent iatrogenic paraphimosis. Elective circumcision is then recommended, more for cosmetic reasons than functional.
Unless the patient has significant urinary obstruction with acute renal failure, nearly all can be managed as outpatients. This patient was diagnosed with a urinary tract infection, and a swab for venereal disease performed. Acute renal failure was ruled out, and the patient was started on appropriate antibiotics, topical steroid cream, and told to follow up with a urologist for elective circumcision evaluation.