Phimosis – If a foreskin is tight and un-retractable.
Paraphimosis – If foreskin already pulled back but will not go forwards again.
It should be reduced. If not possible, send to the Emergency Department.
If the phimosis is symptomatic, management is either medical or surgical.
If asymptomatic, it can be left alone.
Use very potent steroid cream (Dermovate: Clobetasol 0.05%).
The patient should be advised to:
- Massage a small pea sized amount of cream into the tight part of the foreskin (inside and outside), after a week of treatment, the skin will be noticeably thinner;
- Start stretching exercises on the foreskin, usually best by pulling the foreskin back until it feels tight (but not painful), and holding it back under tension for 10 minutes – usually after a bath or shower twice a day.
- Warn the patient about paraphimosis.
- Once wide enough, stretching can be done by easing apart with 2 fingers, again holding for 10 minutes at a time.
- Often very potent steroid required for 2 months or more.
- Aim to wean either frequency of dosing or potency as soon as it has worked.
- Medical treatment is effective for >50% of patients.
- Phimosis may recur.
Procedure: preputioplasty or circumcision.
These are usually done under local anaesthetic.
Surgery may only be funded if medical treatment has been tried and failed.
Circumcision is not permitted for religious reasons.
Accepted clinical indications for referral are:
- Pathological phimosis e.g. due to scarring
- Recurrent balanitis
- Suspected penile malignancy