Phimosis
Background
- Inability to retract the foreskin over the glans penis
- Physiologic phimosis: Normal in uncircumcised infants and young boys; nearly all resolve by age 5-7
- Pathologic phimosis: Scarring from recurrent balanitis, forceful retraction, or lichen sclerosus (balanitis xerotica obliterans)
- Only an ED emergency if it causes acute urinary retention or is mistaken for paraphimosis
Clinical Features
- Inability to retract foreskin over the glans
- Ballooning of foreskin during urination (in children — usually benign)
- Recurrent balanitis or posthitis
- Painful erections (adults)
- Weak urinary stream or acute urinary retention (rare but urgent)
Differential Diagnosis
Non-Traumatic penile diagnoses
- Phimosis
- Balanoposthitis
- Paraphimosis
- Priapism
- STDs
- Paraphimosis — foreskin retracted and trapped behind glans (emergency — must reduce immediately)
Evaluation
- Clinical diagnosis
- Ensure patient can urinate adequately
- Assess for signs of infection (erythema, discharge, warmth)
Management
- Physiologic (pediatric): Reassurance; do NOT forcefully retract (causes scarring and pathologic phimosis)
- Topical steroids: Betamethasone 0.05% or triamcinolone 0.025% BID × 4-6 weeks (success rate 80-90%)
- Acute urinary retention: Gentle dilation of foreskin with hemostat; Foley catheter if needed
- Dorsal slit: Emergency procedure if urinary retention unresponsive to conservative measures
- Circumcision: Definitive treatment for refractory pathologic phimosis (outpatient urology referral)
Disposition
- Discharge with urology or primary care follow-up
- Urgent urology referral if urinary retention, recurrent infections, or failed topical therapy