The document discusses phimosis and paraphimosis, defining them as the inability to retract the foreskin over the glans penis (phimosis) and the entrapment of a retracted foreskin behind the coronal sulcus (paraphimosis). It covers the etiology, pathophysiology, clinical presentation, differential diagnosis, investigations, treatment, and complications of each condition. Potential causes of phimosis include infections, trauma, congenital abnormalities, and scarring from forced retraction of the foreskin, while paraphimosis results from forcibly retracting an unretractable foreskin and not replacing it.

1. Phimosis and
paraphimosis
Presenter: Dr Munthali W
Moderator: Dr Phiri E

2. Outline
• Definition
• Epidermiology
• Anatomy
• Etiology
• Pathophysiology
• Clinical features
• Differential diagnosis
• Investigations
• Treatment
• Complications
• References

3. Definition
-Inability to retract the foreskin(prepuce) over the
glans penis
-physiologic phimosis occurs naturally in the
newborn males
-pathological 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

4. Epidermiology
• Up to 10% of males will have physiologic phimosis
at 3 years of age, and a larger percentage of
children will have only partially retractible
foreskins. One to five percent of males will have
nonretractible foreskins by age 16 yea

5. Anatomy

7. Etiology
• Idiopathic
• Traumatic
• Infections/infestations
• Neoplastic (benign
/malignant)
• Congenital/Genetic
• Nutritional Deficiency/excess
• Autoimmune
• Degenerative /lifestyle
• Iatrogenic
• Psychosomatic
• Poisoning /Toxins/Drug
induced

8. Pathophysiology
• 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.
• Patients with both physiological and pathological
phimosis are at risk of developing paraphimosis if the
foreskin is forcibly retracted over the glans and not
replaced afterwards.

9. • Persistent 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.
• Pathological phimosis may be detected in males
who report painful erections, hematuria, recurrent
urinary tract infections,preputial pain, or weakened
urinary system.

10. Clinical features
• Symptoms
• Painful erections
• Dyspareunia
• Hematuria
• Recurrent urinary tract
infections
• Preputial pain
• Weakened urinary
stream
• Signs
• Inability to retract
foreskin proximally over
the glans penis
• Preputial orifice is
unscarred and healthy in
physiologic
• A white contracted
fibrous ring around the
preputial orifice in
pathologic

11. Mueller et all grading of phimosis
• Grade I - Fully retractable
prepuce with stenotic ring
in the shaft
• Grade II - Partial
retractability with partial
exposure of the glans
• Grade III - Partial
retractability with exposure
of the meatus only
• Grade IV - No retractability

12. Paraphimosis
• 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.

15. Differential diagnosis
• Acute Angioedema
• Allergic Contact Dermatitis
• Anasarca
• Balanitis
• Balanitis xerotica obliterans
• Cellulitis
• Foreign body tourniquet, including hair, thread, metallic object, or
rubber bands
• Insect Bites
• Penile carcinoma
• Penile fracture
• Penile hematoma

16. Investigations
Laboratory
• Routine
• Special
Tissue diagnosis
Cytology
FNAC
Histology
Germ line testing and
molecular analysis
imaging
• Xray
• USG
• CT
• MRI
• ENDOSCOPY
• NUCLEAR SCAN

17. Treatment
• Pts with phimosis rarely require any emergency
intervention,managed on out patient basis by
urologist
• Paraphimosis is urologic emergency and requires
immediate intervention.
• Techniques include ; manual reduction,osmotic
method,puncture method, hyaluronidase
method,aspiration ,vertical incision and emergent
circumcision

18. Complications
Local
• Recurrence
• Posthitis
• Necrosis and gangrene
of the glans
• Autoamputation

19. Reference
1. McGregor TB, Pike JG, Leonard MP. Pathologic and
physiologic phimosis: approach to the phimotic
foreskin. Can Fam Physician. 2007 Mar. 53(3):445-8.
2.Tews M, Singer JI. Paraphimosis: Definition,
pathophysiology, and clinical features.
www.utdol.com. 9/20/2008
3.Dubin J, Davis JE. Penile emergencies. Emerg Med
Clin North Am. 2011 Aug. 29(3):485-99.

20. Zikomo